Pharmacology

NCLEX - ADULT HEALTH PHARMACOLOGY - 739 Potassium chloride administered intravenously must always be diluted in IV fluid and infused via a pump or controller. The usual concentration of IV potassium chloride is 20 to 40 mEq/L. Potassium chloride is never given by bolus (IV push). Giving potassium chloride by IV push can result in cardiac arrest. Dilution in normal saline is recommended, but dextrose solution is avoided because this type of solution increases intracellular potassium shifting. The IV bag containing the potassium chloride is always gently agitated before hanging. The IV site is monitored closely because potassium chloride is irritating to the veins and the risk of phlebitis exists. The nurse monitors urinary output during administration and contacts the physician if the urinary output is less than 30 mL/hr. After adding a medication to a bag of intravenous (IV) solution, the nurse should agitate or rotate the bag gently to mix the medication evenly in the solution. The nurse should then attach a completed medication label. The nurse can then prime the tubing. The IV solution should have been checked for discoloration before the medication was added to the solution. The tubing is attached to the client last. Prednisone is a corticosteroid. With prolonged use, corticosteroids cause adrenal atrophy, which reduces the ability of the body to withstand stress. When stress is severe, corticosteroids are essential to life. Before and during surgery, dosages may be increased temporarily. Ferrous sulfate is an oral iron preparation used to treat iron deficiency anemia. Cyclobenzaprine (Flexeril) is a skeletal muscle relaxant. NCLEX– 182845269.doc

Conjugated estrogen (Premarin) is an estrogen used for hormone replacement therapy in postmenopausal women. These other three medications may be withheld before surgery without undue effects on the client. Anticoagulants alter normal clotting factors and increase the risk of bleeding after surgery. Aspirin has properties that can alter the clotting mechanism and should be discontinued at least 48 hours before surgery. Options 1, 2, and 3 are accurate client statements. Lisinopril is an antihypertensive angiotensin-converting enzyme inhibitor. The usual dosage range is 20 to 40 mg daily. Adverse effects include headache, dizziness, fatigue, orthostatic hypotension, tachycardia, and angioedema. Specific client teaching points include taking one pill a day, not stopping the medication without consulting the physician, and monitoring for side effects and adverse reactions. The client should notify the physician if side effects occur. Polypharmacy is a concern in the geriatric population. Duplication of medications needs to be identified before drug-drug interactions or adverse side effects can be determined. The phone call to the health care provider is the intervention after all other information has been collected. Asthma is a chronic inflammatory disease of the airways. Inhaled aerosolized short-acting β2 agonists are quick relief medications and recommended for clients with status asthmaticus after epinephrine has been administered. Leukotriene modifiers, antiallergic medications, Thursday, October 24, 2013

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and nonsteroidal anti-inflammatory medications are long-term control medications. A topical corticosteroid should be applied sparingly (thin layer) and rubbed into the area thoroughly. The affected area should be cleansed gently before application. A topical corticosteroid should not be applied over extensive areas. Systemic absorption is more likely to occur with extensive application. Hemophilia refers to a group of bleeding disorders resulting from a deficiency of specific coagulation proteins. The primary treatment is replacement of the missing clotting factor; additional medications, such as those to relieve pain, may be prescribed depending on the source of bleeding from the disorder. A child with hemophilia A will be at risk for joint bleeding after a fall. Factor VIII will be prescribed intravenously to replace the missing clotting factor and minimize the bleeding. Desmopressin (DDAVP) is used to stimulate production of factor VIII, but it is not given intravenously. Factor X and cryoprecipitate are not used for clients with hemophilia A. In severe cystic acne, isotretinoin (Accutane) is used to inhibit inflammation. Adverse effects include elevated triglyceride levels, skin dryness, eye discomfort such as dryness and burning, and cheilitis (lip inflammation). Close medical follow-up is required, and dry skin and cheilitis can be decreased by the use of emollients and lip balms. Vitamin A supplements are stopped during this treatment. Salicylic acid is absorbed readily through the skin, and systemic toxicity (salicylism) can result. Symptoms NCLEX– 182845269.doc

include tinnitus, dizziness, hyperpnea, and psychological disturbances. Constipation and diarrhea are not associated with salicylism. Acyclovir is a topical antiviral agent that inhibits DNA replication in the virus. Acyclovir has activity against herpes simplex virus types 1 and 2, varicella-zoster virus, Epstein-Barr virus, and cytomegalovirus. Gentamicin sulfate is an antibacterial and would not be effective in treating herpesvirus. Mupirocin calcium is a topical antibacterial active against Staphylococcus aureus, betahemolytic streptococci, or Streptococcus pyogenes. Salicylic acid is a keratolytic. Coal tar is used to treat psoriasis and other chronic disorders of the skin. Coal tar suppresses DNA synthesis, mitotic activity, and cell proliferation. Coal tar has an unpleasant odor, frequently stains the skin and hair, and can cause phototoxicity. Systemic toxicity does not occur. Sunscreens are most effective when applied about 30 to 60 minutes before exposure to the sun so that they can penetrate the skin. All sunscreens should be reapplied after swimming or sweating. Mafenide acetate is bacteriostatic for gram-negative and gram-positive organisms and is used to treat burns to reduce bacteria present in avascular tissues. The client should be informed that the medication will cause local discomfort and burning. Mafenide acetate is a carbonic anhydrase inhibitor and can suppress renal excretion of acid, thereby causing acidosis. Clients receiving this treatment should be monitored for signs of an acid-base imbalance Thursday, October 24, 2013

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(hyperventilation). If this occurs, the medication should be discontinued for 1 to 2 days. Options 3 and 4 describe local rather than systemic effects. An elevated blood pressure may be expected from the pain that occurs with a burn injury.

The instructions for the use of permethrin include wash, rinse, and towel-dry hair, apply sufficient volume to saturate hair and scalp, allow to remain on hair 10 minutes, and then rinse with water. Options 1, 2, and 3 are incorrect instructions.

Sodium hypochlorite is a solution used for irrigating and cleaning necrotic or purulent wounds. It cannot be used to pack purulent wounds because the solution is inactivated by copious pus. The solution should not come into contact with healing or normal tissue and should be rinsed off immediately following irrigation. The solution loses its potency during storage, so fresh solution should be prepared frequently.

Lindane is applied in a thin layer to the body below the head. No more than 30 g (1 oz) should be used. The medication is removed by washing 8 to 12 hours later. In most cases, only one application is required.

Tretinoin is applied liberally to the skin. The hands are washed thoroughly immediately after applying. Therapeutic results should be seen after 2 to 3 weeks but may not be optimal until after 6 weeks. The skin needs to be cleansed thoroughly before applying the medication. Isotretinoin can elevate triglyceride levels. Blood triglyceride levels should be measured before treatment and periodically thereafter until the effect on the triglycerides has been evaluated. Options 1, 3, and 4 do not need to be monitored specifically during this treatment. Isotretinoin is a metabolite of vitamin A and can produce generalized intensification of isotretinoin toxicity. Because of the potential for increased toxicity, vitamin A supplements should be discontinued before isotretinoin therapy. Options 2, 3, and 4 are not contraindicated with the use of isotretinoin.

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Clients should be advised not to use occlusive dressings (bandages or plastic wraps) to cover the affected site following the application of the topical corticosteroid, unless the physician specifically prescribes wound coverage. Options 1, 2, and 3 are accurate statements related to the use of this medication. Topical corticosteroids can be absorbed into the systemic circulation. Absorption is higher from regions where the skin is especially permeable (scalp, axilla, face, eyelids, neck, perineum, genitalia), and lower from regions where permeability is poor (back, palms, soles). Dextranomer is a cleansing rather than a débriding agent that is effective for wet wounds only. Dextranomer is not packed tightly into the wound because maceration of surrounding tissue may result. Azelaic acid is a topical medication used to treat mild to moderate acne. The acid appears to work by suppressing the growth of Propionibacterium acnes and by decreasing the proliferation of keratinocytes. Options 2, 3, and 4 are incorrect.

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Silver sulfadiazine (Silvadene) is an antibacterial that has a broad spectrum of activity against gramnegative bacteria, gram-positive bacteria, and yeast. It is applied directly to the wound to assist in healing. It does not stain the skin. Fibrinolysin and desoxyribonuclease (Elase) is used to débride wounds, including burns, pressure ulcers, and inflamed or infected lesions. Dextranomer (Debrisan) is not a débriding agent but is a cleansing agent that actually absorbs peptides and proteins. Nitrofurazone (Furacin) and silver sulfadiazine (Silvadene) are antibacterials and are not used for wound débridement. The nurse would schedule the next home care visit in 7 days. Protective hydrocolloid dressings such as DuoDerm are designed to be left in place for 7 days unless leakage occurs around the dressing. Bleeding precautions need to be initiated when the platelet count decreases. The normal platelet count is 150,000 to 450,000/mm3. When the platelets are lower than 50,000 /mm3, any small trauma can lead to episodes of prolonged bleeding. The normal white blood cell count is 5,000 to 10,000/mm3. When the white blood cell count drops, neutropenic precautions need to be implemented. The normal clotting time is 8 to 15 minutes. The normal ammonia value is 15 to 45 mcg/dL. Hyperuricemia is especially common following treatment for leukemias and lymphomas because chemotherapy results in massive cell kill. Although options 1, 2, and 4 also may be noted, an increased uric acid level is related specifically to cell destruction.

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Busulfan (Myleran, Busulfex) is an alkylating medication used to treat acute myelocytic leukemia and in the palliative treatment of chronic myelogenous leukemia. Hyperuricemia can result from the use of this medication. Allopurinol (Zyloprim), an antigout medication, is used with chemotherapy to prevent or treat hyperuricemia that occurs from the rapid destruction of cells by the antineoplastic medication. Allopurinol is not used to prevent arthritis, alopecia, or diarrhea. Hemorrhagic cystitis is a toxic effect that can occur with the use of cyclophosphamide (Cytoxan, Neosar). The client needs to be instructed to drink copious amounts of fluid during the administration of this medication. Clients also should monitor urine output for hematuria. The medication should be taken on an empty stomach, unless gastrointestinal upset occurs. Hyperkalemia can result from the use of the medication; therefore, the client would not be told to increase potassium intake. The client would not be instructed to alter sodium intake. Cardiotoxicity noted by abnormal electrocardiographic findings or cardiomyopathy manifested as congestive heart failure is a toxic effect of daunorubicin. Bone marrow depression is also a toxic effect. Nausea and vomiting is a frequent side effect associated with the medication that begins a few hours after administration and lasts 24 to 48 hours. Fever is a frequent side effect and diarrhea can occur occasionally. Options 1, 2, and 3, however, are not toxic effects. To ensure that the client receives optimal doses of chemotherapy, dosing is usually based on the total body surface area (BSA), which Thursday, October 24, 2013

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requires a current accurate height and weight for BSA calculation (before each medication administration). Asking the client about his or her height and weight may lead to inaccuracies in determining a true BSA and dosage. Calculating body mass index and measuring abdominal girth will not provide the data needed. Bleomycin (Blenoxane) is an antineoplastic medication that can cause interstitial pneumonitis, which can progress to pulmonary fibrosis. Pulmonary function studies along with hematological, hepatic, and renal function tests need to be monitored. The nurse needs to monitor lung sounds for dyspnea and crackles, which indicate pulmonary toxicity. The medication needs to be discontinued immediately if pulmonary toxicity occurs. Options 1, 2, and 3 are unrelated to the specific use of this medication. Chemotherapy agents are usually given in combinations (also called regimens or protocols). The goal of administering combination chemotherapy in cycles or specific sequences is to produce additive or synergistic therapeutic effects. Administering combination therapy by administering several medications with different mechanisms of action and different onset of nadirs and toxicities enhances tumor cell destruction while minimizing medication resistance and overlapping toxicities. Because antineoplastic medications lower the resistance of the body, clients must be informed not to receive immunizations without a physician's or health care provider's approval. Clients also need to avoid contact with individuals who have recently received a live virus vaccine. NCLEX– 182845269.doc

Clients need to avoid aspirin and aspirin-containing products to minimize the risk of bleeding, and they need to avoid alcohol to minimize the risk of toxicity and side effects. Cyclophosphamide (Cytoxan, Neosar) is an antineoplastic medication of the alkylating class. Medications of this type affect all phases of the reproductive cell cycle. Cell cycle phase-specific medications affect cells only during a certain phase of the reproductive cycle. Antimetabolite medications are cell cycle phasespecific and affect the S phase. Vinca alkaloids are cell cycle phase-specific and act on the M phase. Cisplatin (Platinol) is an alkylating type of medication and vincristine (Oncovin, Vincasar PFS) is a vinca (plant) alkaloid. Alkylating medications are cell cycle phase-nonspecific. Vinca alkaloids are cell cycle phase-specific and act on the M phase. Combinations of medications are used to enhance tumoricidal effects and increase the therapeutic response. High concentrations of methotrexate harm and damage normal cells. To save normal cells, leucovorin is given, which is known as leucovorin rescue. Leucovorin bypasses the metabolic block caused by methotrexate, thereby permitting normal cells to synthesize. Note that leucovorin rescue is potentially hazardous. Failure to administer leucovorin in the right dose at the right time can be fatal. A side effect specific to vincristine is peripheral neuropathy, which occurs in almost every client. Peripheral neuropathy can be manifested as numbness and tingling in the fingers and toes. Depression of the Achilles tendon reflex may be the first clinical Thursday, October 24, 2013

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sign indicating peripheral neuropathy. Constipation rather than diarrhea is most likely to occur with this medication, although diarrhea may occur occasionally. Hair loss occurs with nearly all the antineoplastic medications. Chest pain is unrelated to this medication. Asparaginase (Elspar) is contraindicated if hypersensitivity exists, in pancreatitis, or if the client has a history of pancreatitis. The medication impairs pancreatic function and pancreatic function tests should be performed before therapy begins and when a week or more has elapsed between administration of the doses. The client needs to be monitored for signs of pancreatitis, which include nausea, vomiting, and abdominal pain. The conditions noted in options 2, 3, and 4 are not contraindicated with this medication. Tamoxifen (Nolvadex) is an antineoplastic medication that competes with estradiol for binding to estrogen in tissues containing high concentrations of receptors. Tamoxifen is used to treat metastatic breast carcinoma in women and men. Tamoxifen is also effective in delaying the recurrence of cancer following mastectomy. Tamoxifen reduces DNA synthesis and estrogen response. Tamoxifen (Nolvadex) may increase calcium, cholesterol, and triglyceride levels. Before the initiation of therapy, a complete blood count, platelet count, and serum calcium levels should be assessed. These blood levels, along with cholesterol and triglyceride levels, should be monitored periodically during therapy. The nurse should assess for hypercalcemia while the client is taking this medication. Signs of hypercalcemia include increased urine NCLEX– 182845269.doc

volume, excessive thirst, nausea, vomiting, constipation, hypotonicity of muscles, deep bone, and flank pain. Megestrol acetate (Megace) suppresses the release of luteinizing hormone from the anterior pituitary by inhibiting pituitary function and regressing tumor size. Megestrol is used with caution if the client has a history of thrombophlebitis. Options 1, 2, and 4 are not contraindications for this medication. Alopecia (hair loss) can occur following the administration of many antineoplastic medications. Alopecia is reversible, but new hair growth may have a different color and texture. Stomatitis (ulceration in the mouth) can result from the administration of antineoplastic medications. The client should be instructed to examine her or his mouth daily and to report any signs of ulceration. If stomatitis occurs, the client should be instructed to rinse the mouth with baking soda or saline. Food and fluid is important and should not be restricted. If chewing and swallowing are painful, the client may switch to a liquid diet that includes milk shakes and ice cream. Instruct the client to avoid spicy foods and foods with hard crusts or edges. The client should avoid toothbrushing and flossing when stomatitis is severe. Lemon and glycerin swabs may cause pain and further irritation. Busulfan (Myleran, Busulfex) can cause an increase in the uric acid level. Hyperuricemia can produce uric acid nephropathy, renal stones, and acute renal failure. Options 1, 2, and 4 are not specifically related to this medication. A side effect specific to etoposide is orthostatic hypotension. Etoposide Thursday, October 24, 2013

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should be administered slowly over 30 to 60 minutes to avoid hypotension. The client's blood pressure is monitored during the infusion. Hair loss occurs with nearly all the antineoplastic medications. Chest pain and pulmonary fibrosis are unrelated to this medication. Male and female clients who take estrogen or progestins are at increased risk for deep vein thrombosis (DVT). Women receiving estrogens or progestins have irregular but heavy menses, fluid retention, and breast tenderness. Options 1, 2, and 4 are not specifically associated with these type of medications. Redness and swelling and a slowed infusion indicate signs of extravasation. If extravasation occurs during the intravenous administration of an antineoplastic medication, the infusion is stopped and the physician is notified. Ice or heat may be prescribed for application to the site and an antidote may be prescribed to be administered into the site. Increasing the flow rate can increase damage to the tissues. Restarting an IV in the same vein can increase damage to the site and vein. Somatrem (Protropin) is a growth stimulator used in the long-term treatment of growth failure resulting from endogenous growth hormone deficiency. Somatrem stimulates linear growth and increases the number and size of muscle cells and increases red cell mass. Somatrem affects carbohydrate metabolism by antagonizing the action of insulin, increases mobilization of fats, and increases cellular protein synthesis. Options 1, 2, and 4 are not actions of this medication.

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Desmopressin promotes renal conservation of water. The hormone carries out this action by acting on the collecting ducts of the kidney to increase their permeability to water, which results in increased water reabsorption. The therapeutic effect of this medication would be manifested by a decreased urine output. Options 1, 3, and 4 are unrelated to the effects of this medication. Water intoxication (overhydration) or hyponatremia is an adverse reaction to desmopressin. Early signs include drowsiness, listlessness, and headache. Decreased urination, rapid weight gain, confusion, seizures, and coma also may occur in overhydration.

Because of its powerful vasoconstrictor actions, vasopressin can cause adverse cardiovascular effects. By constricting arteries of the heart, vasopressin can cause angina pectoris and even myocardial infarction, especially if administered to clients with coronary artery disease. In addition, vasopressin may cause vascular problems by decreasing blood flow in the periphery. Options 1, 2, and 3 are incorrect. Oral doses of levothyroxine (Synthroid) should be taken on an empty stomach to enhance absorption. Dosing should be done in the morning before breakfast. Excessive doses of levothyroxine (Synthroid) can produce signs and symptoms of hyperthyroidism. These include tachycardia, chest pain, tremors, nervousness, insomnia, hyperthermia, heat intolerance, and sweating. The client should be instructed to notify the physician if

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these occur. Options 1, 3, and 4 are signs of hypothyroidism. Propylthiouracil (PTU) inhibits thyroid hormone synthesis and is used to treat hyperthyroidism, or Graves' disease. Myxedema indicates hypothyroidism. Cushing's syndrome and Addison's disease are disorders related to adrenal function. Desmopressin administered by the intranasal route can cause a runny or stuffy nose. Options 1, 2, and 4 are side effects if the medication is administered by the intravenous route. An adverse effect of somatropin (Humatrope) is hypothyroidism. Thyroid function is monitored throughout therapy. Options 1 and 2 would evaluate pancreatic function, and option 3 evaluates renal function. Lugol's solution is administered to hyperthyroid individuals in preparation for thyroidectomy to suppress thyroid function. Initial effects develop within 24 hours; peak effects develop in 10 to 15 days. In most cases, plasma levels of thyroid hormone are reduced with propylthiouracil (PTU) before Lugol's solution therapy is initiated. Then, Lugol's solution along with propylthiouracil is administered for the last 10 days before surgery. Chronic ingestion of iodine can produce iodism. The client needs to be instructed about the symptoms of iodism, which include a brassy taste, soreness of gums and teeth, vomiting, and abdominal pain. The client needs to be instructed to notify the physician if these symptoms occur. Excessive levels of fludrocortisone acetate (Florinef) cause retention of sodium and water and excessive excretion of potassium, resulting in NCLEX– 182845269.doc

expansion of blood volume, hypertension, cardiac enlargement, edema, and hypokalemia. The client needs to be informed about the signs of sodium and water retention, such as unusual weight gain or swelling of the feet or lower legs. If these signs occur, the physician needs to be notified. Calcium carbonate tablets should be taken with a full glass of water 30 to 60 minutes after meals. Therefore, options 1, 2, and 3 are incorrect. The client who is taking an antihypocalcemic medication should be instructed to avoid eating too much spinach, rhubarb, bran, or whole-grain cereals because they decrease calcium absorption. Good dietary sources of calcium are milk products, dark green, leafy vegetables (although spinach needs to be avoided), clams, oysters, sardines, and orange juice fortified with calcium. Corticosteroids (glucocorticoids) should be administered before 9 AM. Administration at this time helps minimize adrenal insufficiency and mimics the burst of glucocorticoids released naturally by the adrenal glands each morning. Options 1, 2, and 4 are incorrect. Acarbose (Precose) is an alphaglucosidase inhibitor. Taken with the first bite of each major meal, acarbose delays absorption of ingested carbohydrates, decreasing postprandial hyperglycemia. Abdominal pain and flatulence are the most common side effects of this medication. It is not taken at bedtime. Rotation of insulin injections should be done within one anatomical site to maintain consistent absorption of insulin. Options 1, 3, and 4 are correct Thursday, October 24, 2013

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statements regarding insulin administration and thus do not indicate a need for additional client teaching.

Sildenafil is not contraindicated with the use of vitamins. Neuralgia and insomnia are side effects of the medication.

Glucocorticoids can elevate blood glucose levels. Clients with diabetes mellitus may need their dosages of insulin or oral hypoglycemic medications increased during glucocorticoid therapy. Therefore, options 1, 2, and 4 are incorrect.

Exenatide (Byetta) is an incretin mimetic used for type 2 diabetes mellitus only. It is not recommended for clients taking insulin. Hence, the nurse should hold the medication and question the health care provider regarding this order. Although options 1 and 3 are correct statements about the medication, in this situation the medication should not be administered. The medication is packaged in prefilled pens ready for injection without the need for drawing it up into another syringe.

When preparing a mixture of regular insulin with another insulin preparation, the regular insulin is drawn into the syringe first. This sequence will avoid contaminating the vial of regular insulin with insulin of another type. Options 2, 3, and 4 identify the correct actions for preparing NPH and regular insulin. Insulin in unopened vials should be stored under refrigeration until needed. Vials should not be frozen. When stored unopened under refrigeration, insulin can be used up to the expiration date on the vial. Options 1, 3, and 4 are incorrect. When alcohol is combined with glimepiride (Amaryl), a disulfiram-like reaction may occur. This syndrome includes flushing, palpitations, and nausea. Alcohol can also potentiate the hypoglycemic effects of the medication. Clients need to be instructed to avoid alcohol consumption while taking this medication. The items in options 2, 3, and 4 do not need to be avoided. Sildenafil (Viagra) enhances the vasodilating effect of nitric oxide in the corpus cavernosum of the penis, thus sustaining an erection. Because of the effect of the medication, it is contraindicated with concurrent use of organic nitrates and nitroglycerin. NCLEX– 182845269.doc

Repaglinide is a rapid-acting oral hypoglycemic agent that stimulates pancreatic insulin secretion that should be taken before meals, and that should be held if the client does not eat. Hypoglycemia is a side effect of repaglinide and the client should always be prepared by carrying a simple at all times. Metformin is an oral hypoglycemic given in combination with repaglinide and works by decreasing hepatic glucose production. A common side effect of metformin is diarrhea. Muscle pain may occur as an adverse effect from metformin but it might signify a more serious condition that warrants physician notification, not the use of acetaminophen. Metoclopramide is a gastrointestinal stimulant and antiemetic. Because it is a gastrointestinal stimulant, it is contraindicated with gastrointestinal obstruction, hemorrhage, or perforation. It is used in the treatment of emesis after surgery, chemotherapy, and radiation.

