NUR 02 PHARMACOLOGY EXAM 1

NUR 02 PHARMACOLOGY EXAM 1 1-A client with primary hypothyroidism has been taking levothyroxine for 1 year. Laboratory results today show high levels of thyroid stimulating hormone (TSH). Which teaching should the nurse plan to implement? 1. "A new prescription will be issued for a decreased dose of levothyroxine." 2. "Discontinue levothyroxine immediately; we will reassess TSH levels in 3 months." 3. "Start taking your levothyroxine with dietary fiber or calcium to increase its effectiveness." 4. "You will need to get this new prescription filled for an increased dose of levothyroxine." Explanation: Levothyroxine (Synthroid) is a thyroid hormone replacement drug that is the most common treatment for hypothyroidism, a condition in which thyroid hormone deficit slows the metabolic rate. In primary hypothyroidism, the deficit occurs due to a problem in thyroid gland tissue or hormone synthesis. TSH is released from the pituitary and stimulates the thyroid gland to secrete thyroid hormones (T3, T4). In primary hypothyroidism, when the thyroid does not synthesize enough T3 or T4, the pituitary releases additional TSH to compensate. This results in high levels of circulating TSH. Clients are prescribed levothyroxine (or their dose is augmented) to increase T3 and T4; this lowers TSH and leads to a euthyroid (normal) state (Options 1 and 2). (Option 3) For best results, levothyroxine should be taken on a consistent morning schedule before food ingestion. Foods containing certain ingredients (eg, cottonseed meal, walnuts, soybean flower, dietary fiber, calcium) can affect drug absorption. Educational objective: In primary hypothyroidism, the deficit occurs due to a problem in thyroid gland tissue or hormone synthesis. When the thyroid does not synthesize enough T3 or T4, the pituitary releases additional TSH to compensate. This results in high levels of circulating TSH. Levothyroxine is usually started/increased to lead to a euthyroid (normal) state. 2-A client with chronic kidney disease has received a continuous intravenous infusion of heparin for 5 days. The nurse reviews the coagulation studies and the medication administration record. Which prescription would the nurse question? Click on the exhibit button for additional information. 1. Epoetin 2. Sodium polystyrene sulfonate 3.Vitamin K 4. Warfarin Vitamin K (phytonadione) is a fat-soluble vitamin that is administered as an antidote for warfarin-related bleeding. This medication prescription should be questioned as vitamin K reverses the anticoagulant effect of warfarin, and the client's coagulation studies are in the therapeutic range (aPTT 46-70 sec, INR 2- 3). (Option 1) Epoetin (Procrit) is a synthetic hormone that stimulates the production of erythropoietin and is used to treat anemia associated with chronic kidney disease. This is an appropriate prescription. (Option 2) Sodium polystyrene sulfonate (Kayexalate) is a sodium exchange resin administered to reduce elevated serum potassium levels in clients with chronic kidney disease and hyperkalemia. This is an appropriate prescription for this client. (Option 4) Warfarin (Coumadin) is a vitamin K antagonist used for long-term anticoagulation that is started about 5 days before a continuous heparin infusion is discontinued. An overlap of the parenteral and oral anticoagulant is required for about 5 days as this is the time it takes warfarin to reach therapeutic level. This is an appropriate prescription for this client. Educational objective: Anticoagulants stop thrombus formation by interfering with the coagulation cascade. Parenteral heparin and oral warfarin affect the clotting cascade differently; therefore, a 5-day overlap for the 2 drugs is required. This allows warfarin to reach a therapeutic level before the continuous heparin infusion is stopped. 3-A home health nurse visits a client 2 weeks after discharge from the hospital. The client experienced an acute myocardial infarction and subsequent heart failure. Home medications are listed in the exhibit. Which symptom reported by the client is most concerning to the nurse? Click on the exhibit button for additional information. 1. Bruising easily, especially on arms 2. Fatigue 3. Feeling depressed 4.Muscle cramps in legs Explanation: The nurse would be most concerned with the client's report of muscle cramps in the legs. This could be a sign of hypokalemia caused by use of the diuretic furosemide or possibly a reaction from the statin medication atorvastatin. Hypokalemia may manifest as muscle cramps, weakness, or paralysis and typically starts with the leg muscles. Hypokalemia could be dangerous in this client due to possible arrhythmias in the presence of existing cardiac dysfunction. The client may need to be started on supplemental potassium and a high-potassium diet if the serum potassium level is low. If the potassium level is normal, atorvastatin may be responsible for muscle cramps. (Option 1) Bruising, especially on the upper extremities, is common with the use of antiplatelet agents such as aspirin and clopidogrel. The nurse should teach the client to monitor for other, more severe signs of bleeding, such as blood in the stool. (Option 2) The myocardial infarction and heart failure have most likely reduced the client's functional capacity and can cause fatigue. Beta blockers such as metoprolol can also cause fatigue. This will improve with time, and the nurse should talk to the client about possible cardiac rehabilitation. (Option 3) Feeling depressed is common after an acute health-related event such as a myocardial infarction. The client needs to be evaluated further and may need an antidepressant. However, feelings of depression are not immediately life-threatening unless the client exhibits suicidal ideation. Educational objective: The nurse should recognize muscle cramps in the legs as a possible sign of hypokalemia in the client taking diuretics. Muscle cramps should be reported to the health care provider in anticipation of checking a potassium level, adding a potassium supplement, and instructing the client to eat potassium-rich foods. 4-The health care provider (HCP) has told a client to take over-the-counter (OTC) supplemental calcium carbonate 1000 mg/day for treatment of osteoporosis. Which instruction should the clinic nurse give the client? 1. Monthly calcium levels will need to be drawn 2. Stop vitamin D supplements when taking calcium 3. Take calcium at bedtime 4. Take calcium in divided doses with food Explanation: Calcium and vitamin D are essential for bone strength. Calcium carbonate (Caltrate) has the most available elemental calcium of OTC products and is inexpensive; it is therefore the preferred calcium supplement for most clients with osteoporosis. Calcium absorption is impaired when taken in excess of 500 mg per dose. Therefore, most clients should take supplements in divided doses (<500 mg per dose). These should be taken within an hour of meals as food increases calcium absorption. Constipation is a frequent side effect of calcium supplements, so clients should be advised to take appropriate precautions. Calcium carbonate and calcium acetate (PhosLo) are used to reduce serum phosphorous levels in clients with chronic kidney disease. In such cases, calcium should remain in the intestine and bind the phosphorous present in food; the calcium phosphorus product would then be excreted in stool. Therefore, these clients should take calcium supplements before meals. (Option 1) Calcium levels may need to be checked periodically, but it is not necessary to do so monthly. (Option 2) Vitamin D also increases calcium absorption and is important for treatment of osteoporosis. There is no need to stop it. (Option 3) Calcium does not need to be taken at any particular time of day. Educational objective: The nurse should encourage the client with osteoporosis to take supplemental calcium with food to increase its absorption. Vitamin D will also enhance absorption. Multiple daily doses are recommended as calcium absorption is impaired when taken in excess of 500 mg per dose. Constipation is a frequent side effect of calcium supplementation. 5-A nurse in the cardiac intermediate care unit is caring for a client with acute decompensated heart failure (ADHF). The client also has a history of coronary artery disease and peripheral vascular disease. The nurse is preparing to administer medications. Based on the assessment data, the nurse should question which medication? Click on the exhibit button for additional information. 1. Aspirin 2. Atorvastatin 3. Furosemide 4. Metoprolol Explanation: Beta blockers, or "lols" (metoprolol, carvedilol, bisoprolol, atenolol), are the mainstay of therapy for clients with chronic heart failure as these improve survival rates for both systolic and diastolic heart failure. However, in certain situations beta blockers can worsen heart failure symptoms by decreasing normal compensatory sympathetic nervous system responses and myocardial contractility. In this client with acute decompensated heart failure (ADHF), marginally low blood pressure (BP), crackles in the lungs, low oxygen saturation, jugular venous distension (JVD), and peripheral edema, the administration of beta blockers can cause the client to further deteriorate. Beta blockers at low doses may be able to be restarted after this client has stabilized and exacerbation of ADHF has resolved with diuresis. (Options 1 and 2) Aspirin is contraindicated if the client has evidence of bleeding. Statins are contraindicated if there is evidence of severe liver or muscle injury. It is appropriate to administer both of these medications to this client who has coronary artery disease and peripheral vascular disease. (Option 3) This client has crackles, JVD, and peripheral edema, indicating the need for furosemide (Lasix). Therefore, the nurse should continue to monitor the client's BP with the administration of furosemide as it can lower BP. When excess fluid is removed through diuresis, the heart will be able to pump more effectively, which will increase cardiac output and BP. Educational objective: The nurse should question administration of beta blockers in a client with symptoms of acute ADHF due to the possibility of further clinical deterioration. Beta blockers are most useful for chronic heart failure. 6-Which client finding would be a contraindication for the nurse to administer dicyclomine hydrochloride for irritable bowel syndrome? 1.Bladder scan showing 500 mL urine 2. Hemoglobin of 11 g/dL (110 g/L) 3. History of cataracts 4. Reporting frequent diarrhea today Explanation: Dicyclomine hydrochloride (Bentyl) is an anticholinergic medication. Anticholinergics are used to relax smooth muscle and dry secretions. Anticholinergic side effects include pupillary dilation, dry mouth, urinary retention, and constipation. Therefore, the classic contraindications are closed-angle glaucoma, bowel ileus, and urinary retention. The urge to urinate is normally present at 300 mL; pain is usually felt around 500 mL. This client has urinary retention and should not have the bladder smooth muscle further relaxed. (Option 2) Anticholinergic drugs do not affect the blood count. The normal reference range for hemoglobin is 11.7-15.5 g/dL (117-155 g/L) for females and 13.2-17.3 g/dL (132-173 g/L) for males. (Option 3) The common eye contraindication is narrow-angle glaucoma as it could worsen the condition. Cataracts are a clouding of the lens and are not related to drainage flow. (Option 4) Diarrhea is an expected finding with irritable bowel syndrome or other increased peristalsis and is a common reason for the drug to be prescribed. Anticholinergic drugs are contraindicated in the presence of a bowel ileus or atony as constipation is a side effect and further relaxation of the intestines could worsen these conditions. Educational objective: Anticholinergic drugs are contraindicated when smooth muscle relaxation is already a concern. Commonly cited contraindications include narrow-angle glaucoma, urinary retention (including benign prostatic hyperplasia), and bowel ileus/obstruction. 7-The postoperative client on hydromorphone becomes hypoxic, and naloxone is administered per protocol. What is most important for the nurse to consider in the follow-up care of this client? 1.Client's respiratory status 60 minutes later 2. Documenting the client's hypoxic event 3. Obtaining an order for a different analgesic 4. Potential for drug-drug interaction now Explanation: Hydromorphone duration of action is 3-4 hours. The effects of naloxone (Narcan) start to wane at 20- 40 minutes after administration, and its duration of action is approximately 90 minutes. Therefore, depending on the hydromorphone dose, its duration of action can continue beyond the duration of the naloxone. Repeat naloxone doses may be necessary. (Option 2) Documentation is essential, but client care is more important than paperwork. (Option 3) Naloxone will reverse the effects of the narcotic in the body and, as long as it is in the body, will reverse the effects of any additional narcotic administered. This client will need a different class of analgesic at this time. However, adequate respiration/oxygenation as the naloxone wears off is more important. (Option 4) Naloxone is the reversal agent for narcotics, and a drug-drug interaction is not a concern. Educational objective: The half-life of naloxone (Narcan) is shorter than most narcotics. When naloxone is used to reverse the effects of narcotics, the nurse must monitor the client to ensure that the client does not fall again into excessive sedation and/or respiratory depression. 8-In which scenarios should the nurse hold the prescribed medication and question its administration? Select all that apply. 1.Client on IV heparin and the platelet count is 50,000/mm3 (50 x 109/L) 2.Client on newly prescribed lisinopril and is at 8 weeks gestation 3.Client on nitroglycerine patch for heart failure and blood pressure is 84/56 mm Hg 4.Client on phenytoin for epilepsy and the nurse notes gingival hyperplasia 5.Client on warfarin and prothrombin time/International Normalized Ratio is 1.5 times control value Explanation: Heparin is a natural anticoagulant. Its risk is heparin-induced thrombocytopenia (HIT), also known as heparin-associated thrombocytopenia. Normal platelet range is 150,000-400,000/mm3 (150-400 x 109/L). A mild lowering of platelets may occur and resolve spontaneously around the 4th day of administration. The danger is type II HIT, a more severe form in which there is an acute drop in the number of platelets (more than 50% from m baseline), which requires discontinuing heparin (Option 1). Angiotensin-converting enzyme (ACE) inhibitors such as lisinopril are teratogenic. Lisinopril can cause embryonic/fetal developmental abnormalities (cardiovascular and central nervous system) if taken during pregnancy, especially during the first 13 weeks of gestation. During the 2nd and 3rd trimesters, ACE inhibitors interfere with fetal renal hemodynamics, resulting in low fetal urine output (oligohydramnios) and fetal growth restriction (Option 2). Nitroglycerine causes vasodilation and can lower blood pressure. Systolic blood pressure should be >90 mm Hg to ensure renal perfusion (Option 3). (Option 4) Gingival hyperplasia or hypertrophy is a known side effect of phenytoin (Dilantin) and is not a reason to stop the drug. Vigorous dental hygiene beginning within 10 days of initiation of phenytoin therapy can help control it. Signs and symptoms that require discontinuation include toxic levels or phenytoin hypersensitivity syndrome (fever, skin rash, and lymphadenopathy). (Option 5) Warfarin (Coumadin) is used to prolong clotting so that the desired result is a "therapeutic" range rather than the client's "normal" control value when not on the drug. Therapeutic range is considered roughly 1.5-2.5 times the control (International Normalized Ratio [INR] of 2-3), but up to 3-4 times the control (INR of 2.5-3.5) in high-risk situations such as an artificial heart valve. Educational objective: Heparin should be held when there is significant thrombocytopenia. Angiotensin-converting enzyme inhibitors are not administered to pregnant women, and nitrates are not administered when a client is hypotensive. Prothrombin time/International Normalized Ratio is expected to be 1.5-2.5 (up to 4) times the control value when therapeutic effects are reached. Gingival hyperplasia is a side effect of phenytoin (Dilantin) administration and is not a reason to stop the drug. 9-The parent of a child diagnosed with attention-deficit hyperactivity disorder (ADHD), predominantly inattentive type, says to the nurse, "I hate the idea of my child taking a drug that's a stimulant. How will I know that the methylphenidate is even working?" Which is the best response by the nurse? 1. "Methylphenidate is generally a safe and effective drug for children with ADHD." 2. "Methylphenidate will increase the levels of neurotransmitters in your child's brain." 3. "You should see your child's school grades improve." 4. "Your child should be able to more easily complete school assignments and other tasks." Explanation: Although methylphenidate (eg, Ritalin, Concerta) is classified as a stimulant, in children with ADHD it improves attention, decreases distractibility, helps maintain focus on an activity, and improves listening skills. For many years, the effects of methylphenidate in children were labeled as paradoxical. Now, research has shown that methylphenidate significantly increases levels of dopamine in the central nervous system (CNS) that lead to stimulation of the inhibitory system of the CNS. Methylphenidate works quickly; symptom relief is often seen after the first dose. (Option 1) This is a true statement; methylphenidate is generally safe for most children, adolescents, and adults. Methylphenidate can cause adverse reactions, but these affect a very small percentage of users. However, this response does not address the parent's question about how the drug works. (Option 2) This is a true statement but does not give the parent information about the benefits of methylphenidate. In addition, it contains language that most clients would not understand. (Option 3) A child's school grades may improve due to the benefits of methylphenidate. This would be seen over time as a secondary benefit; the immediate therapeutic effects are often observed with the first dose. Educational objective: The therapeutic effects of methylphenidate can be observed very quickly in children with ADHD. Methylphenidate improves attention, decreases distractibility, helps maintain focus on an activity, and improves listening skills. 10-Aclient with schizophrenia that is resistant to other antipsychotic medications is about to start on a course of clozapine. Which of these periodic measurements has the highest priority in this client? 1.Complete blood count (CBC) and absolute neutrophil count (ANC) 2. Electrocardiogram 3. Fasting blood sugar and fasting lipids 4. Height, weight, and waist circumference Explanation: Clozapine is an atypical antipsychotic medication used to treat schizophrenia that has not responded to standard, more traditional treatment. Clozapine is associated with a risk for agranulocytosis and is therefore used only in clients with treatment-resistant schizophrenia. A client must have a white blood cell (WBC) count of ≥3500/mm3 and an ANC of ≥2000/mm3 before starting clozapine treatment, and so it is most important to first obtain a baseline CBC and ANC. Agranulocytosis is reversible if caught early. Therefore, clients taking clozapine must have their WBC and ANC monitored regularly throughout the course of therapy (initially once every week). Clients should also contact the health care provider (HCP) immediately if fever or a sore throat develops, as this may indicate an underlying infection from neutropenia. Other potential adverse effects of clozapine requiring baseline assessment prior to treatment and ongoing monitoring include: •Weight gain—a baseline height, weight, and waist circumference should be obtained, and a BMI can be calculated •Hyperglycemia—symptoms of hyperglycemia (eg, increased thirst and urination, weakness, increased blood glucose) should be monitored