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 incre