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Cholestyramine (Questran) is a bile acid sequestrant used to lower the cholesterol level and client compliance is a problem because of its taste and palatability. The use of flavored products or fruit juices can improve the taste. Some side effects of bile acid sequestrants include constipation and decreased vitamin absorption. The principle manifestations of Crohn's disease are diarrhea and abdominal pain. Infliximab (Remicade) is an immunomodulator that reduces the degree of inflammation in the colon, thereby reducing the diarrhea. Options 1, 3, and 4 are unrelated to this medication. Propantheline bromide is an antimuscarinic anticholinergic medication that decreases gastrointestinal secretions. Propantheline should be administered 30 minutes before meals. The other options are incorrect. Docusate sodium is a stool softener that promotes absorption of water into the stool, producing a softer consistency of stool. The intended effect is relief or prevention of constipation. The medication does not decrease the amount of fat in the stools, stop gastrointestinal bleeding, or relieve abdominal pain. Cascara sagrada is a laxative that causes nausea and abdominal cramps as the most frequent side effects. Other health problems (options 1, 2, and 3) are not determined based on a single symptom. Most rapid results from bisacodyl occur when it is taken on an empty stomach. Bisacodyl will not have a rapid effect if taken with a large meal. If bisacodyl is taken at bedtime, the client will have a bowel movement in NCLEX– 182845269.doc

the morning. Taking the medication with two glasses of juice will not add to its effect. Senna works by changing the transport of water and electrolytes in the large intestine, which causes accumulation of water in the mass of stool and increased peristalsis. The other options are incorrect. Loperamide is an antidiarrheal agent. It is used to manage acute and also chronic diarrhea in conditions such as inflammatory bowel disease. Loperamide also can be used to reduce the volume of drainage from an ileostomy. It is not used for the conditions in options 1, 2, and 4. The client should not exceed the recommended dose because it may be habit-forming. The medication is an antidiarrheal and therefore should not be taken with a laxative. Side effects of the medication include dry mouth and drowsiness. Metamucil is a bulk-forming laxative and should be taken with a full glass of water or juice, followed by another glass of liquid. This will help prevent impaction of the medication in the stomach or small intestine. The other options are incorrect. If the client experiences tardive dyskinesia (rhythmic movements of the face or limbs), the client should stop the medication and call the physician. These side effects may be irreversible. Excitability is not a side effect of this medication. Anxiety, irritability, and dry mouth are side effects that are not so harmful to the client. Trimethobenzamide (Tigan) is an antiemetic agent used to treat nausea and vomiting. The other options are incorrect. Thursday, October 24, 2013

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Ondansetron is an antiemetic used to treat postoperative nausea and vomiting, as well as nausea and vomiting associated with chemotherapy. The other options are incorrect. Magnesium citrate is available as an oral solution and is used commonly as a laxative in preparation for or after certain studies of the gastrointestinal tract. Magnesium citrate should be served chilled and not be allowed to stand for prolonged periods, which would reduce the carbonation and make the solution even less palatable. Options 2, 3, and 4 are incorrect. Prochlorperazine is a phenothiazinetype antiemetic and antipsychotic. The nurse would assess the client for blurred vision as a frequent side effect of prochlorperazine. Other frequent side effects include dry eyes, dry mouth, and constipation. Pancrelipase (Pancrease) is a pancreatic enzyme used in clients with pancreatitis as a digestive aid. The medication should reduce the amount of fatty stools (steatorrhea). Another intended effect could be improved nutritional status. It is not used to treat abdominal pain or heartburn. Its use could result in weight gain but should not result in weight loss if it is aiding in digestion. Calcium carbonate antacids should not be taken with milk, milk products, or foods or supplements high in vitamin D because milk-alkali syndrome (headache, urinary frequency, anorexia, nausea, vomiting, fatigue) can occur. The best item to consume when taking calcium carbonate is water. Aluminum hydroxide tablets should be chewed thoroughly before swallowing. NCLEX– 182845269.doc

This prevents them from entering the small intestine undissolved. They should not be swallowed whole. Antacids should be taken at least 1 hour apart from other medications to prevent interactive effects. Constipation is a side effect of the use of aluminum products, but it is not correct for the client to take a laxative with each dose. This promotes laxative abuse; the client should first try other means to prevent constipation. Calcium carbonate can be used as an antacid for the relief of heartburn and indigestion. Calcium carbonate also can be used as a calcium supplement (option 3) or to bind phosphorus in the gastrointestinal tract with renal failure (option 4). Option 2 is incorrect, although adequate calcium levels are needed for proper neurological function. Sodium bicarbonate is an electrolyte modifier and antacid, and it would aggravate metabolic alkalosis, which is a difficult acid-base imbalance to correct. The other options are incorrect. Cimetidine is a histamine 2 (H2)receptor antagonist. Older clients are especially susceptible to central nervous system side effects of cimetidine. The most frequent of these is confusion. Less common central nervous system side effects include headache, dizziness, drowsiness, and hallucinations. Sucralfate is a gastric protectant. The medication should be scheduled for administration 1 hour before meals and at bedtime. The medication is timed to allow it to form a protective coating over the ulcer before food intake stimulates gastric acid production and mechanical irritation. The other options are incorrect. Thursday, October 24, 2013

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Sucralfate is a gastric protectant. The medication should be scheduled for administration 1 hour before meals and at bedtime. The medication is timed to allow it to form a protective coating over the ulcer before food intake stimulates gastric acid production and mechanical irritation. The other options are incorrect. Ranitidine is a histamine 2 (H2)receptor antagonist. A single daily dose of ranitidine is scheduled to be given at bedtime. This allows for a prolonged effect, and the greatest protection of the gastric mucosa. The other options are incorrect. The client with peptic ulcer disease should avoid taking medications that are irritating to the stomach lining. Irritants would include aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs). The client should be advised to take acetaminophen for a headache. Omeprazole is a proton pump inhibitor classified as an antiulcer agent. The intended effect of the medication is relief of pain from gastric irritation, often called heartburn by clients. Omeprazole is not used to treat the conditions identified in options 1, 3, and 4. Triple therapy for Helicobacter pylori infection usually includes two antibacterial drugs and a proton pump inhibitor. Metronidazole and clarithromycin are antibacterials. Omeprazole is a proton pump inhibitor. These medications will kill the bacteria and decrease acid production. H2-receptor antagonists suppress secretion of gastric acid, alleviate symptoms of heartburn, and assist in preventing complications of peptic NCLEX– 182845269.doc

ulcer disease. These medications also suppress gastric acid secretions and are used in active ulcer disease, erosive esophagitis, and pathological hypersecretory conditions. The other medications listed are proton pump inhibitors. The medication should be administered with food such as milk and crackers to prevent gastrointestinal irritation. Options 1, 2, and 4 are appropriate statements regarding the use of this medication. Theophylline is a bronchodilator that directly relaxes the smooth muscles of the bronchial airway. Options 1, 2, and 3 are not direct actions of this medication. Albuterol is a sympathomimetic bronchodilator. Side effects that can occur from the use of this medication include tremors, nausea, nervousness, palpitations, tachycardia, and dryness of the mouth or throat. Isoniazid and rifampin are contraindicated in clients with acute liver disease or a history of hepatic injury. Option 1 is the only option that addresses hepatic dysfunction. The medications are not contraindicated in the disorders noted in options 2, 3, and 4. The client needs to be instructed that the entire year-long course of the medication needs to be completed. The preferable method of administration is for the client to take the medication 1 hour before or 2 hours after meals. If gastrointestinal irritation occurs, the medication should not be discontinued and, in this situation a small amount of food may be taken to reduce the irritation. Increasing fluid intake during this medication therapy is not necessary. Thursday, October 24, 2013

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Clients diagnosed with active tuberculosis usually are started on more than one medication to be certain that the resistant organisms are eliminated. The doses of some medications initially may be large because the bacilli are difficult to kill. Options 1, 2, and 3 are inaccurate. A nonsteroidal anti-inflammatory drug, which has an analgesic effect, will relieve pain and allow the client to cough and deep-breathe more effectively. Options 1, 3, and 4 are incorrect. Benzonatate is a locally acting antitussive and its effectiveness is measured by the degree to which it decreases the intensity and frequency of cough without eliminating the cough reflex. Options 1, 2, and 3 are not effects of this medication. Pyrazinamide is an antitubercular medication given with other antitubercular medications. Pyrazinamide might not be discontinued if sputum cultures continue to be positive. Options 1, 2, and 4 are not related directly to the use of this medication. Salmeterol (Serevent) is an adrenergic type of bronchodilator and beclomethasone dipropionate is a glucocorticoid. Bronchodilators are always administered before glucocorticoids when both are to be given on the same time schedule. This allows for widening of the air passages by the bronchodilator, which then makes the glucocorticoid more effective. Theophylline is a xanthine bronchodilator. Before drawing of a serum level of the medication, the client should avoid taking foods or beverages that contain xanthine, such NCLEX– 182845269.doc

as colas, coffee, or chocolate. Thus, the client is told to avoid caffeine intake before the test. Antiviral medications for influenza must be taken exactly as prescribed. These medications do not prevent the spread of influenza and clients are usually contagious for up to 2 days after the initiation of antiviral medications. Secondary bacterial infections may occur despite antiviral treatment. Side effects occur with these medications and may necessitate change in activities, especially when driving or operating machinery if dizziness occurs. Theophylline (Theolair) is a methylxanthine bronchodilator. The nurse teaches the client to limit the intake of xanthine-containing foods while taking this medication. These foods include coffee, cola, and chocolate. Hypersensitivity reaction can occur in clients taking salmeterol. Signs and symptoms include rash, urticaria, and swelling of the face, lips, or eyelids. The nurse should call the physician immediately if any of these occur. The other options are incorrect. Omalizumab is an anti-inflammatory used for long-term control of asthma. Anaphylactic reactions can occur with the administration of omalizumab. The nurse administering the medication should have medications for the treatment of severe hypersensitivity available. Options 1, 2, and 3 are unnecessary. Guaifenesin (Humibid) is an expectorant and should be taken with a full glass of water to decrease the viscosity of secretions. Sustainedrelease preparations should not be broken open, crushed, or chewed. The Thursday, October 24, 2013

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medication occasionally may cause dizziness, headache, or drowsiness as side effects. The client should contact the physician if the cough lasts longer than 1 week or is accompanied by fever, rash, sore throat, or persistent headache. The nurse administering naloxone for suspected opioid overdose should have resuscitation equipment readily available to support naloxone therapy if it is needed. Other adjuncts that may be needed include oxygen, mechanical ventilator, and vasopressors. Diphenhydramine (Benadryl) has several uses, including antihistamine, antitussive, antidyskinetic, and sedative-hypnotic. Instructions for use include to take with food or milk to decrease gastrointestinal upset and to use oral rinses or sugarless gum or hard candy to minimize dry mouth. Because the medication causes drowsiness, the client should avoid use of alcohol or central nervous system depressants, operating a car, or engaging in other activities requiring mental awareness during use. The client is taught about side effects that could occur with the use of codeine sulfate. The most common side effects include drowsiness, confusion, hypotension, nausea and vomiting, and constipation. Others include bradycardia, respiratory depression, and urinary retention. Cromolyn sodium (Intal) is an inhaled nonsteroidal antiallergy agent and a mast cell stabilizer. The most common undesired side effects associated with inhalation therapy of cromolyn sodium are bronchospasm, cough, nasal congestion, throat irritation, and wheezing. Clients receiving this NCLEX– 182845269.doc

medication orally may experience pruritus, nausea, diarrhea, and myalgia. Terbutaline (Brethine) is a bronchodilator and is contraindicated in clients with hypersensitivity to sympathomimetics. It should be used with caution in clients with impaired cardiac function, diabetes mellitus, hypertension, or hyperthyroidism, and a history of seizures. The medication may increase blood glucose levels. Zafirlukast (Accolate) is a leukotriene receptor antagonist used in the prophylaxis and long-term treatment of bronchial asthma. Zafirlukast is used with caution in clients with impaired hepatic function. Liver function laboratory tests should be performed to obtain a baseline, and the levels should be monitored during administration of the medication. Isoniazid (INH) is an antitubercular medication. A common side effect of isoniazid is peripheral neuritis, manifested by numbness, tingling, and paresthesias in the extremities. This can be minimized with pyridoxine (vitamin B6) intake. Options 1, 3, and 4 are incorrect. Isoniazid (INH) is hepatotoxic, and therefore the client is taught to report signs and symptoms of hepatitis immediately, which include yellow skin and sclera. For the same reason, alcohol should be avoided during therapy. The client should avoid intake of Swiss cheese, fish such as tuna, and foods containing tyramine because they may cause a reaction characterized by redness and itching of the skin, flushing, sweating, tachycardia, headache, or lightheadedness. The client can avoid developing peripheral neuritis by increasing the intake of pyridoxine Thursday, October 24, 2013

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(vitamin B6) during the course of isoniazid therapy. Rifampin should be taken exactly as directed. Doses should not be doubled or skipped. The client should not stop therapy until directed to do so by a physician. The medication should be administered on an empty stomach unless it causes gastrointestinal upset, and then it may be taken with food. Antacids, if prescribed, should be taken at least 1 hour before the medication. Rifampin causes orangered discoloration of body secretions and will stain soft contact lenses permanently. Ethambutol causes optic neuritis, which decreases visual acuity and the ability to discriminate between the colors red and green. This poses a potential safety hazard when a client is driving a motor vehicle. The client is taught to report this symptom immediately. The client also is taught to take the medication with food if gastrointestinal upset occurs. Impaired hearing results from antitubercular therapy with streptomycin. Orange-red discoloration of secretions occurs with rifampin (Rifadin). Cycloserine (Seromycin) is an antitubercular medication that requires weekly serum drug level determinations to monitor for the potential of neurotoxicity. Serum drug levels lower than 30 mg/mL reduce the incidence of neurotoxicity. The medication needs to be taken after meals to prevent gastrointestinal irritation. The client needs to be instructed to notify the physician if a skin rash or early signs of central nervous system toxicity are noted. Alcohol needs to be avoided because it increases the risk of seizure activity.

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Isoniazid (INH) therapy can cause an elevation of hepatic enzyme levels and hepatitis. Therefore, liver enzyme levels are monitored when therapy is initiated and during the first 3 months of therapy. They may be monitored longer in the client who is older than 50 or abuses alcohol. The laboratory tests in options 1, 3, and 4 are not necessary. Albuterol is an adrenergic bronchodilator. The nurse assesses respiratory pattern, lung sounds, pulse, and blood pressure before and during therapy. The nurse also notes the color, character, and amount of sputum. The client taking adrenergic bronchodilators may experience paradoxical bronchospasm, which is evidenced by the client's wheezing. This can occur with excessive use of inhalers. Further medication should be withheld, and the physician should be notified. Options 1, 3, and 4 are incorrect interpretations. Rifabutin (Mycobutin) may be prescribed for a client with active Mycobacterium avium complex (MAC) disease and tuberculosis. It inhibits mycobacterial DNA-dependent RNA polymerase and suppresses protein synthesis. Side effects include rash, gastrointestinal disturbances, neutropenia (low neutrophil count), red-orange–colored body secretions, uveitis (blurred vision and eye pain), myositis, arthralgia, hepatitis, chest pain with dyspnea, and flu-like syndrome. Vitamin B6 deficiency and numbness and tingling in the extremities are associated with the use of isoniazid (INH). Ethambutol (Myambutol) also causes peripheral neuritis.

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Common laboratory ranges for activated partial thromboplastin time are 20 to 36 seconds. Because the activated partial thromboplastin time should be 1.5 to 2.5 times the normal value, the client's activated partial thromboplastin time would be considered therapeutic if it were 60 seconds. β-Blockers such as metoprolol slow conduction of impulses through the AV node and decrease the heart rate. In rapid atrial fibrillation, the goal first is to slow the ventricular rate and improve the cardiac output and then attempt to restore normal sinus rhythm. Spironolactone is a potassium-sparing diuretic and competes with aldosterone at receptor sites in the distal tubule, resulting in excretion of sodium, chloride, and water and retention of potassium and phosphate. Use of the medications noted in options 1, 2, and 4 could result in hypokalemia. Ecotrin is an aspirin-containing product and should be avoided. Excessive alcohol consumption should be avoided by a client taking warfarin sodium. Taking prescribed medication at the same time each day increases client compliance. The Medic-Alert bracelet provides health care personnel emergency information. Therapeutic levels for digoxin range from 0.5 to 2 mg/mL. Therefore, options 2, 3, and 4 are incorrect. Signs of toxicity from procainamide include confusion, dizziness, drowsiness, decreased urination, nausea, vomiting, and tachydysrhythmias. If the client complains of dizziness, the nurse should assess the vital signs first. NCLEX– 182845269.doc

Although options 2 and 3 may be interventions, these would be done after the vital signs are taken. Nitroglycerin is a vasodilator and will lower the blood pressure. Audible expiratory wheezes may indicate a serious adverse reaction, bronchospasm. β-blockers may induce this reaction, particularly in clients with chronic obstructive pulmonary disease or asthma. Normal decreases in blood pressure and heart rate are expected. Insomnia is a frequent mild side effect and should be monitored. Tea and coffee are stimulants and mild diuretics. These are a poor choice for hydration. Taking the medication at the same time each day improves compliance. Because furosemide is a diuretic, the morning is the best time to take the medication so as not to interrupt sleep. Notification of the health care provider is appropriate if edema is noticed in the hands, feet, or face or if the client is short of breath. Sitting up slowly prevents postural hypotension. The prothrombin time will assess for the therapeutic effect of warfarin sodium (Coumadin), and the activated partial thromboplastin time (aPTT) will assess the therapeutic effect of heparin. Hematocrit and hemoglobin values assess red blood cell concentrations. Baseline assessment, including an aPTT value, should be completed, as well as ongoing daily aPTT values while the client is taking heparin. Heparin doses are determined based on the result of the aPTT. To help prevent tolerance, clients need a 12-hour "no-nitrate" time, sometimes referred to as a pharmacological vacation away from

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the medication. Options 1, 3, and 4 are incorrect. This is a therapeutic, nonjudgmental response. The statement reflects the family's concern but remains nonjudgmental. Option 1 dismisses the family's concerns and disempowers the family. Option 3 creates doubt about the physician's practice without actually knowing the circumstances. Option 4 is argumentative and nontherapeutic. The client receiving dopamine therapy should be assessed for ineffective tissue perfusion related to peripheral vasoconstriction. Options 1, 2, and 4 are not related directly to this medication therapy. Thiazide diuretics such as hydrochlorothiazide are sulfa-based medications, and a client with a sulfa allergy is at risk for an allergic reaction. Also, clients are at risk for hypokalemia, hyperglycemia, hypercalcemia, hyperlipidemia, and hyperuricemia. Nicotinic acid, even an over-thecounter form, should be avoided because it may lead to liver abnormalities. All lipid-lowering medications also can cause liver abnormalities, so a combination of nicotinic acid and cholestyramine resin is to be avoided. Constipation and bloating are the two most common side effects. Walking and the reduction of fats in the diet are therapeutic measures to reduce cholesterol and triglyceride levels. Flushing is a side effect of this medication. Aspirin or a nonsteroidal anti-inflammatory drug can be taken 30 minutes prior to taking the medication to decrease flushing. Alcohol consumption needs to be NCLEX– 182845269.doc

avoided because it will enhance this side effect. The medication should be taken with meals but this will decrease gastrointestinal upset; taking the medication with meals has no effect on the flushing. Clay-colored stools are a sign of hepatic dysfunction and should be immediately reported to the physician. Flushing is a side effect of this medication. Aspirin or a nonsteroidal anti-inflammatory drug can be taken 30 minutes prior to taking the medication to decrease flushing. Alcohol consumption needs to be avoided because it will enhance this side effect. The medication should be taken with meals but this will decrease gastrointestinal upset; taking the medication with meals has no effect on the flushing. Clay-colored stools are a sign of hepatic dysfunction and should be immediately reported to the physician. Bumetanide (Bumex) is a diuretic. The paroxysmal nocturnal dyspnea may be due to increased venous return when the client is lying in bed, and the client needs diuresis. Propranolol is a β blocker, lidocaine is an antiarrhythmic, and streptokinase is a thrombolytic. Denial is the most common reaction when a client has a myocardial infarction or anginal pain. Options 2, 3, and 4 are incorrect. The nurse is responsible for administering the correct medication. When medication orders are vague, the nurse must call the physician to clarify the orders before administering the medication. Waiting for the physician to make rounds delays needed treatment. Double vision, loss of appetite, and nausea are early signs of digoxin Thursday, October 24, 2013

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toxicity. Additional signs of digoxin toxicity include bradycardia, difficulty reading, visual alterations such as green and yellow vision or seeing spots or halos, confusion, vomiting, diarrhea, decreased libido, and impotence. Clients on potassium-wasting diuretics are at high risk for hypokalemia. Clinical manifestations of hypokalemia include fatigue, anorexia, nausea, vomiting, muscle weakness, leg cramps, decreased bowel motility, paresthesias, and dysrhythmias. Most β blockers may be administered with food or on an empty stomach, but propranolol is absorbed best if taken with meals or directly after eating. Exercise will not prevent orthostatic hypotension. Hot showers and baths are not advised. The client needs to be instructed in how to take the pulse rate and to notify the physician if the heart rate falls below 60 beats/min. Enalapril (Vasotec) is an angiotensinconverting enzyme inhibitor. Angioedema is an adverse effect. Swelling of the tongue and lips can result in airway occlusion. Nausea, insomnia, and a cough can occur as side (not adverse) effects of the medication. Nesiritide is a recombinant version of human B-type natriuretic peptide, which vasodilates arteries and veins. It is used for the treatment of decompensated heart failure, increases renal glomerular filtration, and increases urine output. Options 2, 3, and 4 are incorrect. The usual guidelines for administering nitroglycerin tablets for chest pain include administering one tablet every 5 minutes PRN for chest pain, for a total dose of three tablets. If the client NCLEX– 182845269.doc

does not obtain relief after taking a third dose of nitroglycerin, the physician is notified. Because the client is still complaining of chest pain, the nurse would administer a second nitroglycerin tablet. The nurse would assess the client's pain level and check the client's blood pressure before administering each nitroglycerin dose. There are no data in the question that indicate the need to call a Code Blue. Additionally, it is not necessary to contact the client's family unless the client has requested this. Phosphate-binding agents that contain aluminum include Alu-Caps, Basaljel, and Amphojel. These products are made from aluminum hydroxide. Tums are made from calcium carbonate and also bind phosphorus. Tums are prescribed to avoid the occurrence of dementia related to high intake of aluminum. Phosphate-binding agents are needed by the client in renal failure because the kidneys cannot eliminate phosphorus. Trimethoprim (TMP)-sulfamethoxazole (SMX) (Bactrim) may be administered by intravenous infusion but should not be mixed with any other medications or solutions. Trimethoprimsulfamethoxazole is infused over 60 to 90 minutes, and bolus infusions or rapid infusions must be avoided. Nalidixic acid can intensify the effects of oral anticoagulants by displacing these agents from binding sites on plasma protein. When an oral anticoagulant is combined with nalidixic acid, a decrease in the anticoagulant dosage may be needed. Each dose of sulfisoxazole should be administered with a full glass of water, and the client should maintain a high fluid intake. The medication is more Thursday, October 24, 2013

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soluble in alkaline urine. The client should not be instructed to taper or discontinue the dose. Some forms of sulfisoxazole cause urine to turn dark brown or red. This does not indicate the need to notify the physician. Clients taking trimethoprim (TMP)sulfamethoxazole (SMZ) should be informed about early signs of blood disorders that can occur from this medication. These include sore throat, fever, and pallor, and the client should be instructed to notify the physician if these symptoms occur. The other options do not require physician notification. The nurse should instruct the client that a reddish-orange discoloration of urine may occur. The nurse also should instruct the client that this discoloration can stain fabric. The medication should be taken after meals to reduce the possibility of gastrointestinal upset. A headache is an occasional side effect of the medication and does not warrant discontinuation of the medication. Bethanechol chloride (Urecholine) can be hazardous to clients with urinary tract obstruction or weakness of the bladder wall. The medication has the ability to contract the bladder and thereby increase pressure within the urinary tract. Elevation of pressure within the urinary tract could rupture the bladder in clients with these conditions. Toxicity (overdose) produces manifestations of excessive muscarinic stimulation such as salivation, sweating, involuntary urination and defecation, bradycardia, and severe hypotension. Treatment includes supportive measures and the administration of atropine sulfate subcutaneously or intravenously. NCLEX– 182845269.doc

Toxicity (overdosage) of this medication produces central nervous system excitation, such as nervousness, restlessness, hallucinations, and irritability. Other signs of toxicity include hypotension or hypertension, confusion, tachycardia, flushed or red face, and signs of respiratory depression. Drowsiness is a frequent side effect of the medication but does not indicate overdosage. Propantheline bromide (Pro-Banthine) is contraindicated in clients with narrow-angle glaucoma, obstructive uropathy, gastrointestinal disease, or ulcerative colitis. The medication decreases bladder muscle spasms. Nephrotoxicity can occur from the use of cyclosporine (Sandimmune). Nephrotoxicity is evaluated by monitoring for elevated blood urea nitrogen and serum creatinine levels. Cyclosporine does not depress the bone marrow. A compound present in grapefruit juice inhibits metabolism of cyclosporine. As a result, consumption of grapefruit juice can raise cyclosporine levels by 50% to 100%, thereby greatly increasing the risk of toxicity. Amphotericin B deoxycholate, erythromycin, and ketoconazole can elevate cyclosporine levels. When any of these medications is combined with cyclosporine, the dosage of cyclosporine must be reduced to prevent accumulation to toxic levels. To improve palatability, the client should be taught to mix the concentrated medication solution with chocolate milk or orange juice just before administration. Grapefruit juice is avoided because it can raise cyclosporine levels. The client is Thursday, October 24, 2013

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instructed to dilute the concentrate in a glass (not Styrofoam) to ensure ingestion of the complete dose. The most common adverse effects of cyclosporine are nephrotoxicity, infection, hypertension, tremors, and hirsutism. Of these, nephrotoxicity and infection are the most serious. Tacrolimus (Prograf) is used with caution in immunosuppressed clients and in clients with renal, hepatic, or pancreatic function impairment. Tacrolimus is contraindicated in clients with hypersensitivity to this medication or hypersensitivity to cyclosporine. A blood glucose level of 200 mg/dL is significantly elevated above the normal range of 70 to 110 mg/dL and suggests an adverse reaction. Other adverse reactions include neurotoxicity evidenced by headache, tremor, and insomnia, gastrointestinal effects such as diarrhea, nausea, and vomiting, hypertension, and hyperkalemia. Mycophenolate mofetil (CellCept) should be administered on an empty stomach. The capsules should not be opened or crushed. The client should contact the physician if unusual bleeding or bruising, sore throat, mouth sores, abdominal pain, or fever occurs. Antacids containing magnesium and aluminum may decrease the absorption of the medication and therefore should not be taken with the medication. The medication is given with corticosteroids and cyclosporine. Epoetin alfa is used to reverse anemia associated with chronic renal failure. Therapeutic effect is seen when the hematocrit is between 30% and 33%.

