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

Pharmacology Nursing Test The community health nurse prepares a teaching plan for a client with latent tuberculosis who is prescribed oral isoniazid (INH). Which instructions should the nurse inclu de? Select all that apply. Unordered Options Ordered Response 1. Avoid drinking alcohol 2. Expect body fluids to change color to red 3. Report yellowing of skin or sclera 4. Report numbness and tingling of extremities 5. Take with aluminum hydroxide to prevent gastric irritation Explanation Isoniazid (INH) is a first-line antitubercular drug prescribed as monotherapy to treat latent tuberculosis infection. Combined with other drugs, INH is also used for active tuberculosis treatment. Two serious adverse effects of INH use are hepatotoxicity and peripheral neuropathy. A teaching plan for a client prescribed INH includes the following: • Avoid intake of alcohol and limit use of other hepatotoxic agents (eg, acetaminophen) to reduce risk of hepatotoxicity (Option 1) • Take pyridoxine (vitamin B6) if prescribed to prevent neuropathy • Avoid aluminum-containing antacids (eg, aluminum hydroxide (Maalox)) within 1 hour of taking INH • Report changes in vision (eg, blurred vision, vision loss) • Report signs/symptoms of severe adverse effects such as: o Hepatoxicity (eg, scleral and skin jaundice, vomiting, dark urine, fatigue) (Option 3) o Peripheral neuropathy (eg, numbness, tingling of extremities) (Options 4) (Option 2) Rifampin, another antitubercular drug, often causes a red-orange discoloration of body fluids (ie, urine, sweat, saliva, tears). However, this effect is not associated with INH use. (Option 5) Concurrent use of antacids containing aluminum decreases INH absorption. The medication may be taken with food if gastric irritation is a concern. Educational objective: Common potential side effects of INH include hepatotoxicity (eg, jaundice, vomiting, dark urine, fatigue) and peripheral neuropathy (eg, numbness, tingling of extremities). Clients should avoid alcohol use and aluminum-containing antacids, and report any experienced side effects to the health care provider immediately. In which scenarios should the nurse hold the prescribed medication and question its administration? Select all that apply. Unordered Options Ordered Response 1. Client on IV heparin and the platelet count is 50,000/mm3 (50 x 109/L) 2. Client on newly prescribed lisinopril and is at 8 weeks gestation 3. Client on nitroglycerine patch for heart failure and blood pressure is 84/56 mm Hg 4. Client on phenytoin for epilepsy and the nurse notes gingival hyperplasia 5. Client on warfarin and prothrombin time/International Normalized Ratio is 1.5 times control value Explanation Heparin is a natural anticoagulant. Its risk is heparin-induced thrombocytopenia (HIT), also known as heparin-associated thrombocytopenia. Normal platelet range is 150,000-400,000/mm3 (150-400 x 109/L). A mild lowering of platelets may occur and resolve spontaneously around the 4th day of administration. The danger is type II HIT, a more severe form in which there is an acute drop in the number of platelets (more than 50% from baseline), which requires discontinuing heparin (Option 1). Angiotensin-converting enzyme (ACE) inhibitors such as lisinopril are teratogenic. Lisinopril can cause embryonic/fetal developmental abnormalities (cardiovascular and central nervous system) if taken during pregnancy, especially during the first 13 weeks of gestation. During the 2nd and 3rd trimesters, ACE inhibitors interfere with fetal renal hemodynamics, resulting in low fetal urine output (oligohydramnios) and fetal growth restriction (Option 2). Nitroglycerine causes vasodilation and can lower blood pressure. Systolic blood pressure should be >90 mm Hg to ensure renal perfusion (Option 3). (Option 4) Gingival hyperplasia or hypertrophy is a known side effect of phenytoin (Dilantin) and is not a reason to stop the drug. Vigorous dental hygiene beginning within 10 days of initiation of phenytoin therapy can help control it. Signs and symptoms that require discontinuation include toxic levels or phenytoin hypersensitivity syndrome (fever, skin rash, and lymphadenopathy). A client with gout who was started on allopurinol a week ago calls the health care provider's (HCP's) office with several concerns. The nurse should recognize which report by the client as being significant and requiring immediate follow-up? Unordered Options Ordered Response 1. Also takes ibuprofen for pain 2. Frequency of urination has increased 3. Mild red rash has developed over torso 4. Nausea occurs after each dose Explanation Allopurinol is a medication frequently used in the prevention of gout. Gout is a buildup of uric acid deposited in the joints that causes pain and inflammation. The medication helps to prevent uric acid deposits in the joints and the formation of uric acid kidney stones. Any rash in a client taking allopurinol, even if mild, should be reported immediately to the HCP. The nurse should direct the client to stop taking the medication immediately, schedule an appointment, and notify the HCP. A rash caused by allopurinol may be followed by more severe hypersensitivity reactions that can be fatal, including Stevens-Johnson syndrome and toxic epidermal necrolysis. (Option 1) Allopurinol can take several months to become effective. Its primary use is to prevent gout attacks; it is not effective in treating acute attacks. The client will need to continue to take anti-inflammatory drugs (eg, nonsteroidal anti-inflammatory drugs or colchicine) for acute attacks. (Option 2) Clients are directed to take allopurinol with a full glass of water and to increase daily fluid intake to prevent kidney stones. This will cause an increase in urination and is an expected outcome. (Option 4) Nausea can be prevented by instructing the client to take the medication with food or following a meal. Educational objective: The nurse should direct the client taking allopurinol for gout to immediately discontinue the medication and report to the HCP if any rash develops. Allopurinol-induced rashes can develop into severe and sometimes fatal hypersensitivity reactions, such as Stevens-Johnson syndrome. Similar instructions should be given to clients taking anticonvulsants (eg, carbamazepine, phenytoin, lamotrigine) and sulfa antibiotics. A client diagnosed with trichomonal vaginal infection (trichomoniasis) is prescribed metronidazole. Which of the following is essential for the nurse to teach? Select all that apply. Unordered Options Ordered Response 1. Avoid alcohol while taking this medication 2. Perform vaginal douche for 7-10 days 3. Use birth control pills to prevent recurrence of infection 4. Your partner(s) must be treated simultaneously 5. Your urine can change to a deep red-brown color Explanation Trichomoniasis is a sexually transmitted infection (STI). Many women with trichomoniasis are asymptomatic but can have profuse frothy gray or yellow-green vaginal discharge with a fishy odor. Small red lesions (strawberry) may be present in the vagina or cervix. Pruritus is common. Metronidazole (Flagyl) is the initial drug of choice. Clients should avoid alcohol while taking metronidazole and for 24 hours after completion of the therapy due to a reaction that includes flushing, nausea/vomiting, and abdominal pain. The medication can cause a metallic taste and turn the urine a deep red-brown color. It is essential to treat the partner(s) at the same time to avoid reinfection. Clients should abstain from sexual intercourse until the infection is cleared, usually about 1 week after treatment. (Option 2) Routine vaginal douching (with a mixture of water and vinegar) is not recommended as it increases the risk of infections such as bacterial vaginosis. (Option 3) Birth control pills do not protect against transmission of STIs. The use of condoms can help prevent the spread of infection. Educational objective: Trichomoniasis is an STI. Expected symptoms include yellow-green, frothy discharge with a fishy odor and an accompanying itch. Metronidazole is the initial drug of choice. Clients should avoid alcohol while on metronidazole, which can make the urine darker and cause a metallic taste. Partners must be treated simultaneously. A male client with hypertension was prescribed amlodipine. Which of these adverse effects is most important to teach the client to watch for? Unordered Options Ordered Response 1. Erectile dysfunction 2. Dizziness 3. Dry cough 4. Leg edema Explanation Calcium channel blockers (nifedipine, amlodipine, felodipine, nicardipine) are vasodilators used to treat hypertension and chronic stable angina. They promote relaxation of vascular smooth muscles leading to decreased systemic vascular resistance and arterial blood pressure. The most important adverse effects of calcium channel blockers include dizziness (Option 2), flushing, headache, peripheral edema (Option 4), and constipation. The reduced blood pressure may initially cause orthostatic hypotension. The client should be taught to change positions slowly to prevent falls. Leg elevation and compression can help to reduce the edema. Constipation should be prevented with daily exercise and increased intake of fluids, fruits/vegetables, and high-fiber foods. (Option 3) Angiotensin-converting enzyme (ACE) inhibitors prevent the breakdown of bradykinin, which may produce a nonproductive cough in susceptible individuals. Discontinuation of the medication stops the cough. (Option 1) Adverse effects of beta-blockers include bradycardia, bronchospasm, depression, and decreased libido with erectile dysfunction. Educational objective: Calcium channel blockers are utilized to treat hypertension and chronic stable angina. Adverse effects of these medications include dizziness, flushing, headache, peripheral edema, and constipation. During shift report it was noted that the off-going nurse had given the client a PRN dose of morphine 2 mg every 2 hours for incisional pain. What current client assessment would most likely affect the oncoming nurse's decision to discontinue the administration every 2 hours? Unordered Options Ordered Response 1. Client reports burning during injection into the IV line 2. Client reports dizziness when getting up to use the bathroom 3. Client's blood pressure is 106/68 mm Hg 4. Client's respiratory rate is 11/min Explanation Morphine is an opioid analgesic that can be given intravenously for moderate to severe pain. An adverse reaction to morphine administration is respiratory depression. A respiratory rate <12/min would be a reason to hold morphine administration. The nurse should perform a more in-depth assessment of the client's pain and causes. The morphine dose may need to be decreased or the time between administrations may need to be increased. The nurse should not administer additional doses until the respiratory rate increases. (Option 1) Morphine can cause burning during IV administration. This can be reduced by diluting the morphine with normal saline and administering it slowly over 4-5 minutes. (Option 2) The nurse should instruct the client to call for help before getting up to go to use the bathroom to avoid falls caused by dizziness from the morphine. (Option 3) Morphine can lower blood pressure, and clients receiving it should have blood pressure monitored. This blood pressure reading is not severely low and is not a priority over the respiratory depression. Educational objective: Morphine administration can cause respiratory depression. The nurse should hold a dose of morphine for a client whose respiratory rate is <12/min. A client with deep vein thrombosis (DVT) is receiving a continuous infusion of unfractionated heparin. The client asks the nurse what the heparin is for. How should the nurse respond? Unordered Options Ordered Response 1. "Heparin is a blood thinner that will help to dissolve the clot in your leg." 2. "Heparin will help stabilize the clot in your leg and prevent it from breaking off and traveling to your lungs." 3. "Heparin will keep the current clot from getting bigger and help prevent new clots from forming." 4. "I'm sorry. This is something that your health care provider (HCP) can answer better upon arriving." Explanation Venous thrombosis involves the formation of a thrombus (clot) and the inflammation of the vein. Anticoagulant therapy such as heparin does not dissolve the clot. The clot will be broken down by the body's intrinsic fibrinolytic system over time. The heparin slows the time it takes blood to clot, thereby keeping the current clot from growing bigger and preventing new clots from forming. (Option 1) Anticoagulants do not dissolve clots. Thrombolytic agents (fibrinolytics), such as tissue plasminogen activator (tPA), are used to break the clots, but they also carry the risk of serious intracranial hemorrhage and are used only for acute life-/organ- threatening conditions. The body will break down the clot over a period of time. (Option 2) Heparin does not prevent the clot from breaking off but will deter the clot from growing larger. (Option 4) The nurse should be able to answer client questions regarding medications being administered. The HCP can answer any further questions the client may have. Educational objective: The nurse should teach the client that the purpose of unfractionated heparin infusion in the treatment of DVT is to slow the time it takes blood to clot, thereby keeping the current clot from getting bigger and preventing new clots from forming. An elderly client is prescribed codeine for a severe cough. The home health nurse teaches the client how to prevent the common adverse effects associated with codeine. Which client statements indicate an understanding of how to prevent them? Select all that apply. Unordered Options Ordered Response 1. "I'll be sure to apply sunscreen if I go outside." 2. "I'll drink at least 8 glasses of water a day." 3. "I'll drink decaffeinated coffee so I can sleep at night." 4. "I'll sit on the side of my bed for a few minutes before getting up." 5. "I'll take my medicine with food." Explanation Codeine is an opioid drug prescribed as an analgesic to treat mild to moderate pain and as an antitussive to suppress the cough reflex. Although the antitussive dose (10- 20 mg orally every 4-6 hours) is lower than the analgesic dose, clients can still experience the common adverse effects (eg, constipation, nausea, vomiting, orthostatic hypotension, dizziness) associated with the drug. Codeine decreases gastric motility, resulting in constipation. Increasing fluid intake and fiber in the diet and taking laxatives are effective measures to prevent constipation (Option 2). Changing position slowly is effective in preventing the orthostatic hypotension associated with codeine, especially in the elderly (Option 4). Taking the medication with food is effective in preventing the gastrointestinal irritation (eg, nausea, vomiting) associated with codeine (Option 5). (Options 1 and 3) These statements are inaccurate as photosensitivity, insomnia, palpitations, and anxiety are not adverse effects associated with codeine. Educational objective: The common adverse effects of codeine, an opioid drug, include constipation, nausea, vomiting, orthostatic hypotension, and dizziness. Interventions to help prevent them include increasing fluid intake and bulk in the diet, laxatives, taking the medication with food, and changing position slowly. A client is being discharged after having a stent placed in the left anterior descending coronary artery. The client is prescribed clopidogrel. Which client data obtained by the nurse would be concerning in relation to this new medication? Select all that apply. Unordered Options Ordered Response 1. Blood pressure of 140/84 mm Hg 2. Heart rate of 98/min 3. Platelet count of 200,000/mm3 4. Report of Ginkgo biloba use 5. Report of peptic ulcer disease Explanation Antiplatelet agents (eg, clopidogrel, ticagrelor, or prasugrel) prevent platelet aggregation and are given to clients to prevent stent re-occlusion. They prolong bleeding time and should not be taken by clients with a bleeding peptic ulcer, active bleeding, or intracranial hemorrhage. Ginkgo