EXAM CRAM NCLEX-PN 5th Edition

Preparing for the Exam As you prepare to take the National Council Licensure Examination, you may feel over- whelmed and frustrated. There is so much material to review and so many decisions to make. Where do I begin? Most graduates feel that way. This chapter will help you to become aware of the NCLEX® test plan and to know the types of questions you will encounter on the exam. The NCLEX-PN® consists of questions from the cognitive levels of knowledge, compre- hension, application, and analysis. The majority of questions are written at the application and analysis levels. Questions incorporate the five stages of the nursing process (assessment, analysis, planning, implementation, and evaluation) and the four categories of client needs. Client needs are divided into subcategories that define the content within each of the four major categories. These categories and subcategories as well as the percentages of questions allocated to each area are A. Safe, Effective Care Environment Coordinated Care: 18%–24% Safety and Infection Control: 10%–16% B. Health Promotion and Maintenance: 6%–12% C. Psychosocial Integrity: 9%–15% D. PhysiologicalIntegrity Basic Care and Comfort: 7%–13% Pharmacological and Parenteral Therapy: 10%–16% Reduction of Risk Potential: 9%–15% Physiological Adaptation: 7%–13% The Computer Adaptive Test The Computer Adaptive Test (CAT) provides a means of individualized testing of each candi- date seeking licensure. Selecting from a large test bank, the computer chooses questions based on the candidate’s ability and competence as demonstrated on the prior question. The minimum number of questions is 85; the maximum number is 205. The average can- didate’s exam is comprised of approximately 160 items. You must answer the question that appears on the screen before another question is given, and you cannot skip questions nor return to a previous question. It is imperative that you read each question carefully before selecting a response. We suggest that you cover the answers with your nondominant hand and read the stem before looking at the answers. 5 Preparing for the Exam Computerized Adaptive Testing offers the candidate several advantages over the former paper pencil exam. The test questions, which are stored in a large test bank and classified by test plan areas and level of difficulty, are then administered to the candidate. Depending on the answer given by the candidate, the computer presents another question that is either more difficult or less difficult. This allows the computer to determine the candidate’s knowledge of the subject matter more concisely. The pass/fail decision is not based on how many questions the candidate answers correctly but on the difficulty of the questions answered correctly. Even though the candidates may answer different questions and different numbers of questions, the test plan remains the same. All NCLEX-PN® CAT examinations conform to this test plan. Each time you answer a ques- tion correctly, the next question gets harder until you miss a question; then an easier question is given until you answer correctly. This way the computer concludes if a candidate has met the passing standard. If you are clearly above the passing standard at 85 questions, the computer stops asking questions. If you are clearly below the passing standard, the computer stops asking questions. If your ability estimate is close to the passing standard, the computer continues to ask questions until either the maximum number of questions is asked or time expires. Should time expire, the last 60 questions are reviewed. To pass, the candidate must remain above the passing standard on the last 60 items. The CAT exam offers another advantage. The candidate may schedule the exam at a time that is convenient for him; the candidate usually receives test results in 7 days or sooner. The candidate can rewrite the exam after 45 days in most states. We suggest that you review this text and others and, if necessary, take a review seminar prior to taking the NCLEX®. Allow at least one week to study and prepare for the exam. Remember that you want to take the exam only one time. Testing Strategies After learning the materials, you might want to utilize a number of testing strategies. These strategies are intended to provide you with additional skills and are not to be considered as a substitute for good study habits or an adequate knowledge of the content. While some attempt to commit information to memory, it has been shown that merely memorizing facts is of little help because few test items rely on simple recall. Most questions that appear as test items above the pass point require the graduate to pull together information from a variety of sources. If you have a thorough knowledge of the content measured by an exam using good testing skills and can apply this knowledge, you will pass the exam. Remember that testing skills, like any other skill, are improved with practice. 