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Options 2, 3, and 4 are not associated with the action of this medication. The client should be instructed not to shake the bottle. The medication should be refrigerated at all times. The medication should not be frozen. Syringes with a ⅝-inch needle are used for subcutaneous injection. A 1½inch needle may be used for intramuscular injection. Cinoxacin should be administered with caution in clients with renal impairment. The dosage should be reduced, and failure to do so could result in accumulation of cinoxacin to toxic levels. Therefore, the nurse would verify the prescription with the physician if the client had a documented history of renal insufficiency. The laboratory and diagnostic test results are normal findings. Folic acid (vitamin B6) may be prescribed for a client with renal insufficiency to prevent anemia. Myasthenia gravis often can be diagnosed based on clinical signs and symptoms. The diagnosis can be confirmed by injecting the client with a dose of edrophonium (Tensilon). This medication inhibits the breakdown of an enzyme in the neuromuscular junction, so more acetylcholine binds onto receptors. If the muscle is strengthened for 3 to 5 minutes after this injection, it confirms a diagnosis of myasthenia gravis. Another medication, neostigmine (Prostigmin) also may be used because the effect lasts for 1 to 2 hours, giving a better analysis. For either medication, atropine sulfate should be available as the antidote. An edrophonium injection makes the client in cholinergic crisis temporarily worse. This is known as a negative Tensilon test. Thursday, October 24, 2013

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Edrophonium is administered to determine whether the client is reacting to an overdose of a medication (cholinergic crisis) or an increasing severity of the disease (myasthenic crisis). When the edrophonium injection is given and the condition improves temporarily, the client is in myasthenic crisis. This is known as a positive Tensilon test. Dyskinesia and impaired voluntary movement may occur with high levodopa dosages. Nausea, anorexia, dizziness, orthostatic hypotension, bradycardia, and akinesia (the temporary muscle weakness that lasts 1 minute to 1 hour, also known as "onoff phenomenon") is a frequent side effect of the medication. The therapeutic serum drug level range for phenytoin is 10 to 20 mcg/mL. Intravenous infusion of phenytoin should be administered by injection into a large vein. The medication may be diluted in normal saline solution; however, dextrose solution should be avoided because of medication precipitation. The medication is administered as intermittent doses. Continuous intravenous infusions should not be used. Infusion rates of more than 50 mg/min may cause hypotension or cardiac dysrhythmias, especially in older and debilitated clients. Phenytoin enhances the rate of estrogen metabolism, which can decrease the effectiveness of some birth control pills. Options 1, 2, and 4 are inappropriate instructions. The antidote for acetaminophen is acetylcysteine (Mucomyst). The normal therapeutic serum level of acetaminophen is 10 to 20 mcg/mL. A NCLEX– 182845269.doc

toxic level is higher than 50 mcg/mL, and levels higher than 200 mcg/mL could indicate hepatotoxicity. Auranofin (Ridaura) is a gold preparation used to treat rheumatoid arthritis. Fludarabine (Fludara) and pentostatin (Nipent) are antineoplastic agents. In adults, overdose of acetaminophen causes liver damage. Option 3 is an indicator of liver function and is the only option that indicates an abnormal laboratory value. The normal direct bilirubin level is 0 to 0.3 mg/dL. The normal platelet count is 150,000 to 400,000/mm3. The normal prothrombin time is 10 to 13 seconds. The normal sodium level is 135 to 145 mEq/L. Edrophonium is a short-acting acetylcholinesterase inhibitor used as a diagnostic agent. When a client with suspected myasthenia gravis is given 2 mg of the medication intravenously, an increase in muscle strength should be seen in 30 to 60 seconds. If no response occurs, another 4 to 10 mg of edrophonium is given over the next 2 minutes, and muscle strength is tested again. If no increase in muscle strength occurs with this higher dose, the muscle weakness is not caused by myasthenia gravis. Clients receiving injections of this medication commonly demonstrate a drop in blood pressure, feel faint and dizzy, and are flushed. The therapeutic phenytoin level is 10 to 20 mcg/mL. At a level higher than 20 mcg/mL, involuntary movements of the eyeballs (nystagmus) appears. At a level higher than 30 mcg/mL, ataxia and slurred speech occur. Mannitol is an osmotic diuretic that induces diuresis by raising the osmotic pressure of glomerular filtrate, thereby Thursday, October 24, 2013

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inhibiting tubular reabsorption of water and solutes. Mannitol is used to reduce intracranial pressure in the client with head trauma. Mild intoxication with acetylsalicylic acid (aspirin) is called salicylism and is experienced commonly when the daily dosage is higher than 4 g. Tinnitus (ringing in the ears) is the most frequent effect noted with intoxication. Hyperventilation may occur because salicylate stimulates the respiratory center. Fever may result, because salicylate interferes with the metabolic pathways coupling oxygen consumption and heat production. Options 2, 3, and 4 are not associated specifically with toxicity. Adverse effects of carbamazepine appear as blood dyscrasias, including aplastic anemia, agranulocytosis, thrombocytopenia, leukopenia, cardiovascular disturbances, thrombophlebitis, dysrhythmias, and dermatological effects. Morphine sulfate suppresses the cough reflex. Clients need to be encouraged to cough and deepbreathe to prevent pneumonia. Options 1, 2, and 3 are not associated specifically with the use of this medication. Side effects of meperidine (Demerol) include respiratory depression, orthostatic hypotension, tachycardia, drowsiness and mental clouding, constipation, and urinary retention. While the client is taking codeine sulfate, the nurse would monitor vital signs and assess for hypotension. The nurse also should increase fluid intake, palpate the bladder for urinary retention, auscultate bowel sounds, and monitor the pattern of daily bowel activity and stool consistency. The NCLEX– 182845269.doc

nurse should monitor respiratory status and initiate deep-breathing and coughing exercises. Additionally, the nurse monitors the effectiveness of the pain medication. Meperidine hydrochloride is an opioid analgesic. Side effects include respiratory depression, drowsiness, hypotension, constipation, urinary retention, nausea, vomiting, and tremors. Infection and pancytopenia are side effects of etanercept (Enbrel). Laboratory studies are performed prior to and during drug treatment. The appearance of abnormal white blood cell counts and abnormal platelet counts can alert the nurse to a potentially life-threatening infection. Injection site itching and edema are common occurrences following administration. A metallic taste and loss of appetite are not common signs of side effects of this medication. Clients taking allopurinol are encouraged to drink 3000 mL of fluid a day. A full therapeutic effect may take 1 week or longer. Allopurinol is to be given with, or immediately after, meals or milk. A client who develops a rash, irritation of the eyes, or swelling of the lips or mouth should contact the physician because this may indicate hypersensitivity. Colchicine is contraindicated in clients with severe gastrointestinal, renal, hepatic, or cardiac disorders and in clients with blood dyscrasias. Clients with impaired renal function may exhibit myopathy and neuropathy manifested as generalized weakness. This medication should be used with caution in clients with impaired hepatic function, the older client, and the debilitated client.

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Precautions need to be taken with the administration of alendronate to prevent gastrointestinal side effects (especially esophageal irritation) and to increase absorption of the medication. The medication needs to be taken with a full glass of water after rising in the morning. The client should not eat or drink anything for 30 minutes following administration and should not lie down after taking the medication. Baclofen is a skeletal muscle relaxant and acts at the spinal cord level to decrease the frequency and amplitude of muscle spasms in clients with spinal cord injuries or debilitating diseases such as multiple sclerosis. Options 1, 3, and 4 are not associated effects of this medication. Baclofen is a skeletal muscle relaxant and frequently causes drowsiness, dizziness, weakness, and fatigue. Baclofen also can cause nausea, constipation, and urinary retention. Clients should be warned about the possible reactions. Options 1, 2, and 4 are not side effects. Coal tar is used to treat psoriasis and other chronic disorders of the skin. It suppresses DNA synthesis, mitotic activity, and cell proliferation. It has an unpleasant odor, frequently can stain the skin and hair, and can cause phototoxicity. It does not cause diarrhea. The client should be instructed that symptoms such as drowsiness, weakness, and fatigue are more intense in the early phase of therapy and diminish with continued medication use. The client should be instructed never to withdraw abruptly or stop the medication because abrupt withdrawal can cause visual hallucinations, paranoid ideation, and NCLEX– 182845269.doc

seizures. The nurse should inform the client that these symptoms will subside and encourage the client that continuing the use of the medication is the best option. Dose-related liver damage is the most serious adverse effect of dantrolene. To reduce the risk of liver damage, tests of liver function should be performed before treatment and throughout the treatment interval. Dantrolene is administered in the lowest effective dosage for the shortest time necessary. Clients with seizure disorders may have a lowered seizure threshold when baclofen is administered. Concurrent therapy may require an increase in the anticonvulsive medication. The disorders in options 2, 3, and 4 are not contraindications or cautions for the use of this medication. Because cyclobenzaprine (Flexeril) has anticholinergic effects, it should be used with caution in clients with a history of urinary retention, glaucoma, and increased intraocular pressure. Cyclobenzaprine should be used only for a short term (2 to 3 weeks). The client needs to be told that the urine may turn brown, black, or green. Other adverse effects include blurred vision, nasal congestion, urticaria, and rash. The client needs to be instructed that if these adverse effects occur to notify the physician.

Intravenous administration of methocarbamol can cause hypotension and bradycardia. The nurse needs to monitor for these side effects. Options 1, 2, and 4 are not a concern with administration of this medication. Thursday, October 24, 2013

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Allopurinol is an antigout medication that decreases uric acid production. Foods high in purine need to be avoided. Kidney stones can occur as a complication of gout and can be decreased by increasing fluids and limiting calcium intake. Gastrointestinal upset is common with this medication and can be minimized when taken with food. Unprotected exposure to ultraviolet light and sunlight can result in visual changes and should be avoided. Alcohol and vitamin C can increase uric acid levels and need to be avoided. Because emotional stress frequently exacerbates the symptoms of rheumatoid arthritis, the absence of symptoms is a positive finding. DMARDs are given to slow progression of joint degeneration. In addition, the improvement in the range of motion after 3 months of therapy with normal blood work is a positive finding. Temperature elevation and inflammation and irritation at the medication injection site could indicate signs of infection. The most common side effects related to this medication include central nervous system and gastrointestinal system dysfunction. Fluoxetine (Prozac) affects the gastrointestinal system by causing nausea and vomiting, cramping, and diarrhea. Excessive sweating, dry mouth, and cardiovascular symptoms are not side effects associated with this medication. Buspirone (BuSpar) is not recommended for the treatment of drug or alcohol withdrawal, thought disorders, or schizophrenia. Buspirone hydrochloride most often is indicated for the treatment of anxiety.

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Maintenance serum levels of lithium are 0.6 to 1.2 mEq/L. Symptoms of toxicity begin to appear at levels of 1.5 to 2 mEq/L. Lithium toxicity requires immediate medical attention with lavage and possible peritoneal dialysis or hemodialysis. Chloral hydrate (Somnote) is a sedative. This medication does not affect cardiac function. Blood pressure changes are not significant with the use of this medication. The client should call for assistance to the bathroom at night. Additionally, the client may experience residual daytime sedation; therefore, the nurse also should instruct the client to call for ambulation assistance during the daytime hours. Clomipramine (Anafranil) is a tricyclic antidepressant used to treat obsessive-compulsive disorder. Weight gain and tachycardia are side effects of this medication. Sedation sometimes occurs and insomnia is a seldom side effect. Amitriptyline hydrochloride is a tricyclic antidepressant. Depressed individuals sleep for extended periods, have a change in appetite, are unable to go to work, and have difficulty concentrating. They also may experience increased fatigue, feelings of guilt or worthlessness, loss of interest in activities, and possible suicidal tendencies. Once they have had some therapeutic effect from their medication, they will report resolution of many of these complaints and demonstrate an improvement in their appearance. Haloperidol (Haldol) is an antipsychotic used to manage psychotic disorder. Hallucinations, delusions, and altered thought processes are characteristics of a Thursday, October 24, 2013

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psychotic disorder and should decrease with effective treatment. Fixed stare (option 1) and dry mouth (option 4) are side effects of therapy. Option 3 is unrelated to this medication. The nurse monitors for signs of toxicity. Seizure activity is common in bupropion dosages higher than 450 mg daily. This medication does not cause significant orthostatic blood pressure changes. Weight gain is an occasional side effect, whereas constipation is a common side effect of this medication. The abrupt withdrawal of alprazolam (Xanax) could result in seizure activity from rebound central nervous system excitation. All clients receiving this medication should be warned of this danger. The other options are incorrect. Sertraline hydrochloride (Zoloft) is classified as an antidepressant. Sertraline generally is administered once every 24 hours. It may be administered in the morning or evening, but evening administration may be preferable, because drowsiness is a side effect. The medication may be administered without food or with food if gastrointestinal distress occurs. Sertraline is not ordered for use as needed. The client taking clozapine (Clozaril) may experience agranulocytosis, which is monitored by reviewing the results of the white blood cell count. Treatment is interrupted if the white blood cell count drops below 3000/mm3. Agranulocytosis could be fatal if undetected and untreated. The other options are not related specifically to the use of this medication. NCLEX– 182845269.doc

Phenobarbital (Luminal) is an anticonvulsant and hypnotic agent. The client should avoid taking any other central nervous system depressants such as alcohol while taking this medication. The medication may be given without regard to meals. Taking the medication at the same time each day enhances compliance and maintains more stable blood levels of the medication. Using a dose container or "pillbox" may be helpful for some clients. Chlorpromazine hydrochloride (Thorazine) is an antipsychotic medication. A side effect of this medication is that the color of urine may darken. The client should be aware that this effect is harmless. The other options are incorrect. Dry mouth is a common side effect. Frequent mouth rinsing with water, sucking on hard candy, and chewing sugarless gum will alleviate this common side effect. Hypotension and hypertension are rare side effects of fluphenazine (Prolixin). Mild leukopenia may occur, but the temperature does not need to be taken daily. Weight gain is a common side effect, and frequent snacks will worsen the problem. Oxazepam (Serax) causes constipation, and the client is instructed to increase fluid intake and bulk (high fiber) in the diet. If the heart begins to beat fast, the physician is notified, because this could indicate overdose. Additionally, diarrhea could indicate an incomplete intestinal obstruction and, if this occurs, the physician is notified. Risperidone (Risperdal) can cause orthostatic hypotension. Sunlight should be avoided by the client taking this medication. Food interaction is not Thursday, October 24, 2013

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a concern. With any psychotropic medication, caution needs to be taken until the individual can determine whether his or her level of alertness is affected. The therapeutic serum level of lithium is 0.6 to 1.2 mEq/L. A serum lithium level of 1.8 mEq/L indicates moderate toxicity. Serum lithium concentrations of 1.5 to 2.5 mEq/L may produce vomiting, diarrhea, ataxia, incoordination, muscle twitching, and slurred speech. The maximum therapeutic effects of imipramine hydrochloride (Tofranil) may not occur for 2 to 3 weeks after the antidepressant therapy has been initiated. Therefore, options 1, 3, and 4 are incorrect. Depressed individuals will sleep for long periods, are not able to go to work, and feel as if they cannot "do anything." Once they have had some therapeutic effect from their medication, they will report resolution of many of these complaints and demonstrate an improvement in their appearance. Benztropine (Cogentin) is an anticholinergic medication used to treat drug-induced extrapyramidal reactions, except tardive dyskinesia. Options 1, 3, and 4 are antipsychotic medications. Antipsychotic medications can cause extrapyramidal reactions. Tardive dyskinesia is an adverse reaction that can occur from antipsychotic medication. It is characterized by uncontrollable involuntary movements of the body and extremities, particularly the tongue. Torticollis refers to an extrapyramidal side effect involving the upper body. Hypertensive crisis NCLEX– 182845269.doc

can occur from the use of monoamine oxidase inhibitors and is characterized by hypertension, occipital headache radiating frontally, neck stiffness and soreness, nausea, and vomiting. Neuroleptic malignant syndrome is a potentially fatal syndrome that may occur at any time during therapy with neuroleptic (antipsychotic) medications. It is characterized by dyspnea or tachypnea, tachycardia or irregular pulse rate, fever, blood pressure changes, increased sweating, loss of bladder control, and skeletal muscle rigidity. Phenelzine sulfate (Nardil) is a monoamine oxidase inhibitor. The client should avoid taking in foods that are high in tyramine. Use of these foods could trigger a potentially fatal hypertensive crisis. Foods to avoid include yogurt, aged cheeses, smoked or processed meats, red wines, and fruits such as avocados, raisins, or figs. An adverse effect of PTU is agranulocytosis. The client needs to be informed of the early signs of this adverse effect, which include fever and sore throat. Drowsiness is an occasional side effect of the medication. Increased urination and dry mouth are unrelated to this medication. Iodine solution can cause iodine toxicity. Iodine is corrosive and an overdose will injure the gastrointestinal tract. Symptoms include abdominal pain, vomiting, and diarrhea. Swelling of the glottis may result in asphyxiation. Treatment consists of gastric lavage to remove iodine from the stomach and administration of sodium thiosulfate to reduce iodine to iodide. Calcium gluconate is used for acute hypocalcemia. Mucomyst is the Thursday, October 24, 2013

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antidote for acetaminophen (Tylenol) overdose. Vitamin K is the antidote for warfarin (Coumadin). Octreotide (Sandostatin) is used to reduce growth hormone levels in clients with acromegaly. The most common side effects of octreotide include diarrhea, nausea, gallstone formation, and abdominal discomfort. Hypertension, although rare, may occur. Polyuria is not associated with this medication. Levothyroxine (Synthroid) accelerates the degradation of vitamin Kdependent clotting factors. As a result, the effects of warfarin (Coumadin) are enhanced. Therefore, if thyroid hormone replacement therapy is instituted in a client who has been taking warfarin, the dosage of warfarin should be reduced. To prevent acute adrenal insufficiency, glucocorticoids should not be abruptly discontinued. These medications can cause sodium and water retention and the loss of potassium, and clients should be instructed to limit sodium intake and consume potassium-rich foods. Additionally, adequate dietary intake is important. These medications can increase the risk of infection and the client should avoid contact with persons who are ill. NPH insulin is an intermediate-acting insulin. Its onset of action is 3 to 4 hours, it peaks in 4 to 12 hours, and its duration of action is 16 to 20 hours. An insulin vial in current use can be kept at room temperature for up to 1 month without significant loss of activity. Direct sunlight and heat must be avoided. Santyl is used to promote débridement of dermal lesions and severe burns. It is applied once daily NCLEX– 182845269.doc

and covered with a sterile dressing. Options 1, 3, and 4 are incorrect. Somatotropin (Humatrope) should not be administered during or after epiphyseal closure. Efficacy of therapy declines as the client grows older and is usually lost entirely by age 20 to 24 years. Hyperglycemia can occur from the administration of growth hormone, particularly in a client with diabetes mellitus. Growth hormone therapy is associated with a decline in thyroid function. Hypercalciuria can occur, particularly during the first 2 to 3 months of therapy. Glucose and thyroid hormone levels should be monitored. Lindane can penetrate the intact skin and can cause seizures if absorbed in sufficient quantities. Clients at highest risk for seizures are premature infants, children, and those with preexisting seizure disorders. Lindane should not be used on pediatric clients unless safer medications have failed to control infection. Hydrocolloid gel (DuoDerm) contains hydroactive particles embedded in a polymer base, which are softened by wound moisture and act as a protective gel over healing tissue. It is applied directly to the wound and can be left in place for up to 7 days. Lypressin is an antidiuretic hormone used in the treatment of diabetes insipidus. It promotes renal conservation of water by acting on the collecting ducts of the kidney to increase the permeability to water, which results in increased water reabsorption. Options 1, 3, and 4 are not actions of the medication. Somatrem is a growth hormone used in the treatment of dwarfism. When Thursday, October 24, 2013

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treatment is started, height may be increased by as much as 6 inches. To monitor treatment, height and weight should be measured monthly. Options 1, 2, and 4 are incorrect. The effect of lispro insulin begins within 10 minutes of subcutaneous injection, peaks in 1 hour, and has a duration of action of 3 hours. Lispro insulin acts more rapidly than Regular insulin and has a shorter duration of action. Because of its rapid onset, it can be administered immediately before eating. In contrast, Regular insulin is generally administered 30 to 60 minutes before meals. Because Regular insulin forms a true solution and is safe for IV use. It is the only type of insulin that can be administered by the IV route. The most common side effect of metformin (Glucophage) is GI disturbances, including decreased appetite, nausea, and diarrhea. These generally subside over time. This medication does not cause weight gain; in fact, clients lose an average of 7 to 8 lb because the medication causes nausea and decreased appetite. Although hypoglycemia can occur, it is not the most common side effect. Sulfonylureas promote insulin secretion by the pancreas and may also increase tissue response to insulin. Biguanides decrease glucose production by the liver. α-Glucosidase inhibitors inhibit carbohydrate digestion. Thiazolidinediones decrease insulin resistance. When the client with diabetes mellitus becomes ill, control is more difficult. Insulin is not omitted and the client is encouraged to consume liquid carbohydrates if unable to eat regular NCLEX– 182845269.doc

meals. The client is instructed to notify the physician if vomiting or diarrhea occurs, or if the illness progresses past 2 days. Fludrocortisone acetate (Florinef Acetate) has mineralocorticoid activity and also has a modest glucocorticoid effect. It acts primarily on the kidneys distal tubules, enhancing the resorption of sodium and chloride ions and the excretion of potassium and hydrogen ions. It promotes water retention. Laboratory determinations of serum thyroid stimulating hormone (TSH) level are an important means of evaluation. Successful therapy will cause elevated TSH levels to fall. These levels will begin their decline within hours of the onset of therapy and will continue to drop as plasma levels of thyroid hormone build up. If an adequate dosage is administered, TSH levels will remain suppressed for the duration of therapy. Levothyroxine (Synthroid) is used in the treatment of hypothyroidism. Although therapy with levothyroxine may begin with small doses that are gradually increased, the most appropriate response is to inform the client that the full therapeutic effect may take 1 to 3 weeks. For most hypothyroid clients, replacement therapy must be continued for life. Treatment provides symptomatic relief but does not produce a cure. The client should be told that although therapy will cause symptoms to improve, these improvements do not constitute a reason to interrupt or discontinue the medication. Options 2 and 3 are incorrect. Option 1 places the client's question on hold.

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Isoproterenol is an adrenergic bronchodilator. Side effects can include tachycardia, hypertension, chest pain, dysrhythmias, nervousness, restlessness, and headache. The nurse monitors for these effects during therapy. Cinoxacin should be administered with caution in clients with renal impairment. The dosage should be reduced, and failure to do so could result in accumulation of cinoxacin to toxic levels. It is not contraindicated to the disorders identified in options 1, 3, and 4. Administration of bethanechol (Urecholine) with food can cause nausea and vomiting in the client. To avoid this problem, oral doses should be administered 1 hour before meals or 2 hours after meals. Methenamine (Mandelamine) is contraindicated in clients with renal or hepatic disease or clients with severe dehydration. The nurse would question the physician's prescription for this medication in the client with cirrhosis of the liver. Options 2, 3, and 4 are not contraindicated with this medication. Nalidixic acid (NegGram) is used for acute and chronic urinary tract infections, especially gram-negative bacterial infections. The medication is contraindicated in clients with a history of seizures. It is used with caution in clients with liver or renal disorders. It is not contraindicated in the disorders in options 1, 3, or 4. The client needs to be instructed to dispense the oral liquid into a glass container using a specially calibrated pipette. The client should not use any other type of dropper to calibrate the amount of prescribed medication. Options 1, 2, and 4 are correct. NCLEX– 182845269.doc

Hydrocodone is an opioid analgesic that also has antitussive properties. Side effects of this medication include physical and psychological dependence, bradycardia and hypotension, respiratory depression, nausea, vomiting, constipation, sedation, and confusion. Cromolyn sodium (Intal) is an antiasthmatic, antiallergic, and mast cell stabilizer that inhibits the release of mediators from mast cells after exposure to an antigen. It can also interrupt the migration of eosinophils into the inflammatory site and decrease the number of eosinophils. These actions decrease airway hyperresponsiveness in some clients with asthma. It has no bronchodilating action. Because acetylcysteine has a pervasive flavor of rotten eggs, it must be disguised in a flavored ice drink and is preferably drunk through a straw to minimize contact with the mouth. Acetylcysteine is the antidote for acetaminophen. It is a solution that is also used as a mucolytic agent, administered via nebulization. It is not administered by the IV, IM, or subcutaneous route. Side effects of baclofen include drowsiness, dizziness, weakness, and nausea. Occasional side effects include headache, paresthesias of the hands and feet, constipation or diarrhea, anorexia, hypotension, confusion, and nasal congestion. Paradoxical central nervous system excitement and restlessness can occur, along with slurred speech, tremor, dry mouth, nocturia, and impotence. The TENS unit is portable and the client controls the system for relieving pain and reducing the need for Thursday, October 24, 2013

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analgesics. It is attached to the skin of the body by electrodes. Hospitalization is not required. Cinoxacin (Cinobac) is a urinary antiseptic and is administered with meals to decrease gastrointestinal side effects. The normal dosage is 1 g/day administered in two to four divided doses for a period of 7 to 14 days. Nitrofurazone (Furacin) is applied topically to the burn and has a broad spectrum of antibiotic activity. It is used for burns in which bacterial resistance to other agents is a real or potential problem. A {1/16}-inch film is applied directly to the burn. Salinesoaked dressings are not used. The normal serum calcium level is 8.6 to 10.0 mg/dL. This client is experiencing hypercalcemia. Calcium gluconate and calcium chloride are medications used for the treatment of tetany that occurs from acute hypocalcemia. In hypercalcemia, large doses of vitamin D need to be avoided. Calcitonin, a thyroid hormone, decreases the plasma calcium level by increasing the incorporation of calcium into the bones, thus keeping it out of the serum. Sodium polystyrene sulfonate (Kayexalate) is a cation exchange resin used for the treatment of hyperkalemia. The resin passes through the intestine or is retained in the colon. It releases sodium ions primarily in exchange for potassium ions. The therapeutic effect occurs 2 to 12 hours after oral administration and longer after rectal administration. When carbamazepine (Tegretol) is administered, blood levels need to be tested periodically to check for the NCLEX– 182845269.doc

child's absorption of the medication. The amount of the medication prescribed is based on the blood level achieved. Carbamazepine's therapeutic serum range is 3 to 14 mcg/mL. The nurse would anticipate that the physician would continue the presently prescribed dosage. Glucagon is used to treat hypoglycemia resulting from insulin overdose. The family of the client is instructed in how to administer the medication. In an unconscious client, arousal usually occurs within 20 minutes of glucagon injection. Once consciousness has been regained, oral carbohydrates should be given. Lipoatrophy and lipohypertrophy result from insulin injections. Corticosteroid therapy can cause calcium and potassium depletion, sodium retention, and glucose intolerance. The client should be monitored for hyperglycemia. Clients should be encouraged to have an intake of potassium-rich and calciumrich foods. Also, an increase in potassium and a decrease in sodium are recommended to prevent potassium depletion and sodium retention while taking the corticosteroid. Although increased fluids are important for the client with emphysema to maintain thin respiratory secretions, this action is not specific to the use of corticosteroids. Crystals form in a mannitol solution if the solution is cooled but will quickly dissolve if the container is placed in warm water, then cooled to body temperature before administration. Shaking the vial should not be done and will not dissolve the crystals. The medication is not returned to the pharmacy because it is not defective. Thursday, October 24, 2013

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The nurse would not discard the medication. Ototoxicity can occur as a result of the administration of aspirin. Signs and symptoms of tinnitus, hearing loss, dizziness, and ataxia reflects damage to the eighth cranial nerve, the organ of hearing and balance. Purpura and ecchymosis are caused by prolonged bleeding, but not ototoxicity. GI bleeding and upset may be caused by acetylsalicylic acid (aspirin) irritation but are not symptoms of ototoxicity. BenGay is one of many products that are used for the temporary relief of muscular aches, rheumatism, arthritis, sprains, and neuralgia. These types of products contain combinations of analgesics, menthol, local antiseptics, and counterirritants. Heat or a heating pad should never be applied because irritation or burning of the skin could occur. The medication does not act in a systemic manner, nor does the medication produce drowsiness. Lindane can penetrate intact skin and can cause convulsions if absorbed in sufficient quantities. A client with a preexisting seizure disorder is at high risk for convulsions. Other clients at high risk for convulsions include premature infants and children. Lindane should not be used on pediatric clients unless safer medications have failed to control the infection. Options 1, 2, and 3 do not identify contraindications related to the use of this medication. Fomepizole is a medication that is used to treat known or suspected ethylene glycol (antifreeze) intoxication. It is administered via the IV route. Options 1, 2, and 3 are incorrect.

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Fomepizole is used for the treatment of known or suspected ethylene glycol (antifreeze) intoxication. It is administered via the IV route, is not administered undiluted, and is not administered by rapid IV infusion. It is diluted in at least 100 mL of 0.9% normal saline or 5% dextrose in water and administered over a 30-minute period. Fomepizole is used in the treatment of known or suspected ethylene glycol (antifreeze) intoxication. It is administered via the intravenous (IV) route. It is not administered undiluted and is not administered by rapid IV infusion. It is diluted in at least 100 mL of 0.9% normal saline or 5% dextrose in water and administered over a 30minute period. If the medication solidifies in the vial, the nurse should run the vial under warm water. Options 1 and 2 are inappropriate actions and option 3 is unnecessary. Irbesartan (Avapro) is an angiotensin II type 1 (AT1) receptor antagonist. It is used to treat hypertension. This medication is not used to treat renal transplant rejection, diabetes mellitus, or hypothyroidism. Letrozole is used in the palliative treatment for advanced breast cancer in the postmenopausal woman with disease progression after treatment with antiestrogen therapy. Options 1, 3, and 4 are incorrect. Ropinirole hydrochloride is a medication that is used to treat idiopathic parkinsonian syndrome. It normally is administered three times a day to treat the client. This medication is not used to treat diabetes mellitus, coronary artery disease, or depression.

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Tamsulosin hydrochloride is used to relieve mild-to-moderate manifestations that occur in benign prostatic hypertrophy. The medication also improves urinary flow rates. Options 1, 3, and 4 are incorrect. Tamsulosin hydrochloride is a medication that will relieve mild to moderate manifestations of BPH and improve urinary flow rates. The medication should be administered 30 minutes after meals because food decreases the peak plasma concentration and lengthens the time to achieve peak plasma medication concentrations. Options 1, 2, and 3 are incorrect. Bladder spasm following prostatectomy is treated with antispasmodic medications, such as B&O suppository or propantheline bromide (ProBanthine). Opioid analgesics such as meperidine hydrochloride, morphine sulfate, and hydromorphone usually are not effective in treating pain caused by spasm. Epoetin alfa is erythropoietin that has been manufactured through the use of recombinant DNA technology. It is used to treat anemia in the client with chronic renal failure. The medication may be administered subcutaneously or intravenously. Methyldopa is metabolized by the kidneys and requires careful dosage adjustment according to the client's renal function to prevent hypotension. Epoetin alfa is an erythropoietin and is more likely to cause hypertension. Levothyroxine does not cause hypotension. Calcium carbonate is used in the treatment of calcium deficiency and does not cause hypotension when administered via the oral route. Parenteral NCLEX– 182845269.doc

administration of calcium may cause hypotension. A subcutaneous injection of enoxaprin is performed using the same technique as for a heparin injection. The client should use a 25- to 27gauge, 5/8-inch needle to prevent hematoma formation at the injection site. The client should be taught to bunch the skin, rather than placing it flat. The client should not aspirate before injecting the medication and should not massage the area after injection. Isotretinoin is used to inhibit inflammation in the client with severe cystic acne. Adverse effects include elevated triglycerides, skin dryness, and eye discomfort such as dryness and burning. Lip inflammation called cheilitis also can occur. Vitamin A supplements are stopped during this treatment because of their additive effects. An anticoagulant suppresses coagulation by inhibiting clotting factors. A client admitted for elective surgery should have been instructed to discontinue the anticoagulant 7 to 10 days preoperatively. Even if this were unscheduled surgery, the nurse should notify the physician. Vitamin K can be given for reversal of its action, but the client may still have an increased risk of bleeding. The other medications listed are commonly taken and do not constitute an increased risk for the client. Thrombolytics such as streptokinase (Streptase) are most effective when started within 4 to 6 hours of symptom onset. Streptokinase (Streptase) acts to dissolve or lyse existing thrombi that are causing a blockage. Options 2, 3, and 4 are incorrect.

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Clients receiving heparin are at risk for bleeding. An electric razor rather than a straight blade razor is used for shaving. Options 1 and 3 are inappropriate and unnecessary nursing actions. It is not necessary to monitor laboratory values every 4 hours when the client is taking subcutaneous heparin. Additionally, the PT is monitored when the client is taking warfarin (Coumadin). Warfarin (Coumadin) is an anticoagulant, which is used as longterm prophylaxis of thrombosis. Clients must receive detailed instructions regarding the signs of bleeding. Hematuria is a sign of bleeding, which the client should report. Bruising is a common side effect associated with anticoagulant therapy and is almost unavoidable. The client, however, should not stop the medication if bruising occurs. Option 2 is unrelated to the use of warfarin, and option 3 is not completely accurate regarding prevention of a stroke. Generally, a healthy diet provides adequate sources of iron. Because of the expansion of maternal blood volume and the production of fetal red blood cells, iron requirements increase in pregnancy. Hemoglobin measures the amount of oxygen in the blood. Ferrous sulfate is a common iron supplement given to pregnant women to prevent anemia. Prothrombin time, bleeding time, and clotting time are tests performed for clients with bleeding disorders. Enoxaparin (Lovenox) is a lowmolecular-weight heparin that can be administered without the usual activated partial thromboplastin time (aPTT) testing that is required with the use of heparin. Option 2 places the NCLEX– 182845269.doc

client's feelings on hold. Options 3 and 4 devalue the client's feelings. Warfarin (Coumadin) is an oral anticoagulant. The effects of warfarin (Coumadin) overdose can be reversed with phytonadione (vitamin K). Vitamin K is an antagonist to the action of warfarin that can reverse warfarin-induced inhibition of clotting factor synthesis. For mild bleeding, vitamin K should be administered orally; a dose of 10 to 20 mg will cause prothrombin levels to normalize within 24 hours. If bleeding is severe, parenteral vitamin K is indicated. Protamine sulfate is the antidote for heparin sulfate. Heparin sulfate is an anticoagulant and would cause increased bleeding. The question presents no data indicating that potassium supplements are indicated. Aspirin is an antiplatelet and affects the platelet for its life, which is 7 to 10 days. For an elective procedure such as dental surgery, aspirin therapy should be stopped approximately 10 days before the procedure to prevent bleeding complications. Options 2 and 3 are incorrect. Option 4 is not an appropriate response and places the client's issue on hold. It is most important that pregnant clients receive iron supplements because of the extra demands placed on maternal circulation by the fetus. Although option 1 may be true, it is not the appropriate response considering the options presented. Option 3 is an inappropriate and incorrect response because the iron does not have to be discontinued. Option 2 is unnecessary at this time. Liquid iron preparations will stain the teeth. The best advice for the client who needs liquid iron is to dilute the iron in juice or water, drink it through Thursday, October 24, 2013

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a straw, and rinse the mouth well after taking. Brushing before taking the liquid iron would not be of any benefit. The nurse would not instruct a client to take more than the prescribed amount. Ticlopidine (Ticlid) is an antiplatelet that is used for the prevention of thrombotic stroke. Ticlopidine's effects last for the life of the platelet, 7 to 10 days. Ticlopidine also can cause neutropenia, which is an abnormally small number of mature white blood cell (WBCs). Baseline data from a CBC are necessary before implementation of therapy, and the nurse should monitor for neutropenia during this medication therapy. If this adverse effect does occur, therapy should be ceased. The effects of neutropenia are reversible within 1 to 3 weeks. Options 1, 2, and 4 are actions that are not specific to this medication therapy. Ticlopidine is an antiplatelet that is used to assist in preventing a thrombotic stroke. Ticlopidine is best tolerated when taken with meals. The most common adverse effects are GI disturbances. Taking ticlopidine with meals tends to lessen those effects. It is not necessary to contact the physician if GI upset occurs. The medication is used to prevent strokes but does not guarantee that a stroke will not occur. The client should not skip medications. Cyanocobalamin is essential for DNA synthesis. It can take up to 3 years for the vitamin B12 stores to be depleted and for symptoms of pernicious anemia to appear. Symptoms can include weakness, fatigue, anorexia, loss of taste, and diarrhea. To correct deficiencies, a crystalline form of vitamin B12, cyanocobalamin, can be given intramuscularly. The client statements in options 1, 2, and 4 do NCLEX– 182845269.doc

not identify a therapeutic effect of the medication. Option 3 is correct because it validates the issue that the client has with income. The nurse offers help in a nonthreatening manner that will allow the client to accept or decline. Option 1 is incorrect because the client needs to consume a proper diet. Options 2 and 4 block the communication process and are nontherapeutic and nonhelpful statements. Heparin is an anticoagulant that increases the risk of bleeding. Prolonged pressure over the site of an intramuscular injection will ensure that the chances of having an increase of bleeding into the tissue are lessened. It is not necessary to apply a pressure dressing to the IM site of injection. A 5/8-inch needle is not an appropriatesize needle for an IM injection. The heparin infusion is not decreased before an injection and the rate is not adjusted unless specifically prescribed by a physician. Ticlopidine is an antiplatelet that is used for the prevention of thrombotic stroke. Ticlopidine is best tolerated when taken with meals. Blood work is monitored closely, particularly in early therapy, because the medication can cause neutropenia. A client should not stop medication without the physician's permission. Calculate the dosage by dividing the amount ordered by the amount on hand. The physician ordered 6,000 units of heparin; therefore, divide 6,000 units by 10,000 units = 0.6. Then multiply 0.6 × 1 mL = 0.6 mL. Neutropenia or agranulocytosis is the most serious adverse effect associated with the use of ticlopidine. A baseline complete blood cell count with Thursday, October 24, 2013

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differential will be performed for the client. Neutropenia occurs most often within the first 3 months of therapy; therefore, a complete blood cell count with differential is recommended every 2 weeks during the first 3 months. If a diagnosis of neutropenia is determined, then the client will be withdrawn from therapy. This medication is used to prevent a stroke and is not contraindicated in hypertension. GI disturbances can occur as a result of taking the medication, and the client is instructed to take the medication with food to minimize these side effects. Drowsiness is a common side effect of phenobarbital. Blurred vision is not an associated side effect of this medication. Seizure activity could occur from abrupt withdrawal of this medication therapy, or as a toxic reaction. Hypocalcemia is a rare toxic reaction. Regular insulin is always drawn up before the NPH insulin, and the NPH insulin can be drawn into the same syringe as for the Regular insulin. Insulins usually are administered 15 to 30 minutes before a meal. To mix the NPH insulin suspension, the vial should be gently rotated. Shaking introduces air bubbles into the solution. Dimenhydrinate is used to prevent and treat the symptoms of dizziness, vertigo, nausea, and vomiting that accompany motion sickness. The other options are incorrect. Scopolamine is an anticholinergic medication that causes frequent side effects of dry mouth, urinary retention, decreased sweating, and dilation of the pupils. The other options are incorrect.

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The pain experienced with pyelonephritis usually resolves as antibiotic therapy becomes effective. However, clients may be treated for urinary tract pain with phenazopyridine, which is a urinary analgesic. Bethanechol chloride is a cholinergic agent used to treat neurogenic bladder or urinary retention. Oxybutinin chloride and propantheline bromide are antispasmodics that are used to treat bladder spasm. Epidural analgesia is used for clients with expected high levels of postoperative pain. The nurse carefully checks the medication, notes the client's level of sedation, and makes sure that the head of bed is elevated 30 degrees, unless contraindicated. The nurse aspirates with a syringe to make sure that no CSF return occurs. If CSF returns with aspiration, the catheter has migrated from the epidural space into the subarachnoid space. The catheter is not flushed with 6 mL of sterile water. Narcan should be readily available for use if respiratory depression should occur. Chlorpromazine is used to control shivering in hyperthermic states. It is a phenothiazine and has antiemetic and antipsychotic uses, especially when psychosis is accompanied by increased psychomotor activity. Prochlorperazine is a phenothiazine that is an antiemetic and antipsychotic. Fluphenazine is a phenothiazine that is used as an antipsychotic. Buspirone is an anxiolytic. Dexamethasone is an adrenocorticosteroid administered after craniotomy to control cerebral edema. It is given by IV push, and single doses are administered over 1 Thursday, October 24, 2013

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minute. Dexamethasone IV doses are changed to the oral route after 24 to 72 hours and are tapered in dose until discontinued. Additionally, IV fluids are administered cautiously after craniotomy to prevent increased cerebral edema. Aminocaproic acid is an antifibrinolytic agent that prevents clot breakdown or dissolution. It is commonly ordered after subarachnoid hemorrhage if surgery is delayed or contraindicated, to prevent further hemorrhage. Heparin sodium and warfarin are anticoagulants, which interfere with propagation or growth of a clot. Alteplase is a fibrinolytic, which actively breaks down clots. Nimodipine is a calcium channel– blocking agent that has an affinity for cerebral blood vessels. It is used to prevent or control vasospasm in cerebral blood vessels, thereby reducing the chance for rebleeding. It is typically ordered for 3 weeks' duration. For subcutaneous heparin sodium injection, a 25- to 26-gauge, 3/8- to 5/8-inch needle is used, to prevent tissue trauma and inadvertent intramuscular injection. A 1-inch needle would inject the heparin sodium into the muscle. The application of heat may affect the absorption of the heparin and cause bleeding. Aspiration before injection is incorrect technique with heparin administration. Streptokinase converts plasminogen in the blood to plasmin. Plasmin is an enzyme that digests or dissolves fibrin clots wherever they exist. Options 1, 2, and 4 describe mechanisms of action of heparin sodium and warfarin sodium (Coumadin).

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Diltiazem is a calcium channel blocker that inhibits calcium influx through the slow channels of the membrane of smooth muscle cells. These medications decrease myocardial oxygen demands and block calcium channels, thereby decreasing the force of contraction of the ventricular tissue. Paraphrasing is restating the client's or family member's own words. Option 1 represents a communication block that denies the person's right to an opinion. Option 2 is offering a false reassurance. In option 3, the nurse is expressing approval, which can be harmful to the client-nurse or familynurse relationship. It is appropriate to treat atrial fibrillation with the prescribed and calculated dose of digoxin as indicated in the question. The subject of the question is that the client verbalizes inaccurate and unsafe knowledge regarding this medication and the treatment for chest pain. This client needs further education regarding the safe administration of medications for episodes of chest pain. Mannitol is an osmotic diuretic. When used to treat increased ICP, it is given slowly over 30 to 90 minutes, not rapidly and not via IV bolus. Mannitol should not be mixed in solution with antibiotics, and nothing should be piggybacked with packed red blood cells. Blurred vision and nausea are common indicators of lidocaine toxicity. The heart rate and blood pressure noted in option 2 are normal. A headache and elevated temperature are important assessment signs but are not related to the lidocaine. Urine output is greater than the minimum

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amount of 30 mL/hr and therefore is adequate.

hypotension, and possibly cardiac arrest.

The tubing must be pinched above the injection port so that the medication does not go back up the tubing. Most IVP medications should be injected slowly. Considering the need for and action of the medication, it is not diluted unless prescribed.

The nurse monitors the CBC, because hematological side effects of this therapy include aplastic anemia, agranulocytosis, leukopenia, and thrombocytopenia. Other test results that warrant monitoring include serum calcium levels and the results of urinalysis, hepatic, and thyroid function tests.

Reflection of the client's own comment lets the client know that the nurse hears the concern without judging. The nurse cannot understand what the client is experiencing. Option 3 is confrontational and unsupportive. Common GI side effects of benztropine therapy include constipation and dry mouth. Other GI side effects include nausea and ileus. These effects are the result of the anticholinergic properties of the medication. The client should not receive cyclobenzaprine if the client has taken monoamine oxidase inhibitors (MAOIs) such as tranylcypromine or phenelzine within the last 14 days. Otherwise, the client could experience hyperpyretic crisis, convulsions, or death. The client should remain in bed for at least 3 hours after a parenteral dose of diazepam. The medication is a centrally acting skeletal muscle relaxant and also has antianxiety, sedative-hypnotic, and anticonvulsant properties. Cardiopulmonary side effects of the medication include apnea, hypotension, bradycardia, and cardiac arrest. For this reason, resuscitative equipment also is kept nearby. The recommended rate of infusion of diazepam is to give each 5 mg of the medication over at least 1 minute. This will prevent adverse side effects including apnea, bradycardia, NCLEX– 182845269.doc

Drowsiness, unsteadiness, and clumsiness are expected effects of the medication during early therapy. They are dose related and usually diminish or disappear altogether with continued use of the medication. These symptoms do not indicate that a severe side effect is occurring. They also are unrelated to an interaction with another medication. The client is encouraged to take this medication with food to minimize gastrointestinal upset. Clonazepam is a benzodiazepine that is used as an anticonvulsant. During initial therapy and during periods of dosage adjustment, the nurse should initiate seizure precautions for the client. Options 1, 3, and 4 are unrelated to this medication. Precipitation will occur if phenytoin is mixed with any solution other than 0.9% (normal) saline. This is especially true with solutions containing dextrose. An in-line filter reduces the chance of precipitants entering the bloodstream. Phenytoin is very irritating to the vein wall or other tissues. The therapeutic range for serum phenytoin levels is 10 to 20 mcg/mL in clients with normal serum albumin levels and renal function. A level below this range indicates that the Thursday, October 24, 2013

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client is not receiving sufficient medication and is at risk for seizure activity. In this case, the medication dose should be adjusted upward. A level above this range indicates that the client is entering the toxic range and is at risk for toxic side effects of the medication. In this case, the dose should be adjusted downward. Clorazepate is classified as an anticonvulsant, an anxiolytic (antianxiety agent), and a sedativehypnotic (benzodiazepine). One of the nursing implications of clorazepate therapy is that the medication can lead to physical or psychological dependence with prolonged therapy at high doses. For this reason, the amount of medication that is readily available to the client at any one time is restricted. Valproic acid is an anticonvulsant that causes central nervous system (CNS) depression. For this reason, the side effects of the medication include sedation, dizziness, ataxia, and confusion. When the client is taking this medication as a single daily dose, administering it at bedtime negates the risk of injury from sedation and enhances client safety. The medication should be taken at the same time each day. Carbamazepine is an anticonvulsant that should be taken around the clock, precisely as directed. If a dose is omitted, the client should take the dose as soon as it is remembered, so long as it is not immediately before the next dose. The medication should not be double-dosed. If more than one dose is omitted, the client should call the physician. Carbamazepine acts by depressing synaptic transmission in the central nervous system (CNS). Because of NCLEX– 182845269.doc

this, the client should avoid driving or doing other activities that require mental alertness until the effect of the medication on the client is known. The client should use protective clothing and sunscreen to avoid photosensitivity reactions. The medication may cause dry mouth, and the client should be instructed to provide good oral hygiene and use sugarless candy or gum as needed. The medication should not be abruptly discontinued, because this could lead to return of seizures or status epilepticus. Fever and sore throat should be reported to the physician (leukopenia). Ergotamine produces vasoconstriction by stimulating α-adrenergic receptors, which suppresses vascular headaches when the medication is given in the therapeutic dose range. The nurse periodically assesses for hypertension, cool, numb fingers and toes, muscle pain, and nausea and vomiting. Edrophonium commonly is given to test for myasthenic crisis. If the client is in myasthenic crisis, muscle strength improves after administration of the medication, and the improvement lasts for about 30 minutes. Options 1, 2, and 4 are incorrect. Dextroamphetamine is a central nervous system (CNS) stimulant that acts by releasing norepinephrine from nerve endings. The client should take the medication at least 6 hours before going to bed at night to prevent disturbances with sleep. Dextroamphetamine is a central nervous system (CNS) stimulant. Caffeine is a stimulant also, so intake should be limited in the client taking this medication. The client should be

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taught to limit his or her own caffeine intake as well. Signs and symptoms of Parkinson's disease usually begin to resolve within 2 to 3 weeks of starting therapy, although in some clients marked improvement may not be seen for up to 6 months. The client needs to understand this concept to aid in compliance with medication therapy. Trihexyphenidyl is an anticholinergic medication. Thus, it can cause urinary hesitancy and retention, constipation, dry mouth, and decreased sweating. With carbidopa/levodopa therapy, a darkening of the urine or sweat may occur. The client should be reassured that this is a harmless effect of the medication, and its use should be continued. Options 1, 2, and 4 are incorrect. Pyridostigmine is a cholinergic medication used to increase muscle strength in the client with myasthenia gravis. For the client who has difficulty chewing, the medication should be administered 30 minutes before meals to enhance the client's ability to eat. The client should take neostigmine exactly on time. Taking the medication early or late could result in myasthenic or cholinergic crisis. Taking the medication on time is especially important for the client with dysphagia, because the client may not be able to swallow the medication if it is given late. These clients are taught to set a battery alarm clock to remind them of dosage times. The client should never skip or double up on missed doses. The medication should be administered with food or milk to minimize side effects. Amantadine is an antiparkinson agent that potentiates the action of NCLEX– 182845269.doc

dopamine in the central nervous system. The expected effect of therapy is a decrease in akinesia and rigidity. Leukopenia, urinary retention, and hypotension all are adverse effects of the medication. Client teaching should include taking the dose exactly as prescribed each day. If the client misses a dose and more than 12 hours goes by, that dose should be omitted and only the next scheduled dose should be taken; the client should not double-dose. A daily pulse check is necessary, and the client should know the parameters for which the physician should be called. Clients are advised not to mix digoxin in pill boxes with other medications. The physician should be consulted before changing brands, because the bioavailability of another preparation of the medication may be different. Paroxetine is an antidepressant used in the treatment of major depression. Amitriptyline is a tricyclic antidepressant (TCA) used to treat various forms of depression. Tranylcypromine is a monoamine oxidase (MAO) inhibitor used in the symptomatic treatment of severe depression in hospitalized or closely supervised clients, and thioridazine is an antipsychotic medication. For treatment of spasticity, dantrolene is administered orally. The initial dosage in adults is 25 mg once daily. The usual maintenance dosage is 100 mg two to four times daily. If beneficial effects do not develop within 45 days, dantrolene therapy should be discontinued. The client being changed from oral to inhalation glucocorticoids could experience signs of adrenal insufficiency. The nurse teaches the client to report anorexia, nausea, Thursday, October 24, 2013

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weakness, and fatigue. Other signs that can be detected, which are objective in nature, include hypotension and hypoglycemia. A frequent side effect of brompheniramine maleate, an antihistamine, is drowsiness or sedation. Others include blurred vision, hypertension (and sometimes hypotension), dry mouth, constipation, urinary retention, and sweating. Signs of opioid withdrawal include increased temperature and blood pressure, abdominal cramping, vomiting, and restlessness. Time of onset may be anywhere from a few minutes to a few hours after administration of naloxone hydrochloride, depending on the opioid involved, the degree of dependence, and the dose of naloxone. Options 1, 3, and 4 are incorrect. Noroxin is administered 1 hour before or 2 hours after meals because food may hamper absorption. The normal dosage is 400 mg orally twice daily for 7 to 10 days for mild infections and for 10 to 21 days for severe infections. For treatment of acute UTI, the adult dosage is 50 mg three to four times a day. For prophylaxis of recurrent UTI, low doses are used, such as 50 to 100 mg at bedtime for adults. Methenamine, under acidic conditions, decomposes into ammonia and formaldehyde. The formaldehyde denatures bacterial proteins, causing death of the organism. Nalidixic acid (NegGram) is a medication that inhibits the replication of bacterial DNA. Antispasmodics relax smooth muscle of the urinary tract and decrease bladder muscle spasms.

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Nalidixic acid is dispensed in tablets of 250 mg, 500 mg, and 1 g and in suspension of 50 mg/mL for oral use. The adult dosage is 1 g four times a day for 1 week. It should not be administered to children younger than 3 years because it may produce intracranial hypertension in pediatric clients. The normal adult dosage of bethanechol chloride ranges from 10 to 50 mg three to four times daily. The injectable form of bethanechol chloride is intended for subcutaneous administration only. Bethanechol must never be injected intramuscularly or intravenously because the resulting high drug level can cause severe toxicity, resulting in bloody diarrhea, bradycardia, profound hypotension, and cardiovascular collapse. The nurse should plan for a skin test dose before IV administration of antithymocyte globulin to identify hypersensitivity to the medication. Options 2 and 4 are not specific to this medication. The client would not be premedicated with aspirin. Premedication with acetaminophen (Tylenol) or diphenhydramine (Benadryl), or both, may be prescribed to prevent reaction to the medication. Epoetin alfa generally is well tolerated. The most significant adverse effect is hypertension. Occasionally, a tachycardia may occur as a side effect. This medication also may cause an improved sense of well-being. Epoetin alfa stimulates erythropoiesis. It takes 2 to 6 weeks after initiation of therapy before a clinically significant increase in hematocrit is observed. Therefore, this medication is not intended for clients who require immediate correction of severe Thursday, October 24, 2013

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anemia, and it is not a substitute for emergency blood transfusions. The client who is receiving aluminum hydroxide should take the medication with meals. The phosphate-binding effect is most effective when it is taken with food. If tablets are used, they should be chewed well before swallowing. Aluminum-containing antacids are constipating, so the client should be instructed to take a stool softener or additional bulk-type laxatives to relieve this uncomfortable side effect. Options 1, 3, and 4 are incorrect. Feosol is an iron supplement used to treat anemia. Constipation is a frequent and uncomfortable side effect associated with the administration of oral iron supplements. Stool softeners often are prescribed to prevent constipation. Options 1, 3, and 4 are not associated with this medication. Tacrolimus is an alternative medication to cyclosporine (Sandimmune) for prevention of organ rejection in clients after transplantation. The medication is more effective than cyclosporine but is more toxic. Concurrent use of glucocorticoids is recommended during administration of this medication. Potentially fatal anaphylactic reactions can occur with this medication. Manifestations include pulmonary edema, cardiovascular collapse, and cardiac or respiratory arrest. Assessing lung sounds is a priority. Imuran suppresses cell-mediated and humoral immune responses by inhibiting the proliferation of B and T lymphocytes. It generally is used as an adjunct to cyclosporine (Sandimmune) NCLEX– 182845269.doc

and glucocorticoids to help suppress transplant rejection. Options 2, 3, and 4 are incorrect. Gastrointestinal (GI) effects are the most frequent adverse reactions to this medication and can be minimized by administering the medication with milk or meals. Pulmonary reactions manifested as dyspnea, chest pain, chills, fever, cough, and the presence of alveolar infiltrates on radiography would indicate the need to stop the treatment. These abnormalities typically resolve in 2 to 4 days after discontinuation of this medication. Codeine sulfate is an opioid analgesic used for clients after craniotomy. It often is combined with a nonopioid analgesic such as acetaminophen (Tylenol) for added effect. It does not alter the respiratory rate or mask neurological signs as do other opioids. Side effects of codeine sulfate include GI upset and constipation. Chronic use of the medication can lead to physical and psychological dependence. The anticonvulsant medications carbamazepine and phenytoin help relieve the pain in many clients with trigeminal neuralgia. They act by inhibiting the reactivity of neurons in the trigeminal nerve. Opioid analgesics (meperidine hydrochloride, codeine sulfate, oxycodone) are not very effective in controlling pain due to trigeminal neuralgia. Methylprednisolone or adrenocorticotropic hormone may be prescribed to be administered intravenously to accelerate recovery from an exacerbation of multiple sclerosis. Carbamazepine may be prescribed for trigeminal neuralgia, and phenytoin may be prescribed to control seizures. Lioresal and

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diazepam are used to treat muscle spasticity. Rifampin in combination with isoniazid prevents the emergence of drugresistant organisms. This combination taken together daily eliminates the tubercle bacilli from the sputum and improves clinical status. Rifampin produces a harmless red-orange color in all body fluids and should be taken along with the isoniazid 1 hour before or 2 hours after eating to maximize absorption. The treatment regimen is maintained for at least 6 months for effectiveness and the therapeutic effect may be evident in 2 to 3 weeks. Lactulose is a hyperosmotic laxative agent that has the adjunct benefit of lowering serum ammonia levels. This occurs because the medication lowers bowel pH and aids in the conversion of ammonia in the gut to the ammonium ion, which is poorly absorbed. Magnesium hydroxide is a saline laxative. Phenolphthalein is a stimulant laxative. Psyllium hydrophilic mucilloid is a bulk laxative. Itraconazole is an antifungal medication. The client should be instructed to take the medication with food because it increases the absorption of the medication. Fluid should be increased to prevent constipation, which can occur as a side effect. Hepatitis is an adverse reaction associated with the medication, and if anorexia of any degree, abdominal pain, unusual tiredness or weakness, or jaundice develops, the physician should be notified. Adverse reactions associated with kanamycin sulfate include nephrotoxicity evidenced by an increased BUN and creatinine. Irreversible ototoxicity as evidenced NCLEX– 182845269.doc

by tinnitus, dizziness, ringing in the ears, and reduced hearing and neurotoxicity manifested by headache, dizziness, lethargy, and visual disturbances can occur. Gastrointestinal disturbances can occur as a frequent side effect of the medication. The WBC count may be elevated as a result of the respiratory infection. Intermittent IV infusion of phenytoin is administered by injection into a large vein using normal saline solution. Dextrose solutions are avoided because the medication will precipitate in these solutions. Options 1, 3, and 4 identify incorrect solutions for IV administration with this medication. Adverse effects of carbamazepine appear as blood dyscrasias, including aplastic anemia, agranulocytosis, thrombocytopenia, and leukopenia; cardiovascular disturbances; thrombophlebitis; dysrhythmias; and dermatological effects. The incorrect options identify laboratory values that are within normal range. Morphine sulfate depresses respirations. The nurse monitors the client's respiratory status closely. Although the incorrect options may be components of the plan of care, option 3 identifies the priority nursing action. Side effects of meperidine hydrochloride include respiratory depression, orthostatic hypotension, tachycardia, drowsiness and mental clouding, constipation, and urinary retention. Codeine sulfate can cause constipation, so the client is instructed to increase fluid intake to prevent this occurrence. A high-fiber diet and stool softeners may be prescribed to Thursday, October 24, 2013

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prevent constipation. All exercise is not avoided. Dantrolene can cause liver damage; therefore, the nurse should monitor the results of liver function studies. They should be done before therapy starts and periodically throughout therapy. Dantrolene is discontinued if no relief of spasticity is achieved in 6 weeks. The incorrect options are not specifically related to the administration of this medication. Mannitol is an osmotic diuretic that induces diuresis by raising the osmotic pressure of glomerular filtrate, thereby inhibiting tubular reabsorption of water and solutes. It is used to reduce intracranial pressure in the client with head trauma. Option 2 would cause fluid retention, thereby increasing the intracranial pressure. Dexamethasone may be given by direct IV injection or IV infusion. For IV infusion, it may be mixed with 50 to 100 mL of 0.9% sodium chloride or 5% dextrose in water. It is not mixed with lactated Ringer's solution or 10% dextrose in water. Because tetracycline can cause permanent staining of the teeth, a straw should be used and the mouth should be rinsed after administration. The medication should be administered 1 hour before or 2 hours after consumption of milk. Diluting the medication with water is unnecessary. Pitocin is a synthetic hormone that stimulates uterine contractions and commonly is used to induce labor. A major danger associated with oxytocin induction of labor is hyperstimulation of uterine contractions, which can cause fetal distress as a result of decreased placental perfusion. Therefore, oxytocin infusion must be NCLEX– 182845269.doc

stopped when any signs of uterine hyperstimulation are observed. Early decelerations of the fetal heart rate are a reassuring sign and do not indicate fetal distress. Options 3 and 4 do not indicate a need to discontinue the infusion. Clients taking allopurinol are encouraged to drink 3000 mL of fluid a day to prevent formations of crystals in the urine. Allopurinol is given with or immediately after meals or milk. If the client notes development of a rash, irritation of the eyes, or swelling of the lips or mouth, the physician should be notified because this may indicate hypersensitivity. Probenecid inhibits the reabsorption of uric acid by the kidney and promotes excretion of uric acid in the urine. Clients taking this medication are instructed to limit excessive purine intake. High-purine foods to avoid or limit include organ meats, roe, sardines, scallops, anchovies, broth, mincemeat, herring, shrimp, mackerel, gravy, and yeast. Auranofin is the one gold preparation that is given orally, rather than by injection. Gastrointestinal (GI) reactions including diarrhea, abdominal pain, nausea, and loss of appetite are common early in therapy but usually subside in the first 3 months. Early signs and symptoms of toxic reactions include a rash, purple blotches, pruritus, mouth lesions, and a metallic taste in the mouth. Signs and symptoms of toxic reactions are reported to the physician. For acute or chronic rheumatoid arthritis or osteoarthritis, the normal oral adult dose for an older client is 400 to 800 mg three to four times daily. The other options are incorrect.

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Baclofen is a skeletal muscle relaxant and acts at the spinal cord level to decrease the frequency and amplitude of muscle spasms in clients with spinal cord injuries or diseases or with multiple sclerosis. Options 2 and 3 are not directly related to the effects of this medication. Option 4 is incorrect. Baclofen, a skeletal muscle relaxant, also is a central nervous system (CNS) depressant, which can cause urinary retention. The client should not restrict fluid intake. Constipation, rather than diarrhea, is an adverse effect of baclofen. Fatigue is a CNS effect that is most intense during the early phase of therapy and diminishes with continued medication use. It is not necessary to notify the physician if fatigue occurs. Syrup of ipecac is the medication used for induction of emesis after ingestion of many poisons, although its use is contraindicated after ingestion of strong acids or bases and in clients who are comatose, delirious, or experiencing convulsions. The dose for children younger than 1 year of age is 5 to 10 mL, followed by one-half to one glass of water. Diarrhea and sedation are expected side effects of the medication. Options 1 and 2 are incorrect. Asparaginase can cause severe adverse effects; however, they often are different from those of other antineoplastic medications. By inhibiting protein synthesis, the medication can cause coagulation deficiencies and injury to the liver, pancreas, and kidneys. Signs and symptoms of central nervous system depression ranging from confusion to coma can occur. Nausea and vomiting can be intense and may limit the dose that can be tolerated. In contrast with most antineoplastic medications, NCLEX– 182845269.doc

asparaginase does not depress the bone marrow, nor does it cause alopecia, oral ulceration, or intestinal ulceration. Cisplatin is a medication that kills cells primarily by forming cross-links between and within strands of DNA. Its principal use is in the treatment of testicular cancer, although it also can be used to treat carcinomas of the ovary, bladder, head, and neck. It can cause neurotoxicity, nephrotoxicity, bone marrow depression, and ototoxicity, which manifests as tinnitus and high-frequency hearing loss. Nausea and vomiting are expected effects, which can be severe and begin 1 hour after administration, persisting for 1 to 2 days. Ifosfamide is used to treat refractory germ cell cancer of the testes. Concurrent therapy with mesna and at least 2 L of oral or intravenous fluid daily will limit the toxicity of this medication, evidenced by bone marrow depression and hemorrhagic cystitis. Mesna is a detoxifying agent used to inhibit the hemorrhagic cystitis induced by ifosfamide. The medications in options 1, 2, and 4 are not routinely administered with ifosfamide. The medication is massaged into the skin of the entire body, starting with the chin and working downward. The head and face are treated only if needed. Special attention should be given to skin folds and creases. Contact with eyes, mucous membranes, and any region of inflammation should be avoided. A second application is made 24 hours after the first. A cleansing bath should be taken 48 hours after the second application; if needed, treatment can be repeated in 7 days. Thursday, October 24, 2013

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Metronidazole can produce a variety of side effects, but they rarely require termination of treatment. Harmless darkening of the urine may occur and the client should be told of this effect. It is not necessary to discontinue the medication or call the physician. Increasing fluid intake is a good health measure but will not prevent this side effect from occurring. Pancreatitis, which can be fatal, is the major dose-limiting toxicity associated with the administration of didanosine. Clients should be monitored for indications of developing pancreatitis, which include increased serum amylase in association with increased serum triglycerides, decreased serum calcium, and nausea, vomiting, or abdominal pain. If evolving pancreatitis is diagnosed, the medication should be discontinued. The client should be seen by the health care physician. Peripheral neuropathy is an adverse effect associated with the use of zalcitabine, which manifests initially as numbness and burning sensations in the extremities. It may progress to sharp shooting pains or severe continuous burning if the medication is not withdrawn. Pain of severe neuropathy requires opioid analgesics for control. Clients should be informed about the early symptoms of neuropathy and instructed to report them immediately. Neuropathic changes will reverse slowly if the medication is withdrawn early but may become irreversible if the medication is continued. The other options are not associated with use of this medication. Ribavirin is active against RSV, influenza virus types A and B, and herpes simplex virus. It is administered by oral inhalation. The medication is absorbed from the lungs NCLEX– 182845269.doc

and achieves high concentrations in respiratory tract secretions and erythrocytes. It is not administered by the routes identified in options 1, 3, and 4. Amphotericin B exerts direct toxicity on cells of the kidneys and causes renal impairment in most clients. To evaluate renal injury, tests of kidney function should be performed weekly, and intake and output should be monitored. If the serum creatinine level rises above 3.5 mg/dL, the dose of amphotericin B should be reduced. Options 2, 3, and 4 are unrelated to the use of this medication. The major form of dose-limiting toxicity with bleomycin is injury to the lungs. It manifests initially as pneumonitis but can progress to severe pulmonary fibrosis and death. In addition to auscultation of lung sounds, pulmonary function studies should be monitored. Bleomycin is discontinued at the first sign of these adverse changes. Nausea and vomiting usually are mild with the use of this medication, and unlike most other anticancer agents, bleomycin exerts minimal toxicity to bone marrow. It does not directly affect the blood pressure. Peripheral neuropathy is the major dose-limiting toxicity associated with vincristine. Nearly all clients exhibit signs and symptoms of sensory or motor nerve injury such as decreased reflexes, weakness, paresthesia, and sensory loss. In contrast with most anticancer medications, vincristine causes little toxicity to bone marrow. Nausea and vomiting are rare with the use of this medication. Oral erythromycin should be administered on an empty stomach with a full glass of water. Some Thursday, October 24, 2013

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preparations may be administered with food if gastrointestinal upset occurs, but it is best to administer on an empty stomach. Azithromycin should be taken 1 hour before or 2 hours after meals. It is not administered with meals, and it should not be taken with either aluminum- or magnesium-containing antacids. Bethanechol chloride is a direct-acting muscarinic agonist (cholinergic medication). It can cause hypotension secondary to vasodilation and bradycardia. It also can cause excessive salivation, increased secretion of gastric acid, abdominal cramps, and diarrhea. Higher doses can cause involuntary defecation. Bethanechol chloride is a cholinergic medication, which is associated with a high incidence of side effects when given subcutaneously instead of orally. The medication can produce a cholinergic reaction, and the antidote for this type of reaction is atropine sulfate. The other options are incorrect. Atropine sulfate can cause a blockade of muscarinic receptors on the iris sphincter, producing mydriasis (dilation of the pupils). It also produces cycloplegia (relaxation of the ciliary muscles). It is contraindicated in clients with narrow-angle glaucoma. The other options are therapeutic reasons for using the medication. A Tensilon test is performed to distinguish between myasthenic and cholinergic crisis. After administration of the Tensilon, if symptoms intensify, the crisis is cholinergic. Because the symptoms of cholinergic crisis will worsen with the administration of Tensilon, atropine sulfate should be available because it is the antidote. NCLEX– 182845269.doc

Phentolamine is an α-adrenergic blocking agent that prevents dermal necrosis and sloughing after infiltration of norepinephrine or dopamine. Vitamin K is the antidote for warfarin (Coumadin). Atropine sulfate is the antidote for cholinergic crisis. Protamine sulfate is the antidote for heparin. Phentolamine is an α-adrenergic blocking agent that prevents dermal necrosis and sloughing after infiltration of norepinephrine or dopamine. Vitamin K is the antidote for warfarin (Coumadin). Atropine sulfate is the antidote for cholinergic crisis. Protamine sulfate is the antidote for heparin. Clonidine is an antihypertensive medication that is applied to a hairless intact skin area of the upper arm or torso every 7 days. Options 2, 3, and 4 are correct statements. The target range for a therapeutic serum level of phenytoin is between 10 and 20 mcg/mL. Levels below 10 mcg/mL are too low to control seizures. At levels above 20 mcg/mL, signs of toxicity begin to appear. This client has a low serum level, and the dosage is likely to be increased. Intravenous administration of phenytoin is performed slowly (no faster than 50 mg/min) because rapid administration can cause cardiovascular collapse. It should not be added to any existing IV infusion because this is likely to produce a precipitate in the solution. Solutions are highly alkaline and can cause local venous irritation. Gastrointestinal effects from valproic acid are common and typically mild, but hepatotoxicity, although rare, is serious. To minimize the risk of fatal Thursday, October 24, 2013

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liver injury, liver function is evaluated before initiation of treatment and periodically thereafter. The other options are unrelated to the use of this medication. Carbamazepine can cause leukopenia, anemia, thrombocytopenia, and, very rarely, fatal aplastic anemia. To reduce the risk of serious hematological effects, a complete blood cell count should be done before treatment and periodically thereafter. This medication should be avoided in clients with pre-existing hematological abnormalities. The client also is told to report the occurrence of fever, sore throat, pallor, weakness, infection, easy bruising, and petechiae. Options 1, 2, and 3 are not associated with the use of this medication. Dantrium is hepatotoxic. The nurse observes for indications of liver dysfunction, which include jaundice, abdominal pain, and malaise. The nurse notifies the physician if these occur. The items in options 1, 3, and 4 are expected side effects due to the central nervous system (CNS) depressant effects of the medication. Naloxone is an opioid antagonist that is used to treat opioid overdose. Promethazine is an antiemetic medication, and protamine sulfate is the antidote for heparin. Atropine sulfate is an anticholinergic. Before an opioid is administered, respiratory rate, blood pressure, and pulse rate should be assessed. Morphine sulfate should be withheld and the physician notified if the respiratory rate is at or below 12 breaths/min, if the blood pressure is significantly below the pretreatment value, or if the pulse rate is significantly above or below pretreatment value. A temperature of NCLEX– 182845269.doc

99.1° F is not associated with the use of morphine sulfate. Ergotamine tartrate is used to stop an ongoing migraine attack and also is used to treat cluster headaches. The other options are unrelated to the use of this medication. Spironolactone is a potassium-sparing diuretic that causes hyperkalemia as the principal adverse effect. Clients are instructed to restrict their intake of potassium-rich foods, such as citrus fruits and bananas. The other foods listed are appropriate to include in the diet. Moexipril is an angiotensin-converting enzyme (ACE) inhibitor. The client should be instructed to take the medication at least 1 hour before meals. The other ACE inhibitor that should be taken 1 hour before meals is captopril (Capoten). The other options are incorrect instructions to the client. Sodium nitroprusside can be degraded by light and should be protected with an opaque material. It is dispensed in powdered form and must be dissolved and diluted for the IV solution. A fresh solution may have a faint brown coloration, but solutions that are deeply colored, such as blue green or dark red, should be discarded. No other medication should be mixed with the infusion solution. During the infusion, the blood pressure should be monitored continuously either through an arterial line or with an electronic monitoring device. The client should be instructed about symptoms of iodism that can occur with the administration of potassium iodide solution. These symptoms include a brassy taste, burning sensation in the mouth, and soreness of the gums and teeth. The client Thursday, October 24, 2013

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should be instructed to withhold the medication and notify the physician if these symptoms are noted. Intravenous ritodrine can cause pulmonary edema, and the client should be monitored for fluid overload. If pulmonary edema develops, the infusion should be discontinued and standard treatment implemented. The client also is at risk for hypotension and hyperglycemia during infusion of this medication. Peak serum drug levels should be monitored to ensure that the dosage is appropriate and should be drawn 1.5 to 2.5 hours after the IV infusion is completed. Peak levels of 30 to 40 mcg/mL generally are acceptable. Options 1, 3, and 4 are incorrect. Abacavir is used to treat HIV infection, in combination with other agents. It is not used to treat the conditions noted in options 1, 3, and 4. The normal WBC is 5,000 to 10,000/mm3. When the WBC count drops, neutropenic precautions should be implemented to protect the client from infection. Bleeding precautions should be initiated when the platelet count drops and will include avoiding trauma such as from rectal temperatures or injections. The normal platelet count is 150,000 to 450,000 cells/mm3. The normal clotting time is 8 to 15 minutes. The normal ammonia value is 15 to 45 mcg/dL. Warfarin is an anticoagulant. Bleeding is a concern while the client is taking this medication. Orange-colored urine indicates blood in the urine from an overdose of the medication. Bleeding also may be identified by urine that turns red, smoky, or black. The prothrombin time is determined to monitor the clotting mechanism. The NCLEX– 182845269.doc

half-life of the medication is 2 days, the peak effect is between 1 and 3 days, and the anticoagulation effect extends 4 to 5 days after discontinuation. Aspirin is an antiplatelet agent and would increase the risk of bleeding. Hydralazine is an antihypertensive medication used for moderate to severe hypertension. Because the blood pressure and pulse should be monitored frequently after administration, a noninvasive blood pressure cuff should be obtained. The other options are not priority items specific to the use of this medication. Opioids are used for epidural analgesia, which can lead to delayed respiratory depression. For this reason, respirations are monitored for 24 hours after administration of epidural analgesia. Naloxone is a narcotic antagonist, which reverses the effects of opioids and is given if the respiratory rate falls below 6 to 8 breaths/min. Morphine sulfate and meperidine hydrochloride are opioids and would further compromise the respiratory rate. Bethamethasone is a corticosteroid administered to enhance fetal lung maturity. Amphotericin B can cause adverse effects such as chills, fever, headache, vomiting, and impaired renal function. The nurse monitors for these adverse effects and also carefully assesses the IV site because of the irritating effects of the medication. Bethamethasone, a steroidal antiinflammatory, increases the surfactant level and promotes lung maturation, thereby reducing the risk of respiratory distress syndrome in the newborn infant. Surfactant production does not become stable until after 32 weeks of gestation, and if adequate Thursday, October 24, 2013

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amounts of lung surfactant are not present, respiratory distress and death of the newborn infant could result. Delivery should be delayed for at least 48 hours after administration of bethamethasone to allow time for the lungs to mature. The other options are incorrect. The infant should be turned on the side with the affected ear uppermost. With the wrist of the nondominant hand resting on the infant's head, the mother pulls down and back on the earlobe and aims the solution at the wall of the canal, rather than directly onto the eardrum. In the adult, the auricle is pulled up and back to straighten the auditory canal. Mild intoxication with acetylsalicylic acid, called salicylism, commonly occurs when the daily dosage is more than 4 g. Tinnitus (ringing in the ears) is the most frequent effect noted with intoxication. Hyperventilation also may occur because salicylate stimulates the respiratory center. Fever may result because salicylate interferes with the metabolic pathways coupling oxygen consumption and heat production. Options 2, 3, and 4 are not signs of aspirin toxicity. Scopolamine is an anticholinergic medication that causes the frequent side effects of dry mouth, urinary retention, decreased sweating, and dilation of the pupils. The other options are incorrect. Sucralfate is prescribed to treat gastric ulcers. It should be scheduled for administration 1 hour before meals and at bedtime to allow it to form a protective coating over the gastric ulcer to prevent irritation by food, gastric acid, and mechanical

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movement of the stomach. The other options are incorrect. Metamucil is a bulk-forming laxative that should be taken with a full glass of water or juice (not applesauce), followed by another glass of liquid. This will help prevent impaction of the medication in the stomach or small intestine. Both fiber in the diet and fluid intake should not be decreased unless specifically prescribed by the physician. Metoclopramide is a gastrointestinal stimulant. Administration should be scheduled 30 minutes before meals and at bedtime to allow the medication time to begin working before food intake and digestion. The other options are incorrect. Auranofin is a gold preparation used to manage rheumatoid arthritis in clients with insufficient therapeutic response to nonsteroidal anti-inflammatory drugs (NSAIDs). Prednisone is a corticosteroid. Fludarabine and pentostatin are antineoplastic agents. Cycloserine is an antituberculosis medication that requires weekly serum drug level determinations to monitor for neurotoxicity and other adverse effects. Peak concentrations are measured 2 hours after dosing and should be between 25 and 35 mcg/mL. The therapeutic serum drug level range for phenytoin is 10 to 20 mcg/mL. A laboratory value of 8 mcg/mL is below the therapeutic range, indicating an inadequate drug level. If the injectable solution is not clear or if precipitate is present, the medication should not be used and should be discarded. The nurse may have to call the pharmacy department to obtain another vial of the Thursday, October 24, 2013

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medication. Options 2, 3, and 4 are inaccurate actions.

nasal congestion, peripheral edema, and urinary retention.

Because INH therapy can cause elevated hepatic enzymes and hepatitis, liver enzymes are monitored when therapy is initiated and during the first 3 months of therapy. They may be monitored longer in the client who is older than 50 years of age or who abuses alcohol. The other options are incorrect.

The most common side effects of cyclobenzaprine are drowsiness, dizziness, and dry mouth. This medication is a centrally acting skeletal muscle relaxant used in the management of muscle spasm due to a variety of conditions. Fatigue, nervousness, and confusion are less frequent central nervous system effects of cyclobenzaprine.

Rifampin causes orange-red discoloration of body secretions and will permanently stain soft contact lenses. Rifampin should be taken exactly as directed, and doses should not be doubled or skipped. The medication should be taken on an empty stomach unless it causes gastrointestinal upset, and then it may be taken with food. Antacids, if prescribed, should be taken at least 1 hour before the medication. The client should not stop therapy until directed to do so by a physician. Ethambutol causes optic neuritis, which decreases visual acuity and impairs the ability to discriminate between the colors red and green. This form of color blindness poses a potential safety hazard in driving a motor vehicle. The client is taught to report this symptom immediately. The client also is taught to take the medication with food if GI upset occurs. Impaired hearing results from antituberculosis therapy with streptomycin. Orange-red discoloration of secretions occurs with rifampin (Rifadin). Side effects of chlorpromazine can include hypotension, dizziness, and fainting, especially with parenteral use. Additional side effects include drowsiness, blurred vision, dry mouth, lethargy, constipation or diarrhea, NCLEX– 182845269.doc

Diphenhydramine reduces the symptoms of allergic reaction, such as itching or urticaria, when used as a topical agent on the skin. When taken orally, it may provide mild nighttime sedation. It is not used to treat burns or ecchymoses. Tolbutamide is an oral hypoglycemic agent. It is not used to enhance weight loss, treat infection, or decrease blood pressure. Ganciclovir causes neutropenia and thrombocytopenia, and these are the most frequent side effects. For this reason, the nurse implements the same precautions that are used for a client receiving anticoagulant therapy. These include providing a soft toothbrush and an electric razor to minimize risk of trauma that could result in bleeding. Pressure on venipuncture sites should be held for approximately 10 minutes. The medication may cause hypoglycemia, but not hyperglycemia. The medication does not have to be taken on an empty stomach. Benzonatate is a locally acting antitussive that decreases the intensity and frequency of cough without eliminating the cough reflex. The other options are incorrect.

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Foscarnet, an antiviral medication used to treat cytomegalovirus (CMV) retinitis in clients with AIDS, should be administered with a controlled infusion device because of its potential toxicity. The items described in each of the other options are unnecessary. A PT of 28 seconds represents an elevated value. The therapeutic PT for a client receiving warfarin is 1.5 times the normal PT (9.5 to 11.5 seconds). The nurse should withhold the next dose and notify the physician. A medication dose should not be changed without a specific order (options 1 and 4). Akathisia is restlessness or a desire to keep moving. It may appear within 6 hours of administration of the first dose and may be difficult to distinguish from psychotic agitation. The other options describe tardive dyskinesia, which is manifested by uncontrolled rhythmic movements of the mouth, face, and extremities. These movements can include lip smacking or puckering, puffing of the cheeks, uncontrolled chewing, and the presence of rapid or undulating (worm-like) movements of the tongue. The client should be instructed to take a single daily dose of the medication at bedtime, not in the morning, because of the side effects. The client should take the medication exactly as directed and, if a dose is missed, should take it as soon as possible unless it is almost time for another dose. The medication effects may not be noticed for at least 2 weeks, and the client should avoid alcohol or other central nervous system depressants during therapy. At lithium levels of 2.0 to 2.5 mEq/L, the client will experience blurred vision, muscle twitching, severe NCLEX– 182845269.doc

hypotension, and persistent nausea and vomiting. With levels between 1.5 and 2.0 mEq/L, the client experiences vomiting, diarrhea, muscle weakness, ataxia, dizziness, slurred speech, and confusion. At lithium levels of 2.5 to 3.0 mEq/L or higher, urinary and fecal incontinence occurs, as well as seizures, cardiac dysrhythmias, peripheral vascular collapse, and death. Lorazepam is contraindicated in hypersensitivity, cross-sensitivity with other benzodiazepines, comatose state, preexisting central nervous system depression, uncontrolled severe pain, and narrow angle glaucoma. It also is contraindicated in pregnancy and in women who are breast-feeding. Methylphenidate is best taken shortly before meals and no later than 1:00 PM for children or after 6:00 PM for adults because the stimulating effect of the medication may keep the client awake. The other options are incorrect. Etanercept (Enbrel) is an antiarthritic medication that is administered via the subcutaneous route. Adverse effects include heart failure (noted by manifestations of dyspnea and congested lung sounds on auscultation), hypertension or hypotension, pancreatitis, or gastrointestinal hemorrhage. Headache, abdominal discomfort, and dizziness are not side effects of the medication. Olanzapine is an antipsychotic medication that targets both the positive and the negative symptoms of schizophrenia. The other options listed are not indications for use of this medication.

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Etanercept (Enbrel) is an antiarthritic medication that is administered via the subcutaneous route. Adverse effects include heart failure (noted by manifestations of dyspnea and congested lung sounds on auscultation), hypertension or hypotension, pancreatitis, or gastrointestinal hemorrhage. Headache, abdominal discomfort, and dizziness are not side effects of the medication.

should never double the dose of the medication.

Baseline assessment of renal and liver function should be done before the initiation of therapy with risperidone. The medication is used with caution in clients with renal or hepatic impairment, in those with underlying cardiovascular disorders, and in geriatric or debilitated clients. These clients are started on the medication at a reduced dosage level.

After heparin sodium is drawn up from the vial, the needle is changed before injection to prevent contact of the medication with tissue along the needle tract. Heparin sodium administered subcutaneously does not require an infusion device and is injected at least 2 inches from the umbilicus or any scar tissue. The needle is withdrawn rapidly, and the site is not massaged (although pressure is applied).

Potentially fatal reactions may occur if sertraline is administered concurrently with phenelzine, a monoamine oxidase inhibitor (MAOI). MAOIs should be stopped at least 14 days before initiation of sertraline therapy. Likewise, sertraline should be stopped at least 14 days before initiation of MAOI therapy. The other options are incorrect. The caregiver is instructed to notify the physician if nausea, vomiting, diarrhea, rash, jaundice, or changes in the color of the stool occur, because these signs could indicate the development of hepatitis. Tacrine is administered between meals on an empty stomach but may be administered with food if gastrointestinal (GI) upset occurs. Flulike symptoms without fever and GI symptoms are frequent side effects that may occur with use of this medication. The client or spouse NCLEX– 182845269.doc

The client should be instructed to take the medication at bedtime and to swallow the medication whole with a full glass of water. For faster onset of sleep, the client should be instructed not to take the medication with food or immediately after a meal. Antacids affect the absorption of the medication.

A frequent side effect of therapy with any angiotensin-converting enzyme (ACE) inhibitor, including quinapril, is a persistent, dry cough. In general, the cough does not resolve during the course of medication therapy, so clients should be advised to notify the physician if the cough becomes very troublesome. The other options are incorrect. Nitroglycerin is a coronary vasodilator used for coronary artery disease. The client should apply a new patch each morning and leave it in place for 12 to 14 hours in accordance with physician directions. This prevents the client from developing tolerance (as happens with 24-hour use). The client should avoid placing the patch in skin folds or excoriated areas. The client does not need to wait to apply a new patch if it falls off because the

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medication is released continuously in small amounts through the skin.

not directly related to the use of this medication.

Activase is a thrombolytic medication that dissolves thrombi or emboli. Bleeding is a frequent and potentially severe adverse effect of therapy. The nurse assesses for signs of bleeding in clients receiving this therapy using occult blood test strips to test urine, stool, or nasogastric drainage. Pulse oximeter and suction equipment would be needed if the client had evidence of oxygenation or respiratory problems. A flashlight is used for pupil assessment as part of the neurological examination in the client who is neurologically impaired.

Cola, coffee, and chocolate contain xanthine and should be avoided by the client taking a xanthine bronchodilator. The additional xanthine could lead to increased incidence of cardiovascular and central nervous system side effects. Options 1, 2, and 4 identify fluids that are allowed.

Headache is a frequent side effect of nitroglycerin, resulting from its vasodilator action. It often subsides as the client becomes accustomed to the medication and is effectively treated with acetaminophen (Tylenol). The other options are incorrect interpretations. Betaxolol is a β-adrenergic blocking agent used to lower blood pressure, relieve angina, or decrease the occurrence of dysrhythmias. Side effects include bradycardia and signs and symptoms of congestive heart failure, such as weight gain and increased edema. Verapamil is a calcium channel– blocking agent that may be used to treat rapid-rate supraventricular tachydysrhythmias such as atrial flutter or atrial fibrillation. A cardiac monitor is used to determine the client's response to the medication. A noninvasive blood pressure monitor also is helpful, but is not as essential or critical as the cardiac monitor. A pulse oximeter and oxygen are related to respiratory care and may be other useful adjuncts to care, but they are NCLEX– 182845269.doc

A client should drink increased fluids (2000 to 3000 mL/day) to decrease viscosity and increase expectoration of secretions. This is standard advice for clients receiving any of the adrenergic bronchodilators, unless the client has another health problem that contraindicates an increased fluid intake. A dehumidifier will dry secretions, making the situation worse. The client should not take additional medication. Additional exercise will not effectively clear bronchial secretions. The client taking a potassium-wasting diuretic such as chlorothiazide should be monitored for decreased potassium levels. Other possible fluid and electrolyte imbalances that occur with use of this medication include hyponatremia, hypercalcemia, hypomagnesemia, and hypophosphatemia. Amiloride is a potassium-sparing diuretic used to treat edema or hypertension. The daily dose should be taken in the morning to avoid nocturia, and the medication should be taken with food to increase bioavailability. Sodium should be restricted or limited as prescribed. Increased blood pressure is not a reason to withhold the medication; rather, it may be an indication for its use. Thursday, October 24, 2013

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Diazepam is a sedative-hypnotic that also has anticonvulsant and skeletal muscle relaxant properties. The nurse should institute safety measures before leaving the client's room to prevent injury as a result of medication side effects, which include dizziness, drowsiness, and lethargy. The other options listed are useful but not essential to the client's safety in this situation. Because therapeutic and toxic dosage ranges are narrow, lithium blood levels must be monitored closely. They are measured more frequently when the client begins the medication and then once every several months after the levels stabilize. The client should be instructed to stop taking the medication and call the physician if excessive diarrhea, vomiting, or diaphoresis occurs. Lithium is irritating to the gastric mucosa and should be taken with meals. A normal diet and normal salt and fluid intake (1500 to 3000 mL per day) should be maintained because lithium decreases sodium reabsorption by the renal tubules, leading to sodium depletion. A low sodium intake causes a relative increase in lithium retention and could lead to toxicity. Toxic effects include marked drowsiness and lethargy, excessive salivation, a fixed stare, akathisia, acute dystonia, and tardive dyskinesia. Hypotension, nausea, and blurred vision are occasional side effects. With immediate-release preparations, oral theophylline should be administered 4 to 6 hours after discontinuing the IV form of the medication. If the sustained-release form is used, the first oral dose should be administered immediately on discontinuation of the IV infusion. NCLEX– 182845269.doc

Because urinary retention is a side effect of benztropine mesylate, the nurse must assess for dysuria, distended abdomen, infrequent voiding in small amounts, and overflow incontinence. Monitoring of the other options is not necessary with this medication. Lisinopril is an angiotensin-converting enzyme (ACE) inhibitor used in the treatment of hypertension. The client should be instructed to rise slowly from a reclining to a sitting position, and to dangle the legs from the bed for a few moments before standing to reduce the hypotensive effect. It is not necessary to take the medication with food. If nausea occurs, the client should drink a non-cola carbonated beverage and eat salted crackers or dry toast. A full therapeutic effect may be achieved in 1 to 2 weeks. Quinidine gluconate is an antidysrhythmic medication used to maintain normal sinus rhythm after conversion of atrial fibrillation or atrial flutter. It is contraindicated in complete AV block, intraventricular conduction defects, and abnormal impulses and rhythms due to escape mechanisms, and with myasthenia gravis. It is used with caution in clients with preexisting asthma, muscle weakness, infection with fever, and hepatic or renal insufficiency. Quinupristin-dalfopristin is an antimicrobial medication used to treat endocarditis, bacteremia, and infections of the skin. It also is used to treat infections of the urinary tract, central catheter infections, and bone, joint, and respiratory system infections. For intermittent IV infusion (piggyback), the medication should be infused over a 1-hour period.

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Diarrhea, nausea, vomiting, loss of appetite, and dizziness all are common side effects of quinidine gluconate. If any of these occur, the physician or the nurse should be notified; however, the medication should never be discontinued abruptly. Rapid decrease in medication levels of antidysrhythmics could precipitate dysrhythmia. The other options indicate correct information. Diltiazem hydrochloride is a calcium channel blocker used in the treatment of atrial flutter and fibrillation. It decreases myocardial contractility and workload, thereby decreasing the need for oxygen. A bolus of 0.25 mg/kg is given slowly over 2 minutes, and a continuous infusion of 5 to 10 mg/hour may be continued for up to 24 hours. Vasopressin is a vasopressor and an antidiuretic. It increases reabsorption of water by the renal tubules, resulting in a decreased urinary flow rate. It also directly stimulates contraction of smooth muscle, causing vasoconstriction, and stimulating peristalsis. Corticosteroids, thiazide diuretics, and lithium may decrease the effect of glyburide, thus causing hyperglycemia. The medications listed in the incorrect options increase the effect of glyburide, leading to hypoglycemia. Methylergonovine, an oxytocic, is an agent that is used to prevent or control postpartum hemorrhage by contracting the uterus. The immediate dose usually is given intramuscularly, and then if addition medication is needed, it is given by mouth. It increases the strength and frequency of contractions and may elevate the blood pressure. A priority assessment NCLEX– 182845269.doc

component before the administration of methylergonovine is blood pressure. No relationship exists between the action of this medication and lochial drainage. The client taking benztropine mesylate may have decreased tolerance to heat as a result of diminished ability to sweat and should plan rest periods in cool places during the day. The client also is instructed to avoid driving or operating hazardous equipment if drowsy or dizzy. The client should be instructed to stop taking the medication if difficulty swallowing or speaking develops or if vomiting occurs; to inform the physician if central nervous system effects occur; and to monitor urinary output and watch for signs of constipation. Dizziness, nausea, headaches, nervousness, lightheadedness, and excitement, which generally are not major problems, are side effects of buspirone hydrochloride. Buspirone hydrochloride is not sedating, tolerance does not develop, and it is not addicting. Bromocriptine, an antiparkinsonian prolactin inhibitor, is used in the treatment of neuroleptic malignant syndrome. Enalapril maleate is an angiotensin-converting enzyme (ACE) inhibitor used to treat hypertension. Phytonadione is the antidote for warfarin (Coumadin) overdose. Protamine sulfate is the antidote for heparin overdose. Prozac is administered in the early morning. The other options are incorrect. Haloperidol acts by blocking the binding of dopamine to the postsynaptic dopamine receptors in the brain. Donepezil hydrochloride Thursday, October 24, 2013

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(Aricept) inhibits the breakdown of released acetylcholine. Fluoxetine hydrochloride (Prozac) is a potent serotonin reuptake blocker. Imipramine hydrochloride (Tofranil) blocks the reuptake of norepinephrine and serotonin.

Ranitidine should be taken at bedtime, when it is given as a single daily dose. This allows for prolonged effect and provides the greatest protection of the gastric mucosa both during sleep and around the clock. The other options are incorrect.

Before mixing different types of insulin, the NPH bottle should be rotated for at least 1 minute between both hands to resuspend the insulin and warm the medication. Insulin can be stored at room temperature. Additional bottles of insulin for future use should be stored in the refrigerator. Regular insulin is drawn up before NPH insulin. Air does not have to be removed from the insulin bottle.

A client who chronically uses aspirin is prone to gastric mucosal injury, which causes epigastric pain as a symptom. Misoprostol is specifically given to prevent this occurrence. Diarrhea can be a side effect of the medication but is not an intended effect. Bleeding and joint aches are not relieved by misoprostol.

Dimenhydrinate is used to treat and prevent the symptoms and signs of dizziness, vertigo, and nausea and vomiting that accompany motion sickness. The other options are incorrect. Omeprazole is a proton pump inhibitor and is classified as an antiulcer agent. The medication relieves pain from gastric irritation, which often is experienced as "heartburn" by clients. The medication does not relieve the symptoms identified in options 1, 3, and 4. Zollinger-Ellison syndrome is a hypersecretory condition of the stomach, associated with increased risk of problems from irritation of the stomach lining. Aspirin and nonsteroidal anti-inflammatory medications (NSAIDs), such as naprosyn and ibuprofen, should be avoided as potential irritants. The client should take acetaminophen for pain relief.

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Side effects of scopolamine, an anticholinergic medication, are dry mouth, urinary retention, decreased sweating, and dilation of the pupils. Each of the incorrect options state the opposite of a side effect of this medication. Droperidol may be administered by the intramuscular or the intravenous (IV) route. The IV route is the route used when relief of nausea is needed. The other options are incorrect. Propantheline decreases gastrointestinal (GI) secretions because it is an antimuscarinic anticholinergic medication. It should be administered 30 minutes before meals. The other options are incorrect. Docusate is a stool softener that relieves constipation because it promotes absorption of water into the stool, producing a softer consistency of stool. The other options are not effects of this medication. Cascara sagrada is a laxative that causes nausea and abdominal cramps as the most frequent side effects. The incorrect options represent health Thursday, October 24, 2013

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problems that are not caused by this medication.

to treat heartburn, constipation, or abdominal pain.

Most rapid results from bisacodyl occur when it is taken on an empty stomach. It will not have a rapid effect if taken with a large meal or with two glasses of milk. If it is taken at bedtime, the client will have a bowel movement in the morning.

Ondansetron is an antiemetic used for relief of postoperative nausea and vomiting, as well as nausea and vomiting associated with chemotherapy. This medication is not used to treat the other problems identified in options 1, 2, and 4.

Senna works by altering the transport of water and electrolytes in the large intestine, which causes accumulation of water in the mass of stool and increased peristalsis. The other options are incorrect actions for this medication.

Magnesium citrate is available as an oral solution and should be served chilled to make it more palatable. The other options are incorrect.

Loperamide is an antidiarrheal agent commonly administered after the client experiences loose stools. It is used to treat both acute diarrhea and chronic diarrhea from disorders such as inflammatory bowel disease. It also can be used to reduce the volume of drainage from an ileostomy. The client should understand that this medication may be habit-forming, so careful adherence to proper dose is important. The medication is an antidiarrheal and therefore should not be taken with a laxative (cathartic). Side effects of the medication include dry mouth and drowsiness. Drooling and irritability are not associated with the use of this medication.

Prochlorperazine is a phenothiazinetype antiemetic and antipsychotic agent. A frequent side effect is blurred vision. Other frequent side effects of this medication are dry eyes, dry mouth, and constipation. Pancrelipase is a pancreatic enzyme used as a digestive aid for clients with pancreatitis. It should reduce the amount of fatty stools (steatorrhea). Another recognized beneficial effect is improved nutritional status. It is not used to treat abdominal pain or heartburn and does not regulate blood glucose.

Metamucil is a bulk-forming laxative that should be taken with a full glass of water or juice, followed by another glass of liquid. This will help prevent impaction of the medication in the stomach or small intestine. The other options are incorrect.

Aluminum hydroxide tablets should be chewed thoroughly before swallowing, to prevent them from entering the small intestine undissolved. An antacid should not be taken with the medication, to prevent interactive effects. Constipation is a side effect of the use of aluminum products, but the client should not take a laxative with each dose. This would promote laxative abuse and should be avoided if less habit-forming means can be used.

Trimethobenzamide is an antiemetic agent used for relief of nausea and vomiting. Each of the other options is incorrect. The medication is not used

Calcium carbonate can be used as an antacid for the relief of heartburn and indigestion. It also can be used as a calcium supplement or to bind

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phosphorus in the gastrointestinal (GI) tract in clients with renal failure. The other options are incorrect and are not indications for the use of calcium carbonate. Sodium bicarbonate is an electrolyte modifier and antacid. With large doses or long-term use, it can cause metabolic alkalosis. The other options are incorrect. Simethicone is an antiflatulent used in the relief of pain due to excessive gas in the gastrointestinal (GI) tract. Magnesium hydroxide is an antacid and laxative, and droperidol relieves postoperative nausea and vomiting. Acetaminophen is a non-opioid analgesic. Older clients are especially susceptible to the CNS effects of cimetidine, of which confusion is most frequent. Less common CNS side effects include headache, dizziness, drowsiness, and hallucinations. The medication should be taken 1 hour before meals and at bedtime to allow it to form a protective coating over the ulcer to prevent irritation from food, gastric acid, and mechanical movement. The other options are incorrect. The blood pressure is monitored frequently during administration because pentamidine can cause severe and sudden hypotension, even with a single dose. The client should be supine while receiving the medication, and resuscitation equipment should be available. Pyrazinamide is an antituberculosis medication that is given in conjunction with other antituberculosis medications. Its use may be discontinued by the prescriber if NCLEX– 182845269.doc

sputum cultures become negative. Options 1, 3, and 4 are incorrect. The client who receives a continuous IV infusion of heparin is at risk for bleeding. The nurse assesses for signs of bleeding, which include bleeding from the gums, ecchymoses on the skin, cloudy or pink-tinged urine, tarry stools, and body fluids that test positive for occult blood. The other options are not side effects related to this medication. Procainamide is an antidysrhythmic medication used to treat ventricular dysrhythmias unresponsive to lidocaine. The other options are not indications for giving this medication. Colchicine is classified as an antigout agent that interferes with the ability of the white blood cells to initiate and maintain an inflammatory response to monosodium urate crystals. The client should report a decrease in pain and inflammation in the affected joints, as well as a decrease in number of gout attacks. The other options are incorrect. Enoxaparin is an anticoagulant that is administered to prevent deep vein thrombosis and thromboembolism in clients at risk. It is not used to treat the conditions listed in options 1, 2, or 3. Because of the antacid's aluminum base, aluminum hydroxide causes constipation as a side effect. The other side effect is hypophosphatemia, which is noted by monitoring serum laboratory studies. The other options are not side effects of this medication. A common side effect of β-adrenergic blocking agents such as pindolol is impotence. Other common side effects include fatigue and weakness. Central nervous system side effects are rarer Thursday, October 24, 2013

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and include mental status changes, nervousness, depression, and insomnia. Increased appetite, difficulty swallowing, and mood swings are not side effects of this medication.

weakness, irregular rate, and bradycardia. Bowel activity and evidence of congestive heart failure also should be assessed. The other options are incorrect.

Clotrimazole is a topical antifungal agent used in the treatment of cutaneous fungal infections. It is not used for sneezing, fever, or pain.

Ringing in the ears and vertigo are two symptoms of ototoxicity that may indicate dysfunction of the eighth cranial nerve. This is a frequent adverse effect of therapy with the use of aminoglycosides and could result in permanent hearing loss. In clients with these symptoms, the nurse should withhold the dose of the medication and notify the physician. Nausea, vomiting, and hypotension are rare side effects of the medication.

Azithromycin is a macrolide antibiotic used to treat infection. It is not used to treat pain, joint inflammation, or blood pressure. Cyclopentolate is a rapidly acting mydriatic and cycloplegic medication that is used preoperatively to dilate the eye. It is effective in 25 to 75 minutes, and accommodation returns in 6 to 24 hours. The statements in the other options are incorrect. Atropine sulfate must be available in the event of systemic toxicity from pilocarpine hydrochloride. Pilocarpine toxicity is manifested by vertigo, bradycardia, tremors, hypotension, syncope, cardiac dysrhythmias, and seizures. Disulfiram is an alcohol deterrent used in the management of alcoholism in selected clients. Naloxone hydrochloride is an opioid antagonist used to reverse narcoticinduced respiratory depression. Cyclopentolate is a rapidly acting mydriatic and cycloplegic medication used preoperatively for surgical procedures on the eye. Betaxolol is an antiglaucoma medication and a β-adrenergic blocker. Systemic effects of this medication are hypotension, dizziness, nausea, diaphoresis, headache, fatigue, constipation, and diarrhea. The client should have the blood pressure monitored for hypotension and the pulse assessed for strength, NCLEX– 182845269.doc

Amiodarone is an antiarrhythmic used to treat life-threatening ventricular arrhythmias that do not respond to first-line agents. The client requires continuous cardiac monitoring, with infusion of the medication by an intravenous pump. Although the other assessments are not incorrect, monitoring of cardiac rhythm is the priority nursing action. Mild intoxication with aspirin is called salicylism and can be experienced by the client when the daily dosage of aspirin is more than 4 g. Tinnitus (ringing in the ears) is the most frequent effect noted with intoxication. Hyperventilation may occur because salicylates stimulate the respiratory center. Fever may result because salicylates interfere with the metabolic pathways coupling oxygen consumption and heat reduction. Options 1, 2, and 4 are not signs of aspirin intoxication. Sucralfate forms a protective coating over the gastric ulcer. It should be taken 1 hour before meals because food intake will stimulate gastric acid production and mechanical irritation Thursday, October 24, 2013

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causing irritation to the gastric ulcer. It also is taken at bedtime to provide a protective coating over the gastric ulcer during the nighttime hours. Options 1, 2, and 3 are incorrect. Hemorrhagic cystitis is a toxic effect that can occur with the use of this medication. The client who is taking cyclophosphamide needs to be instructed to drink copious amounts of fluids during the administration of this medication. The medication should be taken on an empty stomach, but if the client complains of gastrointestinal (GI) upset, it can be taken with food. Orange juice probably would cause and increase the GI upset. Option 3 will not assist in relieving the discomfort experienced by the client. Bleomycin is an antineoplastic medication that can cause interstitial pneumonitis, which can progress to pulmonary fibrosis. The highest priority is to monitor lung sounds for the presence of crackles, which may indicate pulmonary toxicity. Pulmonary function studies along with hematologic, hepatic, and renal function tests are required in monitoring for toxic effects of this agent. If pulmonary toxicity develops, the medication would be discontinued. Although options 1, 2, and 4 may be a component of the nurse's assessment, option 3 is of the highest priority in administering this medication. Acetylcysteine can be given orally or by nasogastric tube to treat acetaminophen overdose. It is administered by inhalation for use as a mucolytic. Before administration of the medication as an antidote, the nurse would ensure that the client's stomach is empty through emesis or gastric lavage. The solution is diluted in cola, water, or juice to make the solution more palatable. It is not administered NCLEX– 182845269.doc

via nebulizer, intravenously, or subcutaneously for the client experiencing acetaminophen overdose. Codeine sulfate is an opioid analgesic and can cause constipation. The client is instructed to increase fluid intake to prevent constipation. The client also should consume foods high in fiber and should take a stool softener. Dantrolene can cause liver damage, and the nurse should monitor results of the client's liver function studies. Baseline liver function studies are done before therapy starts, and regular liver function studies are performed throughout therapy. Dantrolene is discontinued if no relief of spasticity is achieved in 6 weeks. Options 1, 2, and 3 are not related to the administration of this medication. The normal PT is 12 to 14 seconds. A prolonged PT may be considered therapeutic for the client on anticoagulant therapy such as warfarin sodium. For the client on anticoagulant therapy, a PT of 1.5 to 2.5 times the normal value may be considered appropriate, putting option 4 within the therapeutic range. Filgrastim is a granulocyte colonystimulating factor produced by human recombinant DNA. It is administered to clients with agranulocytosis to promote the growth of neutrophils and enhance the function of mature neutrophils. Options 1, 3, and 4 are not actions of this medication. Filgrastim is a granulocyte colonystimulating factor produced by human recombinant DNA technology. It is given by subcutaneous injection, continuous subcutaneous infusion, or continuous intravenous infusion.

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Filgrastim is used to promote the growth of neutrophils and enhance the function of mature neutrophils. Treatment is continued until the absolute neutrophil count reaches 10,000/mm3. Options 1, 3, and 4 are unrelated to the action of this medication. Filgrastim may be administered by continuous IV infusion. It should be stored in a refrigerator and should be discarded if it has been exposed to room temperature for more than 6 hours. The solution should not be shaken. It is diluted only with D5W when administered by the IV route. Fexofenadine is an antihistamine used to relieve symptoms associated with seasonal allergic rhinitis. The nurse would evaluate for a therapeutic response to the medication by determining if the client has obtained relief of symptoms of red, watery, and itchy eyes and sneezing. Options 2, 3, and 4 are unrelated to the use of this medication. Acetic acid solution is used for irrigating, cleansing, and packing wounds infected by P. aeruginosa. Glycerin is an emollient that is used for dry, cracked, and irritated skin. Aspercreme and Myoflex are used to treat muscular aches. The instructions for the use of malathion are as follows: Sprinkle lotion on dry hair and rub gently until the scalp is moistened; allow to dry naturally; after 8 to 12 hours, wash the hair with a nonmedicated shampoo; rinse and use a fine-toothed comb to remove lice; and repeat in 7 to 9 days if needed. Lindane shampoo is worked into dry hair in the affected area and left in place for 4 minutes. Then the NCLEX– 182845269.doc

shampoo is rinsed off with warm water. Dead nits can be removed with a comb or tweezers. Although one treatment usually is sufficient, a second application in 7 days may be required. BenGay is one of many products used for the temporary relief of muscular aches, rheumatism, arthritis, sprains, and neuralgia. These types of products contain combinations of antiseptics, local anesthetics, analgesics, and counterirritants. A heating pad should not be applied because irritation or burning of the skin may occur. The medication is not addicting, does not act in a systemic manner, and does not cause sleepiness. Lithium is an antimanic medication and is used to treat the manic phase of a manic-depressive disorder. Options 1, 3, and 4 are incorrect. Lindane can penetrate the intact skin and can cause convulsions if absorbed in sufficient quantities. Clients at highest risk for convulsions are premature infants, children, and clients with preexisting seizure disorders. Lindane should not be used in pediatric clients unless safer medications have failed to control the infection. Topical glucocorticoids can be absorbed into the systemic circulation. Absorption is higher from regions where the skin is especially permeable (scalp, axilla, face, eyelids, neck, perineum, genitalia) and lower from regions where penetrability is poor (back, palms, soles). A topical glucocorticoid will relieve inflammation. The mother should be advised not to apply a tight-fitting diaper or plastic pants after applying the medication because these items Thursday, October 24, 2013

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will act as an occlusive dressing. The use of occlusive dressings (bandages or plastic wraps) over the affected site is avoided after application of the topical glucocorticoid, unless the physician specifically prescribes this wound coverage. The medication is gently rubbed into the skin after a thin layer is applied. Topical glucocorticoids can be absorbed in sufficient amounts to produce systemic toxicity. Principal concerns are growth retardation (in children) and adrenal suppression in all age groups. Systemic toxicity is more likely under extreme conditions of use such as with prolonged therapy in which extensive surfaces are treated with high doses of highpotency agents in conjunction with occlusive dressings. Salicylic acid is readily absorbed through the skin, and systemic toxicity (salicylism) can result. Symptoms include tinnitus, hyperpnea, dizziness, and psychological disturbances. Lower leg pains, constipation, and diarrhea are not associated with salicylism. Azelaic acid is a topical medication used to treat mild to moderate acne. It appears to work by suppressing growth of Propionibacterium acnes and by decreasing proliferation of keratinocytes. Options 2, 3, and 4 are accurate statements regarding the use of this medication. A 2% minoxidil solution is used for topical treatment of baldness. The usual dosage is 1 mL applied twice a day. Options 2, 3, and 4 are incorrect. Clotrimazole is a topical antifungal agent used in the treatment of cutaneous fungal infections. The nurse monitors the effectiveness of this medication by noting the presence or NCLEX– 182845269.doc

absence of a skin rash, characteristic of this infection. Options 1, 3, and 4 are unrelated to the use of this medication. Tolbutamide is an oral hypoglycemic agent and is taken in the morning with breakfast to minimize gastric irritation and to enhance diabetic control. It stimulates the pancreas to produce the insulin that is needed during the day. If the tubing is removed from an IV pump and the tubing is not clamped, the client will receive a bolus of the solution and the medication contained in the solution. The client who receives a bolus dose of heparin is at risk for bleeding. If the results of the next PTT are extremely high, a dose of protamine sulfate, the antidote for heparin, may be prescribed. Aminocaproic acid is an antithrombinolytic (inhibits clot breakdown). Enoxaparin is an anticoagulant. Vitamin K is the antidote for warfarin sodium (Coumadin). Procainamide is an antiarrhythmic medication often used to treat ventricular arrhythmias that do not adequately respond to lidocaine (Xylocaine). The effectiveness of this medication is best determined by evaluating the client's cardiac rhythm. Thus, a cardiac monitor would be the most appropriate device for determining the client's response, although the blood pressure cuff and the pulse oximeter would provide general information about the client's cardiovascular status. A glucometer is not needed for this client with the information presented. Inamrinone is an inotropic agent used to relieve the manifestations of heart failure. Therapeutic effects include a Thursday, October 24, 2013

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decrease in edema, weight (fluid), dyspnea, and lung crackles. Blood pressure should remain stable or increase (if the client is hypotensive). Hypotension is a cardiovascular adverse effect of the medication. Hypokalemia can result from longterm use of cascara sagrada, a laxative. The medication stimulates peristalsis and alters fluid and electrolyte transport, thus helping fluid to accumulate in the colon. Options 2, 3, and 4 are not specifically associated with the use of this medication. Drowsiness, dizziness, and dry mouth are the most common side effects of cyclobenzaprine. This medication is a centrally acting skeletal muscle relaxant used in the management of muscle spasm that accompanies a variety of conditions. Options 1, 3, and 4 are incorrect.

or discontinue the medication, because severe rebound hypertension can occur. Enoxaparin sodium is an anticoagulant. Accidental overdose of this medication may lead to bleeding complications. The antidote is protamine sulfate. Vitamin K is the antidote for warfarin sodium (Coumadin). Adrenalin is a trademarked preparation of epinephrine, which normally is used to treat hypersensitivity reactions or acute bronchial asthma attacks and bronchospasms. Insulin dosages are verified by another nurse before administration. When two types of insulins are mixed, the doses must be verified after each is drawn up in order to verify the dosage for each one. The Regular insulin is drawn into the syringe first.

Levofloxacin should be administered with water. Antacids, zinc, and iron supplements decrease absorption and should be taken at least 4 hours before or 2 hours after the medication.

Gemfibrozil is a lipid-lowering agent. It is given as part of a therapeutic regimen that also includes dietary counseling—specifically, the limitation of saturated and other fats in the diet.

If nausea occurs, it is not necessary to notify the physician. The client should be instructed to consume noncaffeinated carbonated beverages, unsalted crackers, or dry toast to alleviate the nausea. To reduce the hypotensive effect of this medication, the client is instructed to rise slowly from a lying to a sitting position and to permit the legs to dangle from the bed momentarily before standing. The client should report signs of a sore throat or fever to the physician because these may indicate infection. The client should be notified that several weeks may be needed for the full therapeutic effect of blood pressure reduction. The client also should be instructed not to skip doses

In atrial fibrillation, the walls of the atria fibrillate. The physician may prescribe a daily aspirin. This will prevent embolus secondary to clot formation along the walls of the atria. Atrial fibrillation puts the client at risk for mural thrombi because of the sluggish blood flow through the atria that occurs as a result of loss of the atrial kick. Although aspirin does have anti-inflammatory properties, it cannot prevent any inflammation from occurring, as stated in option 2. Options 3 and 4 also are incorrect.

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Anaphylactic shock is a possible reaction to penicillin therapy, and the onset of anaphylaxis nearly always occurs within 10 minutes. The client Thursday, October 24, 2013

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should be observed for 30 minutes after intramuscular injection so that if anaphylaxis develops, treatment is immediately available. Options 1 and 4 are inaccurate interventions. Option 3 is unnecessary. Cardiotoxicity can occur with the use of doxorubicin. The medication can produce irreversible toxicity to the heart, including ECG changes and congestive heart failure. Elevated values on renal function tests (options 1 and 2) are not associated with the use of this medication. A red coloration of the urine may occur with the use of this medication, but this effect is harmless. Mupirocin is a topical antibacterial agent active against impetigo caused by staphylococci or streptococci. Acyclovir is a topical antiviral agent that inhibits DNA replication in the virus. It inhibits the activity of herpes simplex types 1 and 2, varicellazoster, Epstein-Barr virus, and cytomegalovirus. Triple antibiotic would not be effective in treating impetigo. Benzoyl peroxide is a keratolytic. Sunscreens are most effective when applied about 30 minutes to 1 hour before exposure to the sun, so that they can penetrate the skin. All sunscreens should be reapplied after swimming or sweating. Fenofibrate (Tricor) is a fibric acid derivative that is used to treat hyperlipidemia. Contraindications to the use of fibrates include known medication allergy, severe liver or kidney disease, cirrhosis, and gallbladder disease. Nitrofurazone is applied topically to the burn and has a broad spectrum of antibiotic activity. It is used in secondNCLEX– 182845269.doc

or third-degree burns when bacterial resistance to other agents is a potential problem. A film of 1/16 inch is applied directly to the burn using a sterile gloved hand. The burn site is washed daily. Saline-soaked dressings are not used. Mafenide acetate is bacteriostatic for both gram-negative and gram-positive organisms and is used to treat secondand third-degree burns to reduce the number of bacteria present in avascular tissues. The client should be informed that the medication will cause local discomfort, stinging, and burning. Mafenide acetate is a carbonic anhydrase inhibitor and can suppress renal excretion of acid, thereby causing acidosis. Clients receiving this treatment should be monitored for acidosis and if the acidosis becomes severe, the medication should be discontinued for 1 to 2 days. An elevated blood pressure may be expected in the client with pain. Hypotension is not associated with the use of this medication. A Vigilon dressing is used to clean small partial-thickness burns. It is a colloidal suspension on a polyethylene mesh support, is permeable to gases and water vapor, and provides a moist environment. It is secured over the wound with gauze or tape and is changed daily. Option 4 is incorrect. Sodium hypochlorite is a solution that is used for irrigating and cleaning necrotic or purulent wounds. It can be used for packing necrotic wounds but cannot be used to pack purulent wounds, because the solution is inactivated by copious pus. It should not come in contact with healing or normal tissue, and it should be rinsed off immediately if used for irrigation. Thursday, October 24, 2013

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Solutions are unstable and must be prepared fresh for each use. Tretinoin decreases cohesiveness of the epithelial cells, increasing cell mitosis and turnover. It is potentially irritating, particularly when used correctly. Within 48 hours of use, the skin generally becomes red and begins to peel. It is not necessary to notify the physician if this occurs. Options 1, 2, and 4 are correct client statements. Tretinoin is applied liberally to the skin. The hands are washed thoroughly immediately after applying. Therapeutic results should be seen after 2 to 3 weeks but may not be optimal until after 6 weeks. The client may use cosmetics, but the skin needs to be cleansed thoroughly before applying the medication. Isotretinoin is administered two times daily for 15 to 20 weeks. The usual adult dosage is 0.5 to 1 mg/kg/day. If needed, a second course may be given, but not until 2 months have elapsed after completing the first course. The medication needs to be taken with food to facilitate absorption. The tablets should be administered whole and not crushed. Isotretinoin can elevate triglyceride levels. Blood triglyceride levels should be measured before treatment and periodically thereafter until the effects on the triglycerides have been determined. The client needs to be instructed about the importance of follow-up to evaluate the triglyceride level. Options 2, 3, and 4 are not necessary to monitor while taking this medication. Doxycycline is a tetracycline. Adverse effects of isotretinoin can be increased by the use of tetracyclines. NCLEX– 182845269.doc

Tetracyclines increase the risk of pseudotumor cerebri and papilledema. Because of the potential for increased toxicity, tetracyclines should be discontinued before isotretinoin therapy. The medications identified in options 1, 3, and 4 are not contraindicated. The wound should be cleansed with a sterile solution and gently patted dry. A thin layer of Elase is applied and covered with a petrolatum gauze. If a dry powder is used, for best effects the solution should be prepared just before use. Azithromycin (Zithromax) is a macrolide antibiotic that has excellent tissue penetration properties and can reach high concentrations in infected tissues. It has a long duration of action, which allows it to be dosed once daily. Taking the medication with food or an antacid decreases both the rate and extent of gastrointestinal absorption. Therefore, it is best to take the medication with water on an empty stomach. Colchicine is classified as an antigout agent. It interferes with the ability of the white blood cells to initiate and maintain an inflammatory response to monosodium urate crystals. The client should report a decrease in pain and inflammation in the affected joints, as well as a decrease in the number of gout attacks. Options 1, 2, and 4 are not associated with the use of this medication. Enoxaparin is an anticoagulant that is administered by the subcutaneous route. It is used in preventing thromboembolism in selected clients at risk. It also may be be administered by the client at home after hospital discharge with follow-up assessments by a home health nurse. Thursday, October 24, 2013

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Zidovudine effectively interferes with HIV replication but can cause bone marrow suppression. Anemia occurs most commonly after 4 to 6 weeks of therapy. Hematology studies need to be monitored for anemia and granulocytopenia. Renal and liver function tests also should be monitored. Options 1, 2, and 3 are not associated with the use of zidovudine. Hair regrowth with the use of minoxidil is most likely to occur when baldness has developed recently and has been limited to a small area. On discontinuation of the medication, newly gained hair is lost in 3 to 4 months, and the natural progression of hair loss resumes. Options 1 and 4 are incorrect. Option 3 places the client's question on hold and is inappropriate. Trolamine salicylate is one of many products used for the temporary relief of muscular aches, rheumatism, arthritis, sprains, and neuralgia. These products contain combinations of antiseptics, local anesthetics, analgesics, and counterirritants. A heating pad should not be applied because irritation or burning of the skin may occur. The medication does not act in a systemic manner (option 2). They are not prescribed to cause the skin to peel, so if this kind of reaction occurs, the physician should be notified. Simethicone is an antiflatulent used to relieve pain caused by excessive gas in the gastrointestinal tract. Magnesium hydroxide is an antacid and laxative. Droperidol is used to treat postoperative nausea and vomiting. Acetaminophen is a nonopioid analgesic. Sulfonamides can intensify the effects of warfarin sodium (Coumadin), phenytoin (Dilantin), and orally NCLEX– 182845269.doc

administered hypoglycemics such as tolbutamide (Orinase). When combined with sulfonamides, these medications may require a reduction in dosage. Phenytoin is an anticonvulsant. Gingival hyperplasia, bleeding, swelling, and tenderness of the gums can occur with the use of this medication. The client needs to be taught good oral hygiene, gum massage, and the need for regular dentist visits. The client should not skip medication doses because inadequate blood levels could precipitate a seizure. Capsules should not be chewed or broken, and they must be swallowed. The client needs to be instructed to report a sore throat, fever, glandular swelling, or any skin reaction because such findings may indicate hematological toxicity. Dexamethasone may be given by direct intravenous injection or intravenous infusion. Dexamethasone may be mixed with 0.9% sodium chloride or 5% dextrose. If administered as an infusion, a minimum amount of diluting solution is needed. Dantrolene can cause liver damage, and the nurse should monitor results of liver function studies. Liver function studies are done before therapy starts to obtain baseline values and then are performed regularly throughout therapy. Dantrolene is discontinued if no relief of spasticity is achieved in 6 weeks. Incoordination and drowsiness are common side effects of diazepam. Options 1, 3, and 4 are unrelated to the use of this medication.

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Permethrin rinse is an over-thecounter scabicide that kills lice and eggs with one application and has residual activity for 10 days. It is applied to the hair after shampooing and left for 10 minutes before rinsing out. The hair should not be shampooed for 24 hours after the treatment. Thioridazine hydrochloride, an antipsychotic, can cause postural hypotension. The client needs to be taught to get out of bed slowly and to rise from a sitting position slowly because of this untoward effect of the medication. Options 1, 2, and 3 are not related to this medication. Lisinopril (Zestril) is an angiotensinconverting enzyme (ACE) inhibitor that is used to treat hypertension or heart failure. It is not used to treat gastroesophageal reflux disorder, venous insufficiency, or immune disorder. An ACE inhibitor is used to treat hypertension or heart failure. An adverse effect of ACE inhibitors is a characteristic dry, nonproductive cough. This can be quite bothersome to a client, and the medication may need to be changed. The cough is reversible with discontinuation of therapy. Options 2, 3, and 4 are incorrect. Uric acid is produced when purine is catabolized. Probenecid is a medication used for clients with gout to inhibit the reabsorption of uric acid by the kidney and promote excretion of uric acid in the urine. Clients are instructed to modify their diets to limit excessive purine intake. High-purine foods to avoid or limit include organ meats, roe, sardines, scallops, anchovies, broth, mincemeat, herring,

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shrimp, mackerel, gravy, yeast, wine, and alcohol. Medications known to lower cyclosporine levels include phenytoin, phenobarbital, rifampin, and trimethoprim-sulfamethoxazole. Cyclosporine levels should be monitored and the dosage adjusted in clients taking these medications. For IV administration of cyclosporine, 1 mL of concentrate is diluted in 20 to 100 mL of 0.9% sodium chloride or 5% dextrose. The initial dose is 5 to 6 mg/kg (one-third the oral dose) administered over 2 to 6 hours. The solution should be protected from light. Muromonab-CD3 is a monoclonal antibody. On binding to the CD3 site, the antibody blocks all T-cell functions. Options 2, 3, and 4 are not actions of this medication. Because of the risk of anaphylaxis during the administration of cyclosporine by the IV route, epinephrine and oxygen must be immediately available for use. An oral airway or a suction machine is not the priority item, and it is not necessary to have a code cart at the bedside. An antihistamine provides relief of symptoms caused by allergy. Antihistamines should be discontinued for at least 3 days (72 hours) before allergy skin testing to avoid falsenegative readings. This client should have the appointment rescheduled for 3 days after discontinuing the medication. Acetylcystine can be given orally or by nasogastric tube to treat acetaminophen overdose, or it may be given by inhalation for use as a mucolytic. Before giving the medication as an antidote to Thursday, October 24, 2013

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acetaminophen, the nurse ensures that the client's stomach is empty through emesis or gastric lavage. The solution is diluted in cola, water, or juice to make the solution more palatable. It is then administered orally or by nasogastric tube. Naloxone hydrochloride is an antidote to opioids, and it also may be given to the postoperative client to treat respiratory depression. When given postoperatively for respiratory depression, it also may reverse the effects of analgesics. Therefore, the nurse must assess the client for a sudden increase in level of postoperative pain. The client taking a single daily dose of theophylline, a xanthine bronchodilator, should take the medication early in the morning. This enables the client to have maximal benefit from the medication during daytime activities. Additionally, this medication causes insomnia. The client should take in at least 2 L of fluid per day to decrease viscosity of secretions. The client should check with the physician before changing brands of the medication because levels of bioavailability may vary for different preparations. The client also should check with the physician before taking over-the-counter cough, cold, or other respiratory preparations because they could have interactive effects, increasing the side effects of theophylline and causing dysrhythmias. Epoetin alfa is administered parenterally either by the intravenous or the subcutaneous route. It cannot be given orally because it is a glycoprotein and would be degraded in the gastrointestinal tract.

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Acetylsalicylic acid (aspirin) may be used to reduce the risk of recurrent transient ischemic attacks (TIAs) or stroke, or reduce the risk of MI in clients with unstable angina or with a history of a previous MI. The normal dose for clients being treated with acetylsalicylic acid (aspirin) to decrease thrombosis and MI is 300 to 325 mg daily, and some physicians may prescribe even a lower dose. Clients taking aspirin to prevent TIAs usually are prescribed 1.3 g daily in two to four divided doses. Clients with rheumatoid arthritis are treated with 3.2 to 6 g daily in divided doses. Diclofenac is a nonsteroidal antiinflammatory drug (NSAID). Interactions may occur with the use of anticoagulants, and the nurse should consult with the physician about a potential medication interaction if an anticoagulant is prescribed. Primidone and phenytoin are anticonvulsant medications. Acetaminophen is a nonopioid analgesic. These medications are not contraindicated with diclofenac. Clients taking antihypocalcemic medications should be instructed to avoid the use of mineral oil as a laxative because it decreases vitamin D absorption, and vitamin D is needed to assist in the absorption of calcium. Options 1, 3, and 4 are basic measures to alleviate constipation. The normal maintenance dose of levothyroxine in an adult is 0.1 to 0.2 mg daily. Maintenance dose for infants 0 to 6 months of age is 0.025 to 0.05 mg daily; for children 1 to 5 years of age, 0.075 to 0.1 mg daily; and for children 6 to 12 months of age, 0.05 to 0.075 mg daily. Abacavir is an antiretroviral agent that inhibits activity of HIV-1 reverse Thursday, October 24, 2013

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transcriptase and inhibits viral DNA growth. Options 2, 3, and 4 are not actions of this medication.

antiretroviral agents. It is not used to treat the conditions noted in options 2, 3, and 4.

Abacavir is an antiretroviral agent that may increase liver enzymes, triglycerides, and the blood glucose level. Baseline liver function studies will be done at the initiation of therapy and at periodic intervals during therapy. The tests identified in the other options are unnecessary.

Zidovudine is a nucleoside reverse transcriptase inhibitor used to treat HIV infection in combination with other antiretroviral agents. It interferes with viral RNA-dependent DNA polymerase, an enzyme necessary for viral HIV replication. It slows HIV replication, reducing the progression of HIV infection. Options 1, 2, and 4 are not actions of this medication.

Abacavir (Ziagen) is an antiretroviral agent that is used to treat human immunodeficiency virus infection in combination with other medications. Frequent side effects include nausea, vomiting, diarrhea, decreased appetite, and insomnia. Options 2, 3, and 4 are not side effects of this medication. Abacavir (Ziagen) is an antiretroviral agent that is used to treat human immunodeficiency virus infection in combination with other medications. Adverse effects include hypersensitivity, hypotension, lactic acidosis, and severe hepatomegaly. Options 1, 2, and 3 are not adverse effects of this medication; rather, they are side effects of the medication. Abacavir is an antiretroviral agent that is used to treat human immunodeficiency virus (HIV) infection in combination with other medications. It will not cure HIV infection, nor will it reduce the risk of transmitting the infection to others. Eating small frequent meals will help offset the nausea. The client taking this medication should check with the physician before taking any over-thecounter medications. Zidovudine is a nucleoside reverse transcriptase inhibitor used to treat HIV infection in combination with other NCLEX– 182845269.doc

Mydriatic eyedrops cause pupillary dilation. The nurse would expect to note dilated pupils if an effective response occurred. Option 1 identifies oval pupils, which sometimes are seen with head injuries or increased intracranial pressure. Option 2 identifies constricted pupils. Option 3 identifies a unilateral dilated pupil, indicating cranial nerve III damage. Zidovudine is a nucleoside reverse transcriptase inhibitor used to treat human immunodeficiency virus (HIV) infection in combination with other antiretroviral agents. A contraindication to the medication is a client history of hypersensitivity to this medication. Cautions include bone marrow suppression, renal and hepatic dysfunction, and conditions that cause decreased hepatic blood flow. The items noted in options 2, 3, and 4 are not contraindications or cautions related to this medication. Zidovudine is a nucleoside reverse transcriptase inhibitor used to treat human immunodeficiency virus (HIV) infection in combination with other antiretroviral agents. Because anemia and granulocytopenia can occur with this medication, a CBC will be done periodically. The tests identified in options 1, 3, and 4 are unnecessary. Thursday, October 24, 2013

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Zidovudine is a nucleoside reverse transcriptase inhibitor used to treat human immunodeficiency virus (HIV) infection in combination with other antiretroviral agents. Common side effects include nausea and a headache. Options 1, 2, and 3 are not side effects of this medication. Zidovudine is a nucleoside reverse transcriptase inhibitor used to treat human immunodeficiency virus (HIV) infection in combination with other antiretroviral agents. Adverse effects include anemia and granulocytopenia, and neurotoxicity as evidenced by ataxia, fatigue, lethargy, and nystagmus. Seizures can also occur. Options 1, 2, and 4 are not adverse effects of this medication. Zidovudine is a nucleoside reverse transcriptase inhibitor used to treat human immunodeficiency virus (HIV) infection in combination with other antiretroviral agents. Diarrhea is an occasional side effect of the medication and does not warrant physician notification. Options 2, 3, and 4 are correct client statements. Capecitabine is an antimetabolite used to treat metastatic breast cancer that is resistant to other therapy. It also is used to treat colon cancer. It is not used to treat the conditions noted in options 1, 2, and 4. Capecitabine is an antimetabolite that inhibits enzymes necessary for the synthesis of essential cellular components. It interferes with DNA synthesis, RNA processing, and protein synthesis. Options 2, 3, and 4 are not actions of this medication. Capecitabine is an antimetabolite used to treat metastatic breast cancer that is resistant to other therapy. A contraindication to the use of this NCLEX– 182845269.doc

medication is severe renal impairment. The items noted in options 1, 2, and 4 are not contraindications to this medication. Capecitabine is an antimetabolite used to treat metastatic breast cancer that is resistant to other therapy. Bone marrow depression can occur from the use of this medication, and a CBC and blood chemistries should be done periodically. The tests identified in options 2, 3, and 4 are unnecessary. Capecitabine is an antimetabolite used to treat metastatic breast cancer that is resistant to other therapy. Bone marrow depression can occur from the use of this medication, and a CBC and blood chemistries should be done periodically. The tests identified in options 2, 3, and 4 are unnecessary. Capecitabine is an antimetabolite used to treat metastatic breast cancer that is resistant to other therapy. Adverse effects include bone marrow depression, cardiovascular toxicity, and respiratory toxicity. Options 1, 3, and 4 are not adverse effects of this medication. Capecitabine is an antimetabolite used to treat metastatic breast cancer that is resistant to other therapy. Adverse effects include bone marrow depression, cardiovascular toxicity, and respiratory toxicity. The client should monitor body temperature and contact the physician if signs of infection occur. Diarrhea is a frequent side effect of this medication, but the client should contact the physician if it becomes severe. The client is instructed to obtain physician approval before receiving immunizations because the medication lowers the body's resistance to infection. Options 1, 2, and 3 are correct client statements. Thursday, October 24, 2013

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A component of therapy for the treatment of DKA is the administration of Regular insulin by the intravenous (IV) route. Regular insulin is the only type of insulin that can be given by the IV route. Propofol is an anesthetic agent that is used to provide continuous sedation in a client receiving mechanical ventilation. It is diluted only with 5% dextrose (D5W). Acetylsalicylic acid is a nonsteroidal agent that is prescribed for its antiinflammatory, antipyretic, and anticoagulant properties. The client may self-administer acetylsalicylic acid to treat a headache, backache, or muscle aches, but a 5-g daily dose would not be used to treat these discomforts. A dosage of 3.2 to 6 g daily in divided doses may be prescribed for the client with rheumatoid arthritis. Acetylsalicylic acid is a nonsteroidal agent that is prescribed for its antiinflammatory, antipyretic, and anticoagulant properties. All of the options identify the action of this medication; however, for the client with angina, this medication is prescribed to inhibit platelet aggregation. Acetylsalicylic acid is a nonsteroidal agent that is prescribed for its antiinflammatory, antipyretic, and anticoagulant properties. Contraindications to the medication include gastrointestinal bleeding or ulceration, bleeding disorders, history of hypersensitivity to aspirin or other nonsteroidal anti-inflammatory medications, impaired hepatic function, and chickenpox or flu in children or teenagers. The items noted in options 1, 2, and 3 are not contraindications to this medication. NCLEX– 182845269.doc

Acetylsalicylic acid is a nonsteroidal agent that is prescribed for its antiinflammatory, antipyretic, and anticoagulant properties. Serum blood levels may be determined periodically to assess for an effective antiarthritic effect. The therapeutic serum level for an antiarthritic effect is 20 to 30 mg/dL. Toxicity occurs if levels are above 30 mg/dL. Acetylsalicylic acid is a nonsteroidal agent that is prescribed for its antiinflammatory, antipyretic, and anticoagulant properties. Occasional side effects include gastrointestinal distress such as cramping, mild nausea, heartburn, and abdominal distention. The client also should selfmonitor for evidence of allergic reaction such as pruritus, urticaria, and difficulty breathing. Acetylsalicylic acid may be used to treat muscle aches. Burning on urination and constipation are not side effects of this medication. Acetylsalicylic acid is a nonsteroidal agent that is prescribed for its antiinflammatory, antipyretic, and anticoagulant properties. High doses can produce gastrointestinal bleeding or gastric mucosal lesions. Low-grade toxicity is characterized by ringing in the ears, generalized pruritus (which may be severe), headache, dizziness, flushing, tachycardia, hyperventilation, sweating, and thirst. Marked toxicity is manifested by hyperthermia, restlessness, abnormal breathing pattern, convulsions, respiratory failure, and coma. Options 2, 3, and 4 are not related to toxic effects of this medication. Acetylsalicylic acid is a nonsteroidal agent and is prescribed for its antiinflammatory, antipyretic, and anticoagulant properties. The medication can cause gastrointestinal Thursday, October 24, 2013

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(GI) side effects, and the client is instructed that the medication can be taken with milk or meals if GI distress occurs. If the client develops ringing in the ears or persistent GI pain, the physician needs to be notified. The enteric-coated form or sustainedreleased form should not be crushed or broken. It may take 1 to 3 weeks for a therapeutic anti-inflammatory effect to occur. Atenolol is a β-adrenergic blocker that is used as an antihypertensive, antianginal, and antiarrhythmic. It is a used to treat conditions such as hypertension and angina pectoris. It is not used to treat the conditions noted in options 1, 2, and 4. Additionally, its use is contraindicated in the client with heart block greater than first degree. Atenolol is a β-adrenergic blocker that is used as an antihypertensive, antianginal, and antiarrhythmic. It blocks β-adrenergic receptors in cardiac tissue and produces the therapeutic effects of slowing the heart rate, decreasing cardiac output, decreasing blood pressure, and decreasing myocardial oxygen demand. Atenolol is a β-adrenergic blocker that is used as an antihypertensive, antianginal, and antiarrhythmic. It blocks β-adrenergic receptors in cardiac tissue and produces the therapeutic effects of slowing the heart rate, decreasing cardiac output, decreasing blood pressure, and decreasing myocardial oxygen demand. Contraindications to the medication include severe bradycardia, cardiac failure, cardiogenic shock, and heart block greater than first-degree. Options 1, 3, and 4 are not contraindications to this medication (option 4 is a normal NCLEX– 182845269.doc

finding). The medication is used to lower the blood pressure (option 1). Although the temperature indicated in option 3 is slightly above normal, it is unrelated to the use of this medication. Atenolol is a β-adrenergic blocker that is used as an antihypertensive, antianginal, and antiarrhythmic. It blocks β-adrenergic receptors in cardiac tissue and produces the therapeutic effects of slowing the heart rate, decreasing cardiac output, decreasing blood pressure, and decreasing myocardial oxygen demand. The nurse would check the client's apical heart rate and blood pressure immediately before administering the medication. If the heart rate is 60 beats/min or lower or if the systolic blood pressure is less than 90 mm Hg, the medication is withheld and the physician is contacted. Options 1, 2, and 3 are unrelated to the administration of this medication. Atenolol is a β-adrenergic blocker that is used as an antihypertensive, antianginal, and antiarrhythmic. It blocks β-adrenergic receptors in cardiac tissue and produces the therapeutic effects of slowing the heart rate, decreasing cardiac output, decreasing blood pressure, and decreasing myocardial oxygen demand. Frequent side effects include hypotension manifested as dizziness, nausea, diaphoresis, headache, cold extremities, fatigue, and constipation or diarrhea. Occasional side effects include insomnia, flatulence, urinary frequency, and impotence or decreased libido. Options 2, 3, and 4 are not side effects of this medication. Atenolol is a β-adrenergic blocker that is used as an antihypertensive, antianginal, and antiarrhythmic. It Thursday, October 24, 2013

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blocks β-adrenergic receptors in cardiac tissue and produces the therapeutic effects of slowing the heart rate, decreasing cardiac output, decreasing blood pressure, and decreasing myocardial oxygen demand. Adverse effects include profound bradycardia or hypotension. Options 1, 2, and 4 are not adverse effects of this medication. Nausea and diaphoresis are side effects of the medication.

Atorvastatin is a 3-hydroxymethyl-3glutaryl–coenzyme A (HMG-CoA) reductase inhibitor used to treat hypercholesterolemia and hypertriglyceridemia. Contraindications to the medication include active liver disease, unexplained elevated liver function tests, pregnancy, and lactation. The items noted in options 1, 2, and 3 are not contraindications to this medication.

Atenolol is a β-adrenergic blocker that is used as an antihypertensive, antianginal, and antiarrhythmic. It blocks β-adrenergic receptors in cardiac tissue and produces the therapeutic effects of slowing the heart rate, decreasing cardiac output, decreasing blood pressure, and decreasing myocardial oxygen demand. Abrupt withdrawal may result in sweating, palpitations, headache, and tremulousness and may precipitate congestive heart failure or myocardial infarction in a client with cardiac disease. Abrupt withdrawal can also cause rebound hypertension. Options 1, 3, and 4 are correct client statements.

Atorvastatin is a 3-hydroxymethyl-3glutaryl–coenzyme A (HMG-CoA) reductase inhibitor used to treat hypercholesterolemia and hypertriglyceridemia. Because the medication is metabolized in the liver, baseline and periodic liver function tests, as well as cholesterol and triglyceride levels, should be done periodically. The tests identified in options 1, 3, and 4 are unnecessary.

Atorvastatin is a 3-hydroxymethyl-3glutaryl–coenzyme A (HMG-CoA) reductase inhibitor used to treat hypercholesterolemia and hypertriglyceridemia. It is not used to specifically treat the conditions noted in options 1, 2, and 4. Atorvastatin is a 3-hydroxymethyl-3glutaryl–coenzyme A (HMG-CoA) reductase inhibitor used to treat hypercholesterolemia and hypertriglyceridemia. It decreases LDL cholesterol and plasma triglycerides and increases HDL cholesterol. Options 2, 3, and 4 are not actions of this medication. NCLEX– 182845269.doc

Atorvastatin is a 3-hydroxymethyl-3glutaryl–coenzyme A (HMG-CoA) reductase inhibitor used to treat hypercholesterolemia and hypertriglyceridemia. A frequent side effect is headache. Occasional side effects include myalgia, rash or pruritus (signs of an allergic reaction), flatulence, and dyspepsia. Options 1, 2, and 4 are not side effects of this medication. Atorvastatin is a 3-hydroxymethyl-3glutaryl–coenzyme A (HMG-CoA) reductase inhibitor used to treat hypercholesterolemia and hypertriglyceridemia. Adverse effects include photosensitivity and the potential for developing cataracts. Options 1, 3, and 4 are not adverse effects of this medication. Atorvastatin is a 3-hydroxymethyl-3glutaryl–coenzyme A (HMG-CoA) reductase inhibitor used to treat Thursday, October 24, 2013

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hypercholesterolemia and hypertriglyceridemia. The client is instructed to follow the recommended diet as an important component of therapy. Liver function tests and cholesterol and triglyceride level determinations will be performed periodically while the client is taking the medication. The client needs to be instructed to consult with the physician before taking any over-thecounter medications. Carbamazepine is classified as an iminostilbene derivative and is used as an anticonvulsant, antineuralgic, antimanic, and antipsychotic. It is not used to treat any of the conditions noted in options 1, 3, and 4. Carbamazepine is classified as an iminostilbene derivative and is used as an anticonvulsant, as well as an antineuralgic, antimanic, and antipsychotic. Options 2, 3, and 4 are not actions of this medication. Carbamazepine is classified as an iminostilbene derivative and is used as an anticonvulsant, antineuralgic, antimanic, and antipsychotic. It is used to treat seizure disorders, trigeminal neuralgia, and diabetic neuropathy. The medication can cause blood dyscrasias as a toxic reaction and is contraindicated if the client has a history of bone marrow depression or of hypersensitivity to tricyclic antidepressants, and with concurrent use of monoamine oxidase inhibitors. Carbamazepine is classified as an iminostilbene derivative and is used as an anticonvulsant, antineuralgic, antimanic, and antipsychotic. The medication can cause blood dyscrasias as a toxic reaction and the client should have a CBC done before therapy and periodically during therapy. Additional laboratory tests NCLEX– 182845269.doc

that should be done include a serum iron determination, urinalysis, and blood urea nitrogen determination. The tests identified in options 1, 2, and 4 are unnecessary. Warfarin sodium is an anticoagulant that prevents further extension of formed existing clots and also prevents new clot formation and secondary thromboembolic complications. The medication should be taken exactly as prescribed and at the same time daily. Because the medication places the client at risk for bleeding, the client is instructed to avoid alcohol and salicylates (acetylsalicylic acid, or aspirin). The client needs to avoid all over-thecounter medications and needs to consult with the physician before taking any other medications because of the risk for medication interactions. Digoxin (Lanoxin) is a cardiac glycoside that is used to treat dysrhythmias such as atrial fibrillation in the client with heart failure. Digoxin blood levels need to be checked while the client is taking this medication to monitor for toxicity. The therapeutic blood serum level of digoxin ranges from 0.8 to 2 ng/mL. Therefore, a blood level of 2.1 ng/mL is just above the high end of the therapeutic range. Additionally, a low K+ level increases the risk of digoxin toxicity. The normal K+ level is 3.5 to 5.1 mEq/L. Thrombolytic medications are used to treat acute thrombolytic disorders. These medications dissolve clots. Because these medications alter the hemostatic capability of the client, if bleeding occurs it can be difficult to control. Options 2, 3 and 4 are not actions of this medication. Streptokinase is a thrombolytic medication that is used to manage Thursday, October 24, 2013

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acute myocardial infarction. It lyses thrombi that are obstructing the coronary arteries, decreases infarct size, improves ventricular function, decreases the risk of congestive heart failure, and limits the risk of death associated with myocardial infarction. Options 1, 3, and 4 are not actions of this medication. Diltiazem is a calcium channel blocker that inhibits calcium movement across cell membranes of cardiac and smooth muscle. It dilates coronary arteries and peripheral arteries and arterioles. Diltiazem decreases the heart rate and slows SA and AV conduction. Propranolol is a β-adrenergic blocker used as an antihypertensive, antianginal, antidysrhythmic, and antimigraine medication. It may precipitate congestive heart failure (CHF) or myocardial infarction in persons with cardiac disease. Signs of CHF include dyspnea (particularly on exertion or lying down), night cough, peripheral edema, and distended neck veins. If signs of CHF occur, the physician needs to be notified. Options 1, 3, and 4 identify side effects of this medication and do not warrant physician notification if they occur. Hydrochlorothiazide is a diuretic and antihypertensive medication used to treat mild to moderate hypertension, edema associated with heart failure, and nephrotic syndrome. The medication is a sulfonamide derivative. A contraindication to the use of this medication is a history of hypersensitivity to sulfonamides. The most common early manifestations of digoxin toxicity are gastrointestinal disturbances such as anorexia, nausea, and vomiting and neurological disturbances as fatigue, headache, weakness, drowsiness, NCLEX– 182845269.doc

confusion, and nightmares. Visual disturbances such as photophobia, light flashes, halos around bright objects, and yellow or green color perception also may be noted. In agranulocytosis, the WBC count decreases as a result of bone marrow suppression, and the deficiency causes the affected person to become susceptible to serious infection. Some antipsychotic medications, such as clozapine, can produce this adverse effect, and a baseline WBC count and periodic evaluation of the WBC count are done during therapy with this medication. A BUN and creatinine above normal may indicate renal disease. Although a basophil count is a component of the WBC differential count, it does not provide adequate data to determine the presence of agranulocytosis. Ringing in the ears and vertigo are two symptoms that may indicate dysfunction of the eighth cranial nerve. Ototoxicity is a toxic effect of therapy with the aminoglycosides and could result in permanent hearing loss. The nurse should withhold the dose and notify the physician. Options 1, 2, and 4 are inappropriate nursing actions. Hydralazine is an antihypertensive medication used in the management of moderate to severe hypertension. The blood pressure and pulse should be monitored frequently after administration, so a blood pressure cuff and a stethoscope are the items to have in place. Options 1, 2, and 3 are not necessary. The client who receives an opioid analgesic should immediately have the siderails raised on the bed, to prevent injury once the medication has taken effect. Dimming the light in Thursday, October 24, 2013

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the room is the next most helpful action. The name bracelet should have been checked before administering the medication. It is unnecessary to do ROM at the site of injection.

of congestive heart failure, and cold hands and feet. Gastrointestinal disturbances, anxiety and nervousness, and unusual tiredness and weakness also can occur.

The nurse should always inspect the vial of insulin before use for changes that may signify loss of potency. NPH insulin normally is uniformly cloudy. Clumping, frosting, and precipitates are signs of insulin damage. In this situation, because potency is questionable, it is safer to discard the vial and draw up the dose from a new vial.

Torsemide is a loop diuretic. The medication can produce acute and profound water loss, volume and electrolyte depletion, dehydration, decreased blood volume, and circulatory collapse. Option 4 is the only option that indicates an electrolyte depletion, because the normal potassium level is 3.5 to 5.1 mEq/L. The normal sodium level is 135 to 145 mEq/L. The normal chloride level is 98 to 107 mEq/L. The normal blood BUN is 5 to 20 mg/dL.

Valproic acid is an anticonvulsant that causes central nervous system (CNS) depression. For this reason, the side effects include sedation, dizziness, ataxia, and confusion. When the client is taking this medication as a single daily dose, administering it at bedtime negates the risk of injury from sedation and enhances client safety. The medication also should be administered at the same time each day. Clients with Parkinson's disease are at risk for postural (orthostatic) hypotension from the disease. This problem is exacerbated with the introduction of levodopa, which also can cause postural hypotension and increase the client's risk for falls. Although knowledge of the client's use of assistive devices and history of falls is helpful, neither of these options is the most important element of the assessment based on the wording of this question. Clients with Parkinson's disease generally have resting tremor, not intention tremor. Sotalol is a β-adrenergic blocking agent. Side effects include bradycardia, palpitations, difficulty breathing, irregular heart beat, signs NCLEX– 182845269.doc

Adverse reactions to or toxic effects of tobramycin sulfate include nephrotoxicity as evidenced by an increased BUN and serum creatinine; irreversible ototoxicity as evidenced by tinnitus, dizziness, ringing or roaring in the ears, and reduced hearing; and neurotoxicity as evidenced by headaches, dizziness, lethargy, tremors, and visual disturbances. A normal white blood cell count is 4500 to 11,000 cells/mm3. The normal sedimentation rate is 0 to 30 mm/hr. The normal total bilirubin level is less than 1.5 mg/dL. The normal BUN concentration is 8 to 25 mg/dL. Clients who are taking antabuse must be taught that substances containing alcohol can trigger an adverse reaction. Sources of hidden alcohol include foods (soups, sauces, vinegars), medicine (cold medicine), mouthwashes, and skin preparations (alcohol rubs, aftershave lotions). Nitroglycerin may be self-administered sublingually 5 to 10 minutes before an activity that triggers chest pain. Thursday, October 24, 2013

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Tablets should be discarded 6 to 9 months after opening the bottle, and a new bottle of pills should be obtained from the pharmacy. Nitroglycerin is very unstable and is affected by heat and cold, so it should not be kept close to the body (warmth) in a shirt pocket; rather, it should be kept in a jacket pocket or purse. Headache often occurs with early use and diminishes in time. Acetaminophen (Tylenol), rather than aspirin (acetylsalicylic acid), may be used to treat headache. Glyburide is a second-generation sulfonylurea used to treat diabetes mellitus. The client is instructed to take a single daily dose 15 to 30 minutes before breakfast. Cholestatic jaundice is a potential adverse reaction, and if the client exhibits signs of jaundice (skin color changes or pale-colored stools), the physician needs to be notified. The medication is not used to prevent foot infections. Altered taste sensation is a frequent side effect and does not warrant physician notification. Fosphenytoin sodium (Cerebyx) is used for short-term parenteral (intravenous [IV]) infusion. A child who is not tolerating medications by mouth and has a seizure disorder would need an anticonvulsant administered by the parenteral route. Phenobarbital (Luminal) is an antiseizure medication that is given by mouth or parenterally, but because the child has been on phenytoin (Dilantin), the medication of choice in this case would be fosphenytoin. Valproic acid (Depakene) and clonazepam (Klonopin) usually are given by mouth. An urticarial reaction is characterized by a rash accompanied by pruritus. This type of transfusion reaction is prevented by pretreating the client with an antihistamine such as NCLEX– 182845269.doc

diphenhydramine. Acetaminophen and acetylsalicylic acid are analgesics, and ibuprofen is a nonsteroidal antiinflammatory drug. Raloxifene (Evista) is an estrogen receptor modulator. It was developed to limit the side effects of estrogen while producing beneficial effects. The purpose of this medication is to increase bone mineral density, which makes option 2 correct. Option 1 is incorrect because leg tenderness or cramps can indicate deep vein thrombosis, which is an adverse effect. The modulating effects of this medication can lead to hot flashes and vaginal bleeding. Dantrolene (Dantrium) acts directly on skeletal muscle to relieve muscle spasticity. The primary action is the suppression of calcium release from the sarcoplasmic reticulum. This in turn decreases the ability of the skeletal muscle to contract. Baclofen is the only skeletal muscle relaxant that can be administered intrathecally within the spinal column. Therefore, options 1, 2, and 3 are incorrect. The normal adult dosage for carisoprodol (Soma) is 350 mg orally three to four times daily. Pyridoxine reverses the therapeutic effects of levodopa. Dietary restrictions are not necessary, but ingredients of multivitamins should be considered. Many multivitamins contain pyridoxine and should be avoided. Careful reading of over-thecounter vitamin labeling is necessary to avoid increasing pyridoxine in the diet. The statements in options 2, 3, and 4 are incorrect. A complication of head injury is diabetes insipidus, which can occur Thursday, October 24, 2013

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with insult to the hypothalamus, the antidiuretic hormone storage vesicles, or the posterior pituitary gland. Urine output that exceeds 9 L per day generally requires treatment with desmopressin. Dexamethasone, a glucocorticoid, is administered to treat cerebral edema. This medication may already be ordered for the headinjured client. Ethacrynic acid and mannitol are diuretics, which would be contraindicated. Naoloxone hydrochloride (Narcan) should be titrated every 2 to 5 minutes according to client response. Therefore, options 1, 2, and 4 are incorrect. Leukocytosis and a slight temperature elevation can indicate an infection in a client on a biological response modifier. These findings warrant physician notification and possible discontinuation of the medication. Irritation and erythema are common and can be decreased by rotating the injection sites. Arthritic symptoms often do not lessen early in the treatment, and arthritic medications often are given other medications, such as a tumor necrosis factor inhibitor. Dolobid may be given with water, milk, or meals. The tablets should not be crushed or broken open. This situation does not warrant physician notification at this time. Baclofen is dispensed in tablets of 10 and 20 mg for oral use. Dosages are low initially and then are increased gradually. Maintenance doses range from 15 to 20 mg administered three to four times a day. Influenza vaccinations are recommended yearly and developed according to predicted strain for NCLEX– 182845269.doc

persons at high risk. Influenza immunization is recommended for high-risk clients. Anyone in close contact with persons with a chronic respiratory or other chronic disorder should receive the vaccine. Adults with chronic metabolic disease such as diabetes mellitus are in the high-risk population. Residents of chronic care facilities are at risk for influenza. Health care workers are in the highrisk population. The influenza vaccine does not treat an active infection with the virus. Healthy children are not in the high-risk population. Ramipril (Altace) is an angiotensinconverting enzyme (ACE) inhibitor, and a serious side effect is profound hypotension. The client's blood pressure should be checked before administration of this medication. The medication does not cause weight gain or loss, bradycardia, or depletion of potassium. Urinary retention is a side effect of benztropine mesylate. The nurse needs to observe for dysuria, distended abdomen, infrequent voiding of small amounts, and overflow incontinence. Options 1, 2, and 4 are unrelated to the side effects of this medication. Enoxaparin is an anticoagulant. A common side effect of anticoagulant therapy is bleeding. Accordingly, the nurse questions the client about signs and symptoms that could indicate bleeding, such as bleeding gums, bruising, hematuria, or dark tarry stools.

The client who has been prescribed sulfasalazine should be checked for history of allergy to either sulfonamides or salicylates because Thursday, October 24, 2013

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the chemical composition of sulfasalazine and that of these medications are similar. The other options are incorrect. Glucocorticoids have three primary uses: replacement therapy for adrenal insufficiency, immunosuppressive therapy, and anti-inflammatory therapy. Exogenous glucocorticoids cause the same effects on cellular activity as those of the naturally produced glucocorticoids; however, exogenous glucocorticoids also may have undesired effects. The glucocorticoids stimulate appetite and increase caloric intake. They also increase the availability of glucose for energy. These combined effects cause the blood glucose levels to rise, making the client prone to hyperglycemia. Options 1, 2, and 4 are not expected effects of the use of glucocorticoids. Soft contact lenses may be permanently damaged by the orange discoloration in body fluids caused by rifampin. Any sign of possible jaundice (yellow-colored skin) should always be reported. If rifampin is not tolerated on an empty stomach, it may be taken with food. The client may be on the medication for 12 months even if cultures give negative results. Tambocor is an antidysrhythmic medication that slows conduction and decreases excitability, conduction velocity, and automaticity. The nurse needs to monitor for the development of a new or a worsening arrhythmia. Options 1, 3, and 4 are components of standard care. Intravenous nitroprusside is a potent vasodilator that reduces preload and afterload. It is the medication of choice for the client with pulmonary edema. Digoxin is a cardiac glycoside NCLEX– 182845269.doc

that increases cardiac contractility. Morphine sulfate is an opioid analgesic. Furosemide is a loop diuretic and can reduce preload by enhancing the renal excretion of sodium and water, which reduces circulating blood volume. Headache, hypertension, tachycardia, nausea, and vomiting are precursors to hypertensive crisis brought about by the ingestion of foods rich in tyramine and tryptophan while the client is taking MAOIs. These medications act by decreasing the amount of MAO in the liver, which is necessary for the breakdown and utilization of tyramine and tryptophan. Hypertensive crisis may lead to circulatory collapse, intracranial hemorrhage, and death. Bumetanide is a loop diuretic that is not potassium sparing. The value given for potassium is below the therapeutic range of 3.5 to 5.1 mEq/L for this electrolyte. The nurse should notify the physician before giving the dose so that potassium supplementation may be ordered. Options 1, 3, and 4 identify normal values. Hydralazine is an antihypertensive medication used in the management of moderate-to-severe hypertension. It is a vasodilator medication that decreases afterload. The blood pressure needs to be monitored. Options 2, 3, and 4 are unrelated to the use of this medication. Ketorolac is a nonopioid analgesic and nonsteroidal anti-inflammatory agent (NSAID). It acts by inhibiting prostaglandin synthesis and produces analgesia that is peripherally mediated. The nurse evaluates the effectiveness of this medication by using the pain rating scale with the Thursday, October 24, 2013

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client. Options 1, 2, and 3 are unrelated to the use of this medication. The client is experiencing signs and symptoms of what is called "red neck syndrome." This is a response due to histamine release that occurs with rapid or bolus injection of this medication. The client may experience chills, fever, flushing of the face or trunk, tachycardia, syncope, tingling, and an unpleasant taste in the mouth. The corrective action is to administer the medication more slowly. An antihistamine such as diphenhydramine (Benadryl) may be administered as well. Atropine sulfate is an anticholinergic medication that causes tachycardia, drowsiness, blurred vision, dry mouth, constipation, and urinary retention. The nurse monitors the client for any of these effects in the immediate postoperative period. Tobramycin is an antibiotic (aminoglycoside) that causes nephrotoxicity and ototoxicity. The medication is working if the WBC count drops back into the normal range and kidney function remains normal. Option 2 indicates an abnormal WBC count, and options 3 and 4 are unrelated to the use of this medication. Lithium is used to treat manic disorders, not depression. Side effects of lithium are nausea, tremors, polyuria, and polydypsia. Serum lithium concentration is assessed approximately every 2 to 4 days during initial therapy, and at longer intervals thereafter. Toxic levels of lithium may induce electrocardiogram changes; however, performing weekly ECGs is unnecessary if therapeutic levels are maintained. NCLEX– 182845269.doc

Hyperpyrexia with body temperatures up to 107° F may be present in NMS. Signs and symptoms develop suddenly and may include respiratory distress and muscle rigidity. As the condition progresses, evidence of tachycardia, hypertension, increasing respiratory distress, confusion, and delirium may appear. The frequency and severity of symptoms are compounded when two or more antipsychotics are taken concomitantly. Phenelzine sulfate is in the monoamine oxidase inhibitor (MAOI) class of antidepressant medications. A person taking an MAOI must avoid aged cheeses, alcoholic beverages, avocados, bananas, and caffeine drinks. Other food items to avoid include chocolate, meat tenderizers, pickled herring, raisins, sour cream, yogurt, and soy sauce. Medications that should be avoided include amphetamines, antiasthmatics, and certain antidepressants. Clients taking MAOI medications also should avoid antihistamines, antihypertensive medications, levodopa, and meperidine (Demerol). Aspirin is irritating to the gastrointestinal (GI) tract of the client with a history of gastritis. The client should be advised to take analgesics that do not contain aspirin, such as acetaminophen. The other medications listed have aspirin in them. Another category of medications that is irritating to the GI tract is that of the nonsteroidal antiinflammatory drugs (NSAIDs). The client taking an angiotensinconverting enzyme (ACE) inhibitor is instructed to take the medication exactly as prescribed, to monitor blood pressure weekly, and to continue with other lifestyle changes to control hypertension. The client Thursday, October 24, 2013

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should change positions slowly to avoid orthostatic hypotension, should report fever, mouth sores, or sore throat to the physician (neutropenia), and needs to avoid salt substitutes and high-potassium foods. Salt substitutes contain potassium, as do high-potassium foods, placing the client at risk for hyperkalemia. Lovastatin is a reductase inhibitor. It results in an increase in high-density lipoprotein (HDL) cholesterol and a decrease in the triglycerides and lowdensity lipoprotein (LDL) cholesterol. This medication is converted by the liver to active metabolites and therefore is not used in clients with active hepatic disease or elevated transaminase levels. Because it is metabolized by the liver, clients are recommended to have periodic liver function studies. Periodic cholesterol levels also are needed to monitor the effectiveness of therapy. Lovastatin is a reductase inhibitor. It results in an increase in high-density lipoprotein (HDL) cholesterol and a decrease in the triglycerides and lowdensity lipoprotein (LDL) cholesterol. This medication is converted by the liver to active metabolites and therefore is not used in clients with active hepatic disease or elevated transaminase levels. Because it is metabolized by the liver, clients are recommended to have periodic liver function studies. Periodic cholesterol levels also are needed to monitor the effectiveness of therapy. Persantine combined with warfarin sodium (Coumadin) is prescribed to protect the client's artificial heart valves. Persantine does not prevent heart attacks, strokes, or hypertension.

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Aspirin can interact with the anticoagulant medication to increase clotting time beyond therapeutic ranges. Avoiding aspirin is a priority. Not all activities need to be avoided. Walking and climbing stairs are acceptable activities. The client does not need to avoid brushing the teeth; however, the client should be instructed to use a soft toothbrush. The client should be taught that ketoconazole is an antifungal medication. It should be taken with food or milk. Antacids should be avoided for 2 hours after it is taken because gastric acid is needed to activate the medication. The client should avoid concurrent use of alcohol, because the medication is hepatotoxic. The client should also avoid exposure to sunlight, because the medication increases photosensitivity. BuSpar may be administered without regard to meals, and the tablets may be crushed. This medication is not available in liquid form. It is premature to advise the client to call the physician for a change in medication without first trying alternative interventions. Mixing the tablet uncrushed in apple sauce will not ensure ease in swallowing. Baclofen is a skeletal muscle relaxant. The client should be cautioned against the use of alcohol and other central nervous system (CNS) depressants because baclofen potentiates the depressant activity of these agents. Constipation rather than diarrhea is an adverse effect. Restriction of fluids is not necessary, but the client should be warned that urinary retention can occur. Fatigue is related to a CNS effect that is most intense during the early phase of therapy and diminishes with continued medication use. The Thursday, October 24, 2013

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client does not need to notify the physician about fatigue.

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