biloba also interferes with platelet aggregation and can cause increased bleeding time. Antiplatelet agents and Ginkgo biloba should not be taken together. If this were to occur, this client would be at an increased risk for bleeding. This information should be reported to the prescribing health care provider (HCP) before the client is discharged. (Option 1) This blood pressure is slightly elevated, but is unaffected by antiplatelet agents. (Option 2) Normal heart rate is between 60/min-100/min. (Option 3) This is a normal platelet count (150,000/mm3-400,000/mm3). Educational objective: If a client is prescribed clopidogrel, the nurse should be concerned about a history of peptic ulcer disease and Ginkgo biloba use. In this situation, the client would be at increased risk for bleeding. This data should be reported to the prescribing HCP before the client is discharged. A client with a history of degenerative arthritis is being discharged home following exacerbation of chronic obstructive pulmonary disease (COPD). After reviewing the discharge medications, the nurse should educate the client about which topics? Select all that apply. Click on the exhibit button for additional information. Unordered Options Ordered Response 1. Dryness of the mouth and throat may occur 2. Notify the health care provider (HCP) if stools are black and tarry 3. Ringing in the ears may occur 4. The albuterol canister should not be shaken before use 5. Tiotropium capsules should not be swallowed Explanation A common side effect of tiotropium (Spiriva) and other anticholinergics (eg, ipratropium, benztropine) is xerostomia (dry mouth) due to the blockade of muscarinic receptors of the salivary glands that inhibits salivation. Sugar-free candies or gum may be used to alleviate dry mouth and throat (Option 1). Tiotropium capsules should not be swallowed. These capsules are placed inside the inhaler device and the capsule is pierced, allowing the client to inhale its contents (Option 5). Glucocorticoids such as prednisone, taken in combination with aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs), can increase the risk of gastrointestinal (GI) ulceration and bleeding. The client should report the presence of black, tarry stools (melena) to the HCP as this could indicate GI bleeding (Option 2). (Option 3) Ringing in the ears is more commonly seen with salicylates such as aspirin. (Option 4) The albuterol canister should be shaken prior to inhalation. Educational objective: The nurse should teach the client who has been prescribed glucocorticoids in combination with aspirin or NSAIDs about the potential risk for GI bleeding or ulceration. Xerostomia is a common side effect of anticholinergic drugs and can be alleviated with sugar-free gum or candies. Discharge medications Albuterol: 2 puffs, every 4-6 hours as needed Prednisone: 40 mg orally, daily Naproxen: 220 mg orally, twice daily Tiotropium: 1 capsule inhaled, daily A client has nausea, abdominal cramping, and persistent mucus-like, watery diarrhea that is positive for Clostridium difficile. The nurse anticipates the client will be prescribed which medication to treat this condition? Unordered Options Ordered Response 1. Ceftriaxone 2. Fluconazole 3. Metronidazole 4. Pantoprazole Explanation C difficile is often associated with antibiotic therapy but can also be a nosocomial hospital-acquired infection. Antibiotics, especially broad-spectrum, reduce normal bacteria in the body. This allows other bacteria, such as C difficile, to take over and cause a superinfection. It grows in the intestinal tract and causes antibiotic-associated diarrhea. Metronidazole (Flagyl) is an anti-infective drug commonly used to treat C difficile. For severe C difficile infection, oral vancomycin may be used; intravenous vancomycin is ineffective. (Option 1) Ceftriaxone (Rocephin) is a cephalosporin antibiotic; its use could cause C difficile infection. (Option 2) Fluconazole (Diflucan) is a broad-spectrum antifungal agent; it is not indicated to treat C difficile. (Option 4) Pantoprazole (Protonix) is a proton pump inhibitor agent; its use has been associated with development of C difficile infection. Educational objective: Antibiotics reduce normal bacteria in the body, allowing other bacteria or fungi, such as C difficile, to take over. C difficile is a toxin-producing microorganism that grows in the intestinal tract and causes antibiotic-associated diarrhea. Metronidazole (Flagyl) and oral vancomycin are commonly used to treat this condition. A client is receiving lithium carbonate 900 mg/day for a schizoaffective disorder. The laboratory notifies the nurse that the client's lithium level is 1.0 mEq/L (1.0 mmol/L). Based on this result, which prescription does the nurse anticipate receiving from the health care provider? Unordered Options Ordered Response 1. Continue at the current dosage 2. Decrease the dosage 3. Discontinue the medication 4. Increase the dosage Explanation Lithium carbonate is used as a mood stabilizer in clients with schizoaffective disorder (combination of schizophrenia and a mood disorder) and bipolar disorders. Lithium has a very narrow therapeutic index (0.6-1.2 mEq/L [0.6-1.2 mmol/L]); levels >1.5 mEq/L (1.5 mmol/L) are considered toxic. Lithium toxicity can be acute (eg, ingesting a bottle of lithium tablets in a suicide attempt) or chronic (eg, slow accumulation due to decreased renal function or drug-drug interactions). Acute or acute-on-chronic toxicity presents predominantly with gastrointestinal symptoms (eg, nausea, vomiting, diarrhea); neurologic manifestations occur later. However, neurologic manifestations occur early in chronic toxicity. Common neurologic manifestations include ataxia, confusion, or agitation, and neuromuscular excitability (eg, tremor, myoclonic jerks). Chronic toxicity also manifests as diabetes insipidus (eg, polyuria, polydipsia). (Options 2, 3, and 4) No dose adjustment is needed as this client's lithium level is therapeutic. Educational objective: Lithium levels should be checked frequently given the narrow therapeutic index (0.6-1.2 mEq/L [0.6-1.2 mmol/L]). A level >1.5 mEq/L (1.5 mmol/L) is considered toxic. Chronic toxicity manifests with neurologic symptoms (eg, confusion, tremor, ataxia) and/or diabetes insipidus (eg, polyuria, polydipsia). The health care provider (HCP) has prescribed spironolactone to be given in addition to hydrochlorothiazide to a client with hypertension. Which finding by the nurse would indicate that the new medication is having the desired effect? Unordered Options Ordered Response 1. Blood glucose of 95 mg/dL 2. Potassium level of 4.2 mEq/L 3. Reduction in dizziness 4. Sodium level of 138 mEq/L Explanation Spironolactone, amiloride, triamterene, and eplerenone are potassium-sparing diuretics. In general, these are very weak diuretics and antihypertensives and are used mainly in combination with thiazide diuretics to reduce potassium (K+) loss. The K+ level of 4.2 mEq/L would indicate that this medication has been effective in preventing hypokalemia in a client receiving a thiazide diuretic such as hydrochlorothiazide or chlorthalidone. (Option 1) Blood glucose levels can be increased by thiazide diuretics but are not affected by potassium-sparing diuretics. (Option 3) All diuretics, including spironolactone, have the potential to cause dizziness. (Option 4) Potassium-sparing diuretics exchange sodium for potassium in the kidneys; potassium is saved but sodium is lost. Therefore, a normal sodium level is not a desired side effect. Educational objective: Potassium-sparing diuretics (eg, spironolactone, amiloride, triamterene, eplerenone) are often combined with thiazide diuretics to reduce potassium loss during hypertension treatment. A child with cystic fibrosis is to receive a dose of pancrelipase at 12:00 PM. The client states that he is not hungry and will eat his lunch in an hour. Which action is appropriate for the nurse to take? Unordered Options Ordered Response 1. Administer the prescribed pancrelipase 2. Hold the pancrelipase until the client eats 3. Notify the health care provider 4. Skip this dose of the pancrelipase Explanation Cystic fibrosis affects the pancreatic excretion of digestive enzymes. Without these enzymes, the client is unable to absorb fats, starches, and some proteins from the diet. Pancrelipase provides these enzymes to the client and must be given with every snack and meal so that the client can digest and absorb the nutrients eaten. If the client is not eating when the medication is scheduled, there are no nutrients to digest. Therefore, the dose should be held until the client eats. Educational objective: Pancrelipase is a medication containing lipase, protease, and amylase. In cystic fibrosis, the client's pancreas does not excrete these necessary enzymes. To prevent malabsorption syndrome, the enzymes must be taken with every snack and every meal. A client with stable chronic obstructive pulmonary disease (COPD) has been prescribed extended-release oral theophylline for the past 2 years. The nurse reviews the serum laboratory results. Which value would the nurse report to the health care provider immediately? Unordered Options Ordered Response 1. Theophylline level 23.6 mcg/mL 2. Theophylline level 10.4 mcg/mL 3. Theophylline level 15.3 mcg/mL 4. Theophylline level 18.0 mcg/mL Explanation Theo-24 (theophylline) is a long-acting, slow-release methylxanthine bronchodilator that relaxes bronchial smooth muscles, improves contractility of the diaphragm, and facilitates mucus transport by the cilia. Methylxanthines (eg, aminophylline, theophylline) are sometimes administered in addition to first-line drugs (eg, beta agonists, anticholinergics, corticosteroids) to prevent and treat reversible bronchospasm in clients with long-standing COPD. Theophylline has a narrow therapeutic index, and toxicity can occur from accumulation by reduced clearance or decreased metabolism. Medications, diet, underlying disease, and smoking can affect plasma theophylline clearance. To provide the desired effect of the drug and limit side effects, serum theophylline levels are monitored periodically (every 6 months) to maintain a target blood level of 10–20 mcg/mL. In some cases, symptom management may be attained at a lower target range (8–15 mcg/mL). (Options 2, 3, and 4) All values are within the normal adult target range (10–20 mcg/mL). Educational objective: Theophylline relaxes bronchial smooth muscles, improves contractility of the diaphragm, and facilitates mucus transport by the cilia in clients with COPD. However, due to its narrow therapeutic index, theophylline levels are monitored periodically to maintain a target blood level of 10–20 mcg/mL. The nurse is preparing to administer medications to a client admitted with atrial fibrillation. The nurse notes the vital signs shown in the exhibit. Which medications due at this time are safe to administer? Select all that apply. Click on the exhibit button for additional information. Unordered Options Ordered Response 1. Albuterol inhaler 2. Diltiazem extended-release PO 3. Heparin subcutaneous injection 4. Lisinopril PO 5. Metoprolol PO 6. Timolol eye drops Explanation Clients with atrial fibrillation can have either bradycardia (slow ventricular response) or tachycardia (rapid ventricular response). This client's vital signs are significant for bradycardia (heart rate <60/min). Therefore, the medications that can decrease heart rate should be held and the health care provider (HCP) should be notified. The reason for holding the medication (heart rate 46/min) and an HCP contact note should be documented. Albuterol, a short-acting beta-adrenergic inhaler to control asthma, can increase the heart rate and is a safe choice (Option 1). Heparin is an anticoagulant; the subcutaneous injection is most commonly used to prevent deep venous thrombosis in hospitalized clients on bed rest. This medication will not affect the vital signs and so is also safe to administer (Option 3). Lisinopril, an ACE inhibitor, does not lower the heart rate and is not contraindicated in clients with bradycardia (Option 4). This client's blood pressure is considered normal and lisinopril is safe to administer. Withholding this medication could cause rebound hypertension. (Option 2) Diltiazem is a calcium channel blocker that can decrease the heart rate and so should be held. Verapamil, another calcium channel blocker, can also cause bradycardia. (Options 5 and 6) This client is on 2 beta blockers, oral metoprolol and timolol eye drops that can be absorbed systemically. All beta blockers can further decrease the heart rate and should be held until the prescriptions can be clarified by the HCP. Educational objective: Medications that decrease the heart rate should be held in clients with bradycardia. These include beta blockers such as metoprolol (including eye drops) and some types of calcium channel blockers (eg, diltiazem, verapamil). Vital signs Temperature 98.4 F (36.9 C) Blood pressure 116/70 mm Hg Heart rate 46/min and irregularly irregular Respirations 22/min The nurse admits a client to the unit who reports taking high doses of aspirin to ease the pain of chronic headaches. The nurse should monitor for which adverse effects? Select all that apply. Unordered Options Ordered Response 1. Black tarry stools 2. Bradycardia 3. Bruising 4. Hypertension 5. Ringing in the ears Explanation Aspirin is a nonsteroidal anti-inflammatory drug (NSAID). NSAIDs can cause gastrointestinal (GI) bleeding by decreasing the production of prostaglandins, which protect the lining of the stomach and intestines from digestive acids. NSAIDs (especially aspirin) also decrease platelet aggregation and thereby inhibit blood clotting. Coffee-ground emesis and black tarry stools (melena) are signs of GI bleeding. Bruising can occur due to the decreased platelet aggregation. Tinnitus (ringing in the ears) is the earliest sign of aspirin toxicity. (Options 2 and 4) An NSAID overdose will cause tachycardia (not bradycardia) and hypotension (not hypertension). However, tachycardia and hypotension occur later, secondary to blood loss and dehydration due to nausea and vomiting (common side effects). Educational objective: Aspirin and other NSAIDs inhibit platelet aggregation, resulting in GI bleeding complications. They also promote development of gastric ulcers with long-term use. Tinnitus (ringing in the ears) is the earliest sign of aspirin toxicity. The parent of a child diagnosed with attention-deficit hyperactivity disorder (ADHD), predominantly inattentive type, says to the nurse, "I hate the idea of my child taking a drug that's a stimulant. How will I know that the methylphenidate is even working?" Which is the best response by the nurse? Unordered Options Ordered Response 1. "Methylphenidate is generally a safe and effective drug for children with ADHD." 2. "Methylphenidate will increase the levels of neurotransmitters in your child's brain." 3. "You should see your child's school grades improve." 4. "Your child should be able to more easily complete school assignments and other tasks." Explanation Although methylphenidate (eg, Ritalin, Concerta) is classified as a stimulant, in children with ADHD it improves attention, decreases distractibility, helps maintain focus on an activity, and improves listening skills. For many years, the effects of methylphenidate in children were labeled as paradoxical. Now, research has shown that methylphenidate significantly increases levels of dopamine in the central nervous system (CNS) that lead to stimulation of the inhibitory system of the CNS. Methylphenidate works quickly; symptom relief is often seen after the first dose. (Option 1) This is a true statement; methylphenidate is generally safe for most children, adolescents, and adults. Methylphenidate can cause adverse reactions, but these affect a very small percentage of users. However, this response does not address the parent's question about how the drug works. (Option 2) This is a true statement but does not give the parent information about the benefits of methylphenidate. In addition, it contains language that most clients would not understand. (Option 3) A child's school grades may improve due to the benefits of methylphenidate. This would be seen over time as a secondary benefit; the immediate therapeutic effects are often observed with the first dose. Educational objective: The therapeutic effects of methylphenidate can be observed very quickly in children with ADHD. Methylphenidate improves attention, decreases distractibility, helps maintain focus on an activity, and improves listening skills. A client has just been prescribed allopurinol for chronic gout. Which instruction is most important for the nurse to emphasize to the client? Unordered Options Ordered Response 1. Report for periodic laboratory tests for kidney, liver, and blood functions 2. Store the medication in a cool, dry place away from direct heat and light 3. Take the medication after a meal to prevent gastric distress 4. Take the medication with a full glass of water and increase fluids during the day Explanation Allopurinol is prescribed to prevent gout attacks (pain and inflammation in joints caused by uric acid deposits). It inhibits uric acid production and improves solubility. Allopurinol should be taken with a full glass of water, and it is very important for the nurse to educate the client about fluid intake with this medication. The client should also increase daily fluid intake as this will help prevent the formation of renal stones and promote diuresis (increase drug and uric acid excretion). (Option 1) Biosynthesis of uric acid occurs in the liver, and antigout medications are excreted via the kidneys; therefore, liver and renal function should be checked periodically. In addition, blood counts should be monitored as some antigout medications can cause blood dyscrasias. This is important but does not have priority over the daily need for increased fluids. (Option 2) This is a common instruction given about the storage of many medications. It helps to ensure potency of the medication and prevent deterioration. (Option 3) Taking allopurinol with food or after a meal can help to prevent gastric upset. Educational objective: It is important for the nurse to educate the client taking allopurinol about drinking a full glass of water with each dose and increasing overall fluid intake. Increased fluids help to prevent renal stones and promote diuresis and uric acid excretion. A client with uncontrolled hypertension is prescribed clonidine. What instruction is most important for the clinic nurse to give this client? Unordered Options Ordered Response 1. Avoid consuming high-sodium foods 2. Change positions slowly to prevent dizziness 3. Don't stop taking this medication abruptly 4. Use an oral moisturizer to relieve dry mouth Explanation Central-acting alpha2 agonists (eg, clonidine, methyldopa) decrease the sympathetic response from the brainstem to the peripheral vessels, resulting in decreased peripheral vascular resistance and vasodilation. Clonidine is a highly potent antihypertensive. Abrupt discontinuation (including the patch) can result in serious rebound hypertension due to the rapid surge of catecholamine secretion that was suppressed during therapy. Clonidine should be tapered over 2-4 days. Abrupt withdrawal of beta blockers can also result in rebound hypertension and in precipitation of angina, myocardial infarction, or sudden death. (Option 1) Avoiding high-sodium foods is important for blood pressure control but is not the most important advice for this client as consumption of these is not immediately life- threatening. (Option 2) Dizziness is a side effect of clonidine. The nurse should teach the client to change positions slowly and sit for a few minutes before rising to prevent falls. Drowsiness is also quite common with clonidine. Clients should not use it with alcohol or central nervous system depressants. However, dizziness and drowsiness should diminish with continued use of the medication. (Option 4) Dry mouth is a side effect of clonidine. Use of over-the-counter mouth moisturizers, chewing gum, or hard candy may be helpful for clients with dry mouth. Educational objective: Clonidine is a very potent antihypertensive. Abrupt discontinuation can result in serious rebound hypertensive crisis. Other common side effects of clonidine include dizziness, drowsiness, and dry mouth (the 3 Ds). Beta blockers, another class of blood pressure medications, can result in withdrawal symptoms if discontinued suddenly. A client is in the cardiovascular clinic for a 3-month follow-up visit. At the first visit, the client was prescribed hydrochlorothiazide and amlodipine for hypertension. Which statement by the client would be concerning to the nurse and should be reported to the primary health care provider (PHCP)? Unordered Options Ordered Response 1. "I like to have a banana every morning with my breakfast." 2. "I occasionally experience slight dizziness when I get up in the morning." 3. "I started taking licorice root for my occasional heartburn." 4. "I usually take my hydrochlorothiazide first thing in the morning." Explanation Licorice root is an herbal remedy sometimes used for gastrointestinal disorders such as stomach ulcers, heartburn, colitis, and chronic gastritis. Clients with heart disease or hypertension should be cautious about using licorice root. When used in combination with a diuretic such as hydrochlorothiazide, it can increase potassium loss, leading to hypokalemia. Hypokalemia can cause dangerous cardiac dysrhythmias. Thiazide diuretics are considered "potassium-wasting" diuretics, so this client is already at risk for hypokalemia. The addition of licorice root could potentiate the potassium loss. The nurse should discourage the client from using this herbal remedy and report the client's use to the PHCP. (Option 1) Bananas are rich in potassium. Eating one each morning is beneficial. (Option 2) Diuretics and calcium channel blockers (eg, nifedipine, amlodipine, felodipine) commonly cause postural hypotension or dizziness on rising. The nurse should encourage the client to rise slowly and sit on the side of the bed for a few minutes before getting up. Persistent dizziness should be reported to the PHCP. (Option 4) Diuretics should be taken in the morning as nighttime dosing will cause nocturia and interrupted sleep. Educational objective: The nurse should discourage the client from using the herbal remedy licorice root when taking thiazide diuretics. Licorice root can potentiate potassium loss and increase the client's risk for hypokalemia. Use of licorice root should be reported to the PCHP. The home health nurse prepares to give benztropine to a 70-year-old client with Parkinson disease. Which client statement is most concerning and would warrant health care provider notification? Unordered Options Ordered Response 1. "I am going for repeat testing to confirm glaucoma." 2. "I am not able to exercise as much as I used to." 3. "I started taking esomeprazole for heartburn." 4. "My bowel movements are not regular." Explanation Parkinson disease (PD) is a progressive neurological disorder characterized by bradykinesia (loss of autonomic movements), rigidity, and tremors. Clients with PD have an imbalance between dopamine and acetylcholine in which dopamine is not produced in high enough quantities to inhibit acetylcholine. Anticholinergic medications (eg, benztropine, trihexyphenidyl) are commonly used to treat tremor in these clients. However, in clients with benign prostatic hyperplasia or glaucoma, caution must be taken as anticholinergic drugs can precipitate urinary retention and an acute glaucoma episode. As a result, such medications are contraindicated in these clients. (Option 2) Decreased ability to exercise is common in clients with PD due to tremors and bradykinesia, and they require physical and occupational therapy consultations. However, acute glaucoma can be sight threatening and is the priority. (Option 3) Esomeprazole is safe to take with benztropine and will not cause an adverse reaction. (Option 4) Constipation is a common side effect of benztropine. Due to the characteristic decreased mobility, PD can also cause constipation. The client should be instructed to increase dietary fiber intake and drink plenty of water. However, this is not the most concerning issue. Educational objective: Anticholinergic medications (eg, benztropine, trihexyphenidyl) are used to treat Parkinson disease tremor. However, they can precipitate acute glaucoma and urinary retention and are therefore contraindicated in susceptible clients (eg, those with glaucoma or benign prostatic hyperplasia). The nurse on the neurosurgery step-down unit is assigned to a stable client with a closed-head injury who is 1 day postoperative craniotomy. The nurse prepares to administer the 7:00 AM medications and reviews the client's medication administration record. Which prescription prompts the nurse to contact the prescribing health care provider (HCP) for prescription clarification? Click on the exhibit button for additional information. Unordered Options Ordered Response 1. Acetaminophen 1000 mg IV every 6 hours 2. Gabapentin 300 mg orally every 8 hours 3. Hydrocodone/acetaminophen (5 mg/325 mg) orally, every 4 hours PRN 4. Phenytoin 100 mg orally, every 12 hours Explanation The recommended dose for acetaminophen should not exceed 4 g in 24 hours, as it can lead to liver injury. The nurse should contact the HCP to question the prescription for the PRN opioid analgesic hydrocodone/acetaminophen (5 mg/325 mg) (Vicodin). The client is already receiving acetaminophen 1000 mg IV every 6 hours (4,000 mg). If the client needed and received the maximum possible dose of 6 tablets of hydrocodone/acetaminophen (5 mg/325 mg), the total dose of acetaminophen (4,000 mg + 1,950 mg [6 tablets] = 5,950 mg) would exceed the recommended daily dose. (Option 1) Acetaminophen is an antipyretic and nonopioid analgesic. The HCP may prescribe this drug to manage mild to moderate pain and fever in the initial postoperative period. The antipyretic effects of the drug can mask fever in clients medicated for postoperative pain. The nurse would not question this prescription. (Option 2) Gabapentin (Neurontin) is an analgesic adjunct and anticonvulsant drug prescribed to promote comfort and decrease the incidence of seizures. The nurse would not question this prescription. (Option 4) Phenytoin (Dilantin) is an anticonvulsant prescribed to prevent and/or treat post-traumatic seizure activity in clients following a head injury. The nurse would not question this prescription. Educational objective: Higher-than-recommended doses of acetaminophen can lead to hepatotoxicity. The nurse should monitor the total amount of acetaminophen administered to a client in a 24-hour period, including the amount combined with opioid drugs (eg, hydrocodone/acetaminophen [Vicodin]). The nurse would notify the HCP if the combined dose exceeds the recommended dose of 4 g in 24 hours. A client is being discharged on enoxaparin therapy following total knee replacement surgery. Which teaching instruction does the nurse include in the teaching plan? Unordered Options Ordered Response 1. "Eliminate green, leafy, vitamin K-rich vegetables from your diet." 2. "Mild bruising or redness may occur at the injection site." 3. "You can take over-the-counter drugs such as ibuprofen to relieve mild discomfort." 4. "You will need PT/INR assessments at regular intervals while on enoxaparin therapy." Explanation Enoxaparin (Lovenox) is a low molecular weight heparin (LMWH) that may be prescribed for up to 10-14 days following hip and knee surgery to prevent deep venous thrombosis. Discharge teaching for the client on enoxaparin therapy includes: 1. Pinch an inch of skin upwards and insert the needle at a 90-degree angle into the fold of skin. 2. Continue to hold the skin fold throughout the injection and then remove the needle at a 90-degree angle. 3. Mild pain, bruising, irritation, or redness of the skin at the injection site is common. Do NOT rub the site with the hand. Using an ice cube on the injection site can provide relief (Option 2). 4. Avoid taking aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), and herbal supplements (Ginkgo biloba, vitamin E) without health care provider approval as these can increase the risk of bleeding (Option 3). 5. Monitor complete blood count to assess for thrombocytopenia. (Option 1) Vitamin K-rich foods do not need to be eliminated from the diet during enoxaparin therapy; prothrombin time (PT) and international normalized ratio (INR) are not affected. However, PT and INR are decreased when a vitamin K antagonist (eg, warfarin [Coumadin]) is taken with vitamin K-rich foods. (Option 4) Routine coagulation studies (eg, PT, INR, partial thromboplastin time [PTT]) do not need to be monitored in a client who is taking enoxaparin. However, periodic assessment of complete blood count (CBC) is usually required to monitor for hidden bleeding and thrombocytopenia (especially in older clients with renal insufficiency). Educational objective: LMWH (Enoxaparin) requires monitoring of CBC (thrombocytopenia) but not coagulation studies. Administration of unfractionated heparin requires monitoring with PTT, whereas warfarin requires PT/INR monitoring. Clients on these medications should avoid aspirin and NSAIDs. A post-surgical client is unresponsive to painful stimuli and is given naloxone. Within 5 minutes, the client is arousable and responds to verbal commands. One hour later, the client is again difficult to arouse, with minimal response to physical stimuli. Which actions should the nurse take? Select all that apply. Unordered Options Ordered Response 1. Administer oxygen 2. Assess respiratory rate 3. Initiate rapid response or code team 4. Notify the health care provider 5. Prepare a second dose of naloxone Explanation A client in the post-operative period that is unresponsive to painful stimuli is likely still under the effects of medications used during anesthesia. Using the opioid antagonist naloxone (Narcan) will temporarily reverse the effects of any opioid medications. Unfortunately, the half-life of naloxone is much shorter than most opioid medications, wearing off in 1–2 hours. The nurse should make repeat assessments of the post- surgical client's respiratory rate and administer prescribed oxygen for respiratory support. The health care provider should be notified and a second dose of naloxone should be prepared and administered as prescribed (either as a one-time dose or a continuous drip, depending on the prescription). (Option 3) An overly sedated client is not an indication for a rapid response team. Although this intervention is unlikely to cause harm to the client, it is not necessary and may result in overuse of personnel resources. If additional information indicates a more serious situation (eg, respiratory rate <8 breaths/min, oxygen saturation <90%), it may be appropriate to initiate the emergency response system. Educational objective: Naloxone (Narcan) is usually prescribed as needed for post-surgical clients for over- sedation related to opioid use. The nurse should continue to monitor clients who are given naloxone with the understanding that the opioid antagonist has a shorter half-life than most of the opioids it is meant to counteract. As a result, a second dose of naloxone may be necessary. The nurse provides teaching about methotrexate to a 28-year-old client with rheumatoid arthritis (RA). Which client statement indicates the need for further instruction regarding this drug? Unordered Options Ordered Response 1. "I know my resistance to germs will be lower, so I should get a flu shot this year." 2. "I should not become pregnant while I take this medicine." 3. "I will make sure to have my eyes checked every 6 months." 4. "It will be hard for me not to have wine with my dinner!" Explanation Methotrexate (Rheumatrex) is classified as a folate antimetabolite, antineoplastic, immunosuppressant drug to treat various malignancies and as a nonbiologic disease- modifying antirheumatic drug (DMARD) to treat RA and psoriasis. The statement in option 3 indicates that further teaching is necessary as eye examinations every 6 months are not indicated for clients prescribed methotrexate. They are indicated for those prescribed the nonbiological DMARD antimalarial drug hydroxychloroquine (Plaquenil) as it can cause retinal damage. (Option 1) Methotrexate is an immunosuppressant and can cause bone marrow suppression. Clients are at risk for infection. They should avoid crowded places and individuals with known infection. They should receive appropriate killed (inactivated) vaccines (eg, influenza, pneumococcal). Live vaccines (eg, herpes zoster) are contraindicated. (Option 2) The client should not become pregnant while taking methotrexate or for at least 3 months after it is discontinued as the drug is teratogenic. (Option 4) Clients taking methotrexate should avoid alcohol as the drug is hepatotoxic, and drinking alcohol increases the risk for hepatotoxicity. Educational objective: Methotrexate is a DMARD used to treat RA. The major adverse effects associated with methotrexate include bone marrow suppression, hepatotoxicity, and congenital abnormalities and fetal death A client with a brain tumor is admitted for surgery. The health care provider prescribes levetiracetam. The client asks why. What is the nurse's response? Unordered Options Ordered Response 1. "It destroys tumor cells and helps shrink the tumor." 2. "It prevents seizure development." 3. "It prevents blood clots in legs." 4. "It reduces swelling around the tumor." Explanation Levetiracetam (Keppra) is a medication often used to treat seizures in various settings. It has minimal drug-drug interactions compared to phenytoin and is often the preferred antiepileptic medication. (Option 1) Chemotherapy and radiation therapy would kill tumor cells and reduce tumor size. (Option 3) Hospitalized clients and clients with malignancy are at higher risk for venous thromboembolism. These clients would benefit from anticoagulation (eg, heparin, enoxaparin, rivaroxaban, apixaban). (Option 4) Dexamethasone, a corticosteroid, is used to treat cerebral edema associated with a brain injury/tumor by decreasing inflammation. Educational objective: Levetiracetam (Keppra) is a medication often used to treat seizures in various settings. Corticosteroids are used to reduce inflammation and cerebral edema in clients with brain injury and tumors. A newly admitted client describes symptoms of dizziness and feeling faint on standing. The client has a history of type 2 diabetes, coronary artery disease, and bipolar disorder. Which medications may be contributing to the client's symptoms? Select all that apply. Unordered Options Ordered Response 1. Atorvastatin 2. Metformin 3. Metoprolol 4. Olanzapine 5. Omeprazole Explanation Drugs commonly associated with orthostatic hypotension include: 1. Most antihypertensive medications, particularly sympathetic blockers such as beta blockers (eg, metoprolol) and alpha blockers (eg, terazosin) (Option 3) 2. Antipsychotic medications (eg, olanzapine, risperidone) and antidepressants (eg, selective serotonin reuptake inhibitors) (Option 4) 3. Volume-depleting medications such as diuretics (eg, furosemide, hydrochlorothiazide) 4. Vasodilator medications (eg, nitroglycerine, hydralazine) 5. Narcotics (eg, morphine) Clients at risk for developing orthostatic hypotension should be instructed to: 1. Take medications at bedtime, if approved by the health care provider 2. Rise slowly from a supine to standing position, in stages (especially in the morning) 3. Avoid activities that reduce venous return and worsen orthostatic hypotension (eg, straining, coughing, walking in hot weather) 4. Maintain adequate hydration (Option 1) Muscle cramps and liver injury, not orthostatic hypotension, are the major adverse effects of statin medications (eg, atorvastatin). (Option 2) Major side effects of metformin are lactic acidosis and gastrointestinal disturbances (metallic taste in the mouth, nausea, and diarrhea). Unlike insulin, metformin does not usually cause hypoglycemia. Orthostatic hypotension is not a common side effect. (Option 5) Proton pump inhibitors (eg, omeprazole) are associated with increased risk of pneumonia, Clostridium difficile diarrhea, and calcium malabsorption (osteoporosis), but not orthostatic hypotension. Educational objective: Medications commonly associated with orthostatic hypotension include most antihypertensives, most antipsychotics and antidepressants, and volume-depleting agents. Clients are instructed to rise slowly when standing to prevent a drop in blood pressure. The nurse is preparing to administer IV cefazolin to a client who is newly admitted with cellulitis. The client's allergies include amoxicillin, ciprofloxacin, and sulfa drugs. What should the nurse do first? Unordered Options Ordered Response 1. Administer the medication as ordered 2. Clarify the order with the health care provider (HCP) 3. Get more information from the client about the client's allergies 4. Notify the pharmacy that the drug is inappropriate for this client Explanation The nurse should find out more about this client's allergies before giving the medication. Specifically, the nurse must learn what type of reaction the client had to amoxicillin, a penicillin antibiotic. With a history of anaphylaxis to penicillin, cephalosporins (eg, cefazolin) are contraindicated. Penicillin-cephalosporin cross- sensitivity occurs due to the structural similarity between the cephalosporin and penicillin molecules. If this client's reaction to amoxicillin was only a rash or other mild reaction that was not life-threatening, the cephalosporin can be safely administered. However, if the client had an anaphylactic reaction to penicillin, the HCP will need to prescribe a different antibiotic. (Option 1) The nurse should hold the medication until more is known about the client's reaction to amoxicillin. (Option 2) The nurse does not have enough information to determine whether the HCP needs to be called. (Option 4) The nurse does not have enough information to determine whether the medication is appropriate. Educational objective: A client with a penicillin allergy may be allergic to cephalosporin antibiotics. Cephalosporins may be safely administered to clients with a history of mild allergic reaction, such as rash, but they are contraindicated in clients with a history of penicillin anaphylaxis. A parent calls the after-hours triage nurse about a 3-year-old who is sick with the flu. Which report by the parent would necessitate intervention by the nurse? Unordered Options Ordered Response 1. Acetaminophen being given every 4 hours for fever 2. Bismuth subsalicylate being used for nausea 3. Ibuprofen being given every 6 hours for body aches 4. Popsicles and gelatin desserts being used for hydration Explanation The nurse should tell the parent to discontinue the use of bismuth subsalicylate (Pepto-Bismol) as it contains a salicylate (same class as aspirin) and could possibly cause Reye syndrome. Reye syndrome can develop in children with a recent viral illness such as varicella or influenza. It can cause acute encephalopathy and hepatic dysfunction. Children with viral infections should not be given aspirin or products containing salicylates. (Options 1 and 3) Acetaminophen and ibuprofen are being used appropriately. (Option 4) Sufficient fluids are important to maintain hydration in the child with influenza. Water and fluids should be offered frequently; popsicles and gelatin desserts (eg, Jell-O) provide a palatable means of getting children to ingest fluids. Educational objective: The nurse should tell the parent not to administer any product containing aspirin or salicylates to a child with a viral infection (eg, influenza, varicella) to prevent Reye syndrome. The nurse is providing discharge teaching to several clients with new prescriptions. Which instructions by the nurse are correct in regards to medication administration? Select all that apply. Unordered Options Ordered Response 1. Avoid salt substitutes when taking valsartan for hypertension 2. Take levofloxacin with an aluminum antacid to avoid gastric irritation 3. Take sucralfate (for a gastric ulcer) PC to minimize gastric irritation 4. When taking ethambutol, notify the health care provider (HCP) for changes in vision. 5. When taking rifampin, notify the HCP if the urine turns red- orange in color Explanation Both ACE inhibitors ("prils" – captopril, enalapril, lisinopril, ramipril) and angiotensin receptor blockers ("sartans" – valsartan, losartan, telmisartan) cause hyperkalemia. Salt substitutes contain high potassium and must not be taken without consulting the HCP (Option 1). Ethambutol (Myambutol) is used to treat tuberculosis but can result in an ocular toxicity that causes vision loss and loss of red-green color discrimination. Vision acuity and color discrimination must be monitored regularly (Option 4). (Option 2) Levofloxacin (Levaquin) is a quinolone antibiotic. For this class of antibiotics, 2 hours should pass between the drug ingestion and taking aluminum/magnesium antacids, iron supplements, multivitamins with zinc, or sucralfate. In addition, these substances can bind up to 98% of the drug and make it ineffective. (Option 3) Sucralfate (Carafate, Sulcrate) should be administered before meals (AC) to coat the mucosa to prevent irritation from the acid during the meal. It should also be administered at least 30 minutes to 2 hours before or after other medications to prevent binding with them and rendering them less effective. (Option 5) Rifampin (Rifadin) normally causes red-orange discoloration of all body fluids. The client should be alerted to expect this change, but it does not require HCP notification. In addition, most antituberculosis medications (eg, rifampin, isoniazid, pyrazinamide) can cause hepatitis. Educational objective: Watch for vision changes with ethambutol. Do not give potassium supplements or salt substitutes to a client taking an ACE inhibitor or angiotensin receptor blocker. Sucralfate must be given AC to coat the gastric ulcer mucosa. Quinolone antibiotics should not be given with antacids or supplements that will bind with the drug. The nurse is discharging a client who has been prescribed warfarin for chronic atrial fibrillation. The nurse should instruct the client to avoid excess or inconsistent intake of which foods? Select all that apply. Unordered Options Ordered Response 1. Bananas 2. Broccoli 3. Grapefruit juice 4. Red meat 5. Spinach Explanation Large amounts of vitamin K-rich foods can decrease the anticoagulant effects of warfarin therapy. Clients are not instructed to remove those foods from their diet but are encouraged to be consistent in the intake of foods high in vitamin K, including leafy green vegetables, asparagus, broccoli, kale, Brussels sprout, and spinach. Several beverages also affect warfarin therapy. Green tea, grapefruit juice, and cranberry juice may alter its anticoagulant effects. (Option 1) Certain fruits (eg, bananas, oranges) are rich in potassium and may increase the risk for hyperkalemia with the use of potassium-sparing diuretics (eg, spironolactone, triamterene, eplerenone). However, bananas and oranges are low in vitamin K and are not known to interact with warfarin. (Option 4) Eating less red meat and reducing sodium intake are part of a heart-healthy diet but are not specific to a warfarin regimen. Educational objective: The nurse should teach the client receiving warfarin therapy to be consistent with intake of foods high in vitamin K. Clients do not need to restrict vitamin K-rich foods completely. Leafy green vegetables and grapefruit juice are the most important to teach. A nurse is caring for a client with an exacerbation of chronic obstructive pulmonary disease (COPD) and a history of type 2 diabetes mellitus requiring insulin. The client has been prescribed prednisone. The nurse anticipates which need? Unordered Options Ordered Response 1. Close monitoring for hypotension 2. Gradually increasing the prednisone dose 3. Increasing the insulin dose 4. Monitoring and recording intake and output Explanation Corticosteroids (eg, methylprednisolone, prednisone, dexamethasone) are given to combat inflammation in the lungs in clients with COPD exacerbation. All glucocorticoids can cause an increase in blood sugar. This may lead to the need for a higher dose of insulin based on the client's blood sugar level. (Option 1) Most glucocorticoids have some mineralocorticoid activity, causing fluid retention and worsening hypertension. (Option 2) Prednisone is started at a higher dose and then gradually decreased for COPD exacerbation and most other conditions. A slow taper will prevent adrenal crisis. (Option 4) Intake and output are not affected by corticosteroids. Educational objective: Corticosteroids commonly cause hyperglycemia and worsen hypertension. When taken in combination with NSAIDs, they can increase the risk of peptic ulcer disease. Corticosteroids in general are started at high doses and slowly tapered to reduce the risk of sudden adrenal crisis. A client in the intensive care unit is receiving IV vancomycin and gentamicin. The nurse should monitor for which potential complication with the administration of these medications? Unordered Options Ordered Response 1. Blood in nasogastric tube drainage 2. Decrease in red blood cell (RBC) count 3. Increase in serum creatinine level 4. Onset of muscle aches and cramping Explanation Vancomycin and aminoglycosides (eg, gentamicin, amikacin, tobramycin) are strong antibiotics that can cause nephrotoxicity and ototoxicity. The client receiving these medications simultaneously would be at an even higher risk for these adverse reactions. The nurse should monitor the client's renal function by assessing blood urea nitrogen (BUN) and creatinine levels and measuring urinary output. Increased levels of BUN and creatinine may indicate kidney damage. The health care provider should be notified before continuing these medications. (Option 1) Blood in the nasogastric tube could be a complication of peptic ulcer disease and the use of nonsteroidal anti-inflammatory drugs and corticosteroids. (Option 2) A decrease in the RBC count may be evidence of bone marrow suppression that can occur with use of certain cancer drugs (eg, methotrexate). (Option 4) Muscle cramping can occur occasionally with use of gentamicin but is not an indication to stop the infusion. Muscle aching and cramping that may signify a complication occur with the use of statins (eg, atorvastatin, rosuvastatin) and fibrates (eg, gemfibrozil, fenofibrate). Educational objective: The nurse should recognize that the risk of nephrotoxicity and ototoxicity is potentiated when vancomycin and aminoglycosides (eg, gentamicin) are administered together. Kidney and hearing functions should be closely monitored in these clients. A client with stable angina is being discharged home with a prescription for a transdermal nitroglycerin patch. The nurse has reviewed discharge instructions on the medication with the client. Which statement by the client indicates that teaching has been effective? Unordered Options Ordered Response 1. "I can continue to take my prescription of sildenafil." 2. "I should take the patch off when I shower." 3. "I will remove the patch if I develop a headache." 4. "I will rotate the site where I apply the patch." Explanation Nitroglycerin patches are transdermal patches used to prevent angina in clients with coronary artery disease. They are usually applied once a day (not as needed) and worn for 12–14 hours and then removed. Continuous use of patches without removal can result in tolerance. No more than one patch at a time should be worn. The patch should be applied to the upper body or upper arms. Clean, dry, hairless skin that is not irritated, scarred, burned, broken, or calloused should be used. A different location should be chosen each day to prevent skin irritation. (Option 1) Phosphodiesterase inhibitors used in erectile dysfunction (eg, tadalafil, sildenafil, vardenafil) are contraindicated with the use of nitrates. Both have similar mechanisms and cause vascular smooth muscle dilation. Combined use can result in severe hypotension. (Option 2) Patches may be worn in the shower. (Option 3) Headaches are common with the use of nitrates. The client may need to t