6 Chapter 1: Preparing for the National Council Exam for Licensed Practical Nurses Before discussing strategies for successful test-taking, you should be familiar with the follow- ing terms: . Test item—The entire question . Stem—The portion of the test item that asks a question or proposes the problem . Options—All potential answers . Alternative item—Items utilizing a diagram, listing in order of priority, checking all that apply, calculating math or intake and output, viewing streaming video or audio, or filling blanks Reading the Question Carefully Scores are affected by reading ability. Before selecting an answer, ask the following questions: . What is the question asking? . Are there keywords? . Is there relevant information in the stem? . How would I ask this question (in my own words)? . How would I answer this question (in my own words)? After answering these questions, see if there is an option similar to your answer. Is this option the best or most complete answer to the question? Look for Keywords Keywords in the stem should alert you to use care in choosing an answer. Avoid selecting answers that include keywords such as always, never, all, every, only, must, no, except, and none. Answers that contain these keywords are seldom correct because they limit and qualify poten- tially correct answers. Watch for Specific Details Careful reading of details in the stem can provide important clues to the correct option. For example, if the item seeks information on a short-term goal, look for something to be accom- plished within the hospital stay; if the item seeks information on a long-term goal, look for something to be accomplished in the home or community. The following list gives you more hints on how to watch for details in the answer stems: 7 Preparing for the Exam . Eliminate options that are clearly wrong or incorrect—By systematically eliminat- ing distractors, you increase the probability of selecting the correct option. With the elimination of each distractor, you increase the probability of selecting the correct option by 25%. . Look for similar options—If a test item contains two or more correct options that are similar in meaning, look for an umbrella term or phrase that encompasses the other correct options. Correct options will include or exclude all the other options. . Look at the parts of the options—If an answer contains two or more parts, you can reduce the number of possible correct answers by identifying one part as incorrect. . Identify specific determiners—Look for the same or similar words in the stem and in the options. The word in the stem that clues you to a similar word in the option or that limits potential options is referred to as a specific determiner. The option with the specific determiner is often the correct answer. . Identify words in the option that are closely associated with, but not identical to, words in the stem—An option that contains a word(s) closely associated with a word(s) appearing in the stem is often the correct answer. . Be alert for grammatical inconsistencies—The correct option must be consistent with the form of the question. If the item demands a response in the singular, look for an option in the singular—that is, an option in the plural would be incorrect. . Use relevant information from an earlier question—Test writers often provide information that can be used in subsequent questions. This information can help you make correct selections to later items. Be sure that you review the Cram Sheet before you enter the testing area. . Look for the answer that is different from the other options—If the question asks, “Which finding indicates that the client needs further teaching?” you will find that three answers indicate that the client understands and one indicates that the client does not understand your teaching. This testing strategy will really help you with teaching questions. . Look for opposite answers—When you see opposites, one of these options is usually correct. . Do not read into the question—If you find yourself saying “what if?”, stop and reread the stem. Reading into the question will create errors in judgment. . Choosereasonableoptions—Chooseonlyanoptionthatisreasonableandobtainable. 8 Chapter 1: Preparing for the National Council Exam for Licensed Practical Nurses . Choose an option that focuses on or is directed at the client’s feeling. . Choose items related to maintaining life—If the item asks for an immediate action or response or for priority, choose the option that is critical to maintaining the life or safety of the client. . Do not select an option that contains exceptions to the general rule—And don’t select answers that are controversial or that are degrading to the client. . Look for subjective and objective assessment data—When you see both types of data and all options are correct, the most objective data is correct. CAUTION CAUTION CAUTION When dealing with legalities of nursing practice, assign the most critical patients to the registered nurse and the most stable patients to the nursing assistant. If skilled nursing care is required, assign the stable client to the licensed practical nurse and self-assign the most critical. When organizing client care, visit the most critical first. Remember your ABCs: airway, breathing, and circulation. Remember infection control. Do not coassign or assign to room clients who have active infections with surgical or immune-compromised clients. Exam Prep Questions 1. The client is scheduled for a glucose tolerance test. Place in ordered response the correct sequence for performance of this test. A. B. C. D. E. Instruct the client to drink a 75gm glucose solution. Tell the client to eat a high carbohydrate diet for three days prior to the exam. Instruct the client to remain NPO after midnight. Obtain a fasting blood glucose level. Obtain a two-hour post-prandial glucose level. 2. The most important information for the nurse to have when planning care for the client with diabetes is the client’s A. B. C. D. Family medical history Blood glucose history 24-hour dietary history Medical history 3. The nurse has just received the shift report. Which one of the following clients should be seen first? A. B. C. A 14-year-old one day post-appendectomy with a WBC of 6500 A 5-year-old three days post-fracture of the right tibia with a tempera- ture of 101° Fahrenheit An 11-month-old admitted during the previous shift with dehydration and a hematocrit of 40 D. 4. Which client should receive a private room? A. B. C. D. A client with diabetes A client with Cushing’s disease A client with Graves’ disease A client with gastric ulcers An 8-week-old admitted four hours earlier with sub-sternal retractions and an oxygen saturation of 90% 9 Exam Prep Questions 10 Chapter 1: Preparing for the National Council Exam for Licensed Practical Nurses 5. The nurse is making assignments for the day. The staff consists of an RN, an LPN, and a nursing assistant. Which client should be assigned to the nursing assistant? A. B. C. D. A client with laparoscopic cholecystectomy A client with viral pneumonia A client with suspected ectopic pregnancy A client with intermittent chest pain 6. The nurse knows that the client with peripheral vascular disease understands her instructions in ways to improve circulation if the client states A. B. C. D. “I will massage my legs three times a day.” “I will elevate the foot of my bed on blocks.” “I will take a brisk walk for 20 minutes each day.” “I will prop my feet up when I sit to watch TV.” TIP Look at B and D in the previous question. These are similar answers. Remember that the answer that is different is most often correct. Answer C is the “odd answer” or the answer that is different. Walking will develop muscles and muscles support blood vessels. 7. Which action by the client indicates an acceptance of his recent amputation? A. B. C. D. He verbalizes acceptance. He looks at the operative site. He asks for information regarding prosthesis. He remains silent during dressing changes. 8. The client with cancer of the larynx is admitted to the unit with Acute Respiratory Distress Syndrome. Which nursing diagnosis should receive priority? A. B. C. D. Alteration in oxygen perfusion Alteration in comfort/pain Alteration in mobility Alteration in sensory perception 9. Treatment of sickle cell crises includes the application of: TIP A. B. C. D. A heating pad to the joints An ice pack to the joints A CPM device to the lower leg A TENS unit to the back In the previous question, notice that A and B are opposites. 10. The client is admitted to the intensive care unit with severe chest pain. Which infor- mation provides the nurse with the most data that can be utilized in planning care? TIP A. B. C. D. The blood pressure The vital signs The pulse oximeter TheEEG 11 Answer Rationales This is an umbrella answer. If you find one answer is included in another answer, that option is most often correct. Answer Rationales 1. Answer: When placing in chronological order, the nurse should: 2. tell the client to increase the amount of carbohydrates for three days prior to the exam; 3. instruct the client to remain NPO after midnight the day of the exam; 4. obtain a fasting blood glucose level; 1. instruct the client to drink a 75 gm glucose solution; and 5. obtain a two-hour post-prandial glucose level. The candidate is asked to place answers in a logi- cal sequence. Think about the natural order of the question. 2. Answer B is correct. The most objective answer is the blood glucose history. Answers A, C, and D are more subjective. This information is reported data. 3. Answer D is correct. There is nothing in answer A that indicates the client is unstable. Answer B is a good choice, but the client three days post-fracture may have a slight temperature, so he should be seen second. Answer C is also a good choice, but if the 12 Chapter 1: Preparing for the National Council Exam for Licensed Practical Nurses child is dehydrated, the hematocrit will be increased due to a decreased blood volume and hemoconcentration. 4. Answer C is correct. Gravess’ disease is hyperthyroidism. These clients have insomnia and any noise will wake them. Lack of sleep makes their condition worse. Answer B is a good choice, but if you answered B, you are reading into the question because the question does not say that the client should be placed in a room with any client who is infected with any microorganism. Answers A and D are vague answers; stay away from vague answers. The answer does not tell us if they are in the hospital for diagnostic studies or for complications of their diseases. 5. Answer A is correct. The client with laser surgery has three or four very small inci- sions. These clients’ vital signs become stable very quickly, and they are generally discharged within 12–24 hours. We are not, however, suggesting that the nursing assis- tant be assigned to obtain the post-operative vital signs. This should be done by the nurse. The registered nurse should obtain the first vital signs, and the licensed practical nurse may obtain the remaining vital signs. Answers B, C, and D are all more critical clients and should be assigned to a registered nurse. 6. Answer C is correct. Answer A is totally wrong. If this is done, a clot may be present that can become a pulmonary emboli. 7. Answer B is correct. Any time there is a change in body image, looking at the operative site is the best indicator of acceptance. 8. Answer A is correct. Remember the ABCs: Airway is always first. 9. Answer A is correct. Sickle cell anemia is an autosomal recessive trait found most commonly in African-American individuals. The treatment for this condition is heat, hydration, oxygenation, and pain relief. 10. Answer B is correct. Notice that the vital signs include a blood pressure. CHAP2TER TWO Simplifying Pharmacology Terms you’ll need to understand: Adverse reactions Agonist Allergic response Antagonists Buccal Contraindications Enteral administration Enteric coating FDA Intradermal Intramuscular Nursing implication Nursing skills you’ll need to master: Making drug calculations Administering oral medication Administering parenteral medication Oral Peak drug level Pharmacodynamics Pharmacokinetics Pharmacotherapeutics Side effects Spansules Subcutaneous Synergistic Toxicity Trough drug level Administering suppositories Interpreting normal lab values 14 Chapter 2: Simplifying Pharmacology Pharmacology For a number of years, I have searched for a way to help students understand and apply knowl- edge of pharmacology to nursing practice. The graduate nurse is frequently responsible for instructing the client and the client’s family regarding the safe administration of medications. The study of pharmacology is constantly changing as new drugs are constantly being approved for public use by the Food and Drug Administration (FDA). The recent test plan approved by the National Council Licensure Exam devotes 13%–19% of the Physiological Integrity sec- tion to pharmacology. This chapter contains useful information to help you look at the clas- sification and generic name of drugs. If you can remember the drug classification, frequently you can understand why the drug was ordered. Three Areas of Pharmacology It is important to note that the study of pharmacology includes three areas: . Pharmacokinetics—This is the study of how drugs are absorbed, distributed, metabo- lized, and excreted by the body. Elderly clients and clients with renal or liver disease frequently have difficulty metabolizing and excreting medications. These clients can develop drug toxicity more easily than those with no renal or liver impairment. . Pharmacodynamics—This is the study of how drugs are used by the body. For example, pharmacodynamics of oral hypoglycemics explain how the blood glucose is reduced by stimulating the pancreatic beta cells to produce more insulin, by also mak- ing insulin receptor sites more sensitive to insulin, and by increasing the number of insulin receptor cells. These drugs are effective only if the client’s pancreas is produc- ing some insulin. . Pharmacotherapeutics—This is the study of how the client responds to the drug. A client might experience side effects such as gastrointestinal symptoms to a number of medications, including antibiotics. Side effects may cause discomfort but are usually not severe enough to warrant discontinuation of the medication. Demerol (meperidine HCl) is a narcotic analgesic that can cause nausea and vomiting. To prevent these side effects, the physician frequently orders an antiemetic called Phenergan (promethazine) to be given with Demerol. These drugs have a synergistic effect that provides pain relief while preventing the discomfort of side effects. Adverse effects of medications result in symptoms so severe that it is necessary to reduce the dosage or discontinue the medication completely. Antituberculars and anticonvulsants are two categories of medications that can have adverse effects on the liver. The nurse should carefully assess the client for signs of jaundice that indicate drug-related hepatitis, in which case the medication will be discontinued. 15 How Nurses Work with Pharmacology How Nurses Work with Pharmacology Nurses are expected to utilize their knowledge of pharmacology to . Recognize common uses, side effects, and adverse effects of the client’s medication . Challenge medication errors . Meet the client’s learning needs Generally, the medication the nurse is expected to administer depends on the area of practice and the assigned client. The following medication classifications are commonly prescribed for adult clients within a medical/surgical setting: . Anti-infectives—Used for the treatment of infections. . Antihypertensives—These lower blood pressure and increase blood flow to the myo- cardium. . Antidiarrheals—Decrease gastric motility and reduce water content in the intestinal tract. . Diuretics—Decrease water and sodium absorption from the Loop of Henle (loop diuretics) or inhibit antidiuretic hormone (potassium-sparing diuretics). . Antacids—Reduce hydrochloric acid in the stomach. A common side effect of calcium- and aluminum-based antacids is constipation. Magnesium-based antacids frequently cause diarrhea. . Antipyretics—Reduce fever. . Antihistamines—Block the release of histamine in allergic reactions. Common side effects of antihistamines are dry mouth, drowsiness, and sedation. . Bronchodilators—Dilate large air passages and are commonly prescribed for clients with asthma and chronic obstructive lung disease. A common side effect of these is tachycardia. . Laxatives—Promote the passage of stool. Types of laxatives include stool softeners, cathartics, fiber, lubricants, and stimulants. . Anticoagulants—Prevent clot formation by decreasing vitamin K levels and blocking the clotting chain or by preventing platelet aggregation. . Antianemics—Increase factors necessary for red blood cell production. Examples of antianemics include B12, iron, and Epogen (erythropoetin). 16 Chapter 2: Simplifying Pharmacology . Narcotics/analgesics—Relieve moderate-to-severe pain. Medications in this category include opioids (morphine and codeine), synthetic opioids (meperidine), and NSAIDs (ketorolac). . Anticonvulsants—Used for the management of seizure disorder and the treatment of bipolar disorder. Medications used as anticonvulsants include lorazepam (Ativan), phe- nobarbital, and phenytoin (Dilantin). . Anticholinergics—Cause the mucous membranes to become dry; therefore, oral secretions are decreased. Anticholinergics such as atropine are often administered pre- operatively. . Mydriatics—Dilate the pupils. Mydriatics are used in the treatment of clients with cataracts. . Miotics—Constrict the pupil. Miotics such as pilocarpine HCl are used in the treat- ment of clients with glaucoma. Time-Released Drugs The following abbreviations indicate to the nurse that the drug is time-released. These prepa- rations should not be crushed or opened: . Dur = Duration . SR = Sustained release . CR = Continuous release . SA = Sustained action . Contin = Continuous action . LA = Long acting Enteric-coated tablets and caplets are those coated with a thick shell that prevents the medica- tion from being absorbed in the upper GI tract, allowing the medication to be absorbed more slowly. Spansules are capsules containing time-released beads that are released slowly. The nurse should not alter the preparation of these types of medications. The physician should be notified to obtain an alternative preparation if the client is unable to swallow a time-released preparation. Administering Medications When preparing to administer medications, the nurse must identify the client by reviewing the physician’s order. She must also administer the medication by the right route. Many medica- tions are supplied in various preparations. The physician orders the method of administration. The choice of medication administration is dependent on several factors, including the desired blood level, the client’s ability to swallow, and the disease, or disorder being treated. The Seven Rights of Administering Medication The nurse is expected to use the seven rights when administering medications to the client. These include five rights of drug administration, plus two from the Patient’s Bill of Rights. The Patient’s Bill of Rights was enacted to protect the client’s well-being, both mentally and physically. The client has the right to refuse treatment that may include medications. The nurse must document any treatment provided to the client. Documentation of care given must be made promptly to prevent forgetting any details and to ensure that another nurse does not duplicate medication administration. The seven rights of medication administration are . Right client—Identification of the client must be done by asking the client to state his name and checking the identification band. . Right route—The physician orders the prescribed route of administration. . Right drug—Checking both the generic and trade names with the physician’s order ensures that the right drug is administered. If the client’s diagnosis does not match the drug category, the nurse should further investigate the ordered medication. . Right amount—The nurse is expected to know common dosages for both adults and children. . Right time—The nurse can administer the medication either 30 minutes before the assigned time or 30 minutes after. . Right documentation (from the Patient’s Bill of Rights and legality issues in nursing)—This right is different from the others in that it must be done to prevent duplicating drug administration. . Right to refuse treatment (from the Patient’s Bill of Rights)—The client has the right to refuse medication or treatment. 17 How Nurses Work with Pharmacology 18 Chapter 2: Simplifying Pharmacology Understanding and Identifying the Various Drugs It is important to know that drugs generally have several names. The following list explains these different names for you: . Chemical name—This is often a number or letter designation that tells you the chem- ical makeup of the drug. This name is of little value to the nurse in practice. . Generic name—This is the name given by the company that developed the drug, and it remains the same even after the patent is released and other companies are allowed to market the medication. . Trade name—This is the name given to the drug by the originating company. This name may change after the patent is released. It is much safer for the nurse to remember the generic name rather than the trade name because the trade name will probably change. CAUTION Approximately 80% of the time generic drugs in the same category have common syllables. If you can identify the commonality within the generic names, you can more easily learn the needed information for the NCLEX. Let’s look at some commonly given categories of drugs and see whether we can recognize the commonalities in the names. As you will see, each drug has a common part in its name. This is a hint we want to point out that will help you to quickly identify a particular drug by the common part of the name for that drug category. Let’s begin with the angiotensin-converting agents drug category to see how this works. Angiotensin-Converting Enzyme Inhibitors This category of drugs is utilized to treat both primary and secondary hypertension. These drugs work by inhibiting the conversion of angiotensin I to angiotensin II. Notice that all the generic names include the syllable pril. When you see these letters, you will know that they are angiotensin-converting enzyme (ACE) inhibitors. Table 2.1 highlights these in more depth. On the NCLEX exam, both the generic and trade names of medications might be included for clarification. The generic name will be given. 19 Understanding and Identifying the Various Drugs TABLE 2.1 Angiotensin-Converting Enzyme Inhibitors Action/Use DrugName* Antihypertensives Benazepril(Lotensin) Lisinopril (Zestril) Captopril (Capoten) Enalapril (Vasotec) Fosinopril (Monopril) Moexipril (Univas) Quinapril (Acupril) Ramipril (Altace) *The generic name is listed first with the trade name in parentheses. When working with angiotensin-converting enzyme inhibitors, it is important to know the potential side effects. The following list details the possible side effects/adverse reactions with this drug category: . Hypotension . Hackingcough . Nausea/vomiting . Respiratorysymptoms The following items are nursing considerations to know when working with ACE inhibitors: . Monitor the vital signs frequently. . Monitor the white blood cell count. . Monitor the electrolyte levels. Beta Adrenergic Blockers Beta adrenergic blockers are drugs that help lower blood pressure, lower pulse rate, and lower cardiac output. They are also used to treat migraine headaches and other vascular headaches. Certain preparations of the beta blockers are used to treat glaucoma and prevent myocardial infarctions. These drugs act by blocking the sympathetic vasomotor response. Notice the syllable olol. When you see these letters, you will know that these drugs are beta blockers. Table 2.2 highlights these beta blockers in more detail. 20 Chapter 2: Simplifying Pharmacology TABLE 2.2 Beta Adrenergic Blockers Action/Use DrugName* Act by blocking sympathetic vasomotor response Acebutolol (Monitan, Rhotral, Sectral) Atenolol (Tenormin, Apo-Atenol, Nova-Atenol) Esmolol (Brevibloc) Propanolol (Inderal) Carvedilol (Coreg) Note: does not end in “olol” but in ilol. *The generic name is listed first with the trade name in parentheses. The potential side effects/adverse reactions of beta adrenergic blockers are listed here: . Orthostatichypotension . Bradycardia . Nausea/vomiting . Diarrhea . Congestive heart failure . Blooddyscrasias The following list gives you some nursing interventions for working with clients using beta adrenergic blockers: . Monitor the client for changes in lab values (protein, BUN, creatinine) that indicate nephrotic syndrome. . Monitor the client’s blood pressure, heart rate, and rhythm. . Monitor the client for signs of edema. . Teach the client to . Riseslowly. . Report bradycardia, dizziness, confusion, depression, or fever. . Taper off the medication. Anti-Infectives (Aminoglycosides) Anti-infective drugs include bactericidals and bacteriostatics. They interfere with the protein synthesis of the bacteria, causing the bacteria to die. They are active against most aerobic Gram-negative bacteria and against some Gram-positive organisms. 21 Understanding and Identifying the Various Drugs Notice that these end in cin, and many of them end in mycin. So, when you see either of these syllables, you know these are anti-infectives. Table 2.3 explains the various anti-infectives. TABLE 2.3 Anti-Infective Drugs Action/Use DrugName* Interfere with the protein synthesis of the bacteria, causing the bacteria to die Gentamicin (Garamycin, Alcomicin, Genoptic) Kanamycin (Kantrex) Neomycin (Mycifradin) Streptomycin (Streptomycin) Tobramycin (Tobrex, Nebcin) Amikacin (Amikin) *The generic name is listed first with the trade name in parentheses. The following list highlights some possible side effects/adverse reactions from the use of anti- infectives (aminoglycosides): . Ototoxicity . Nephrotoxicity . Seizures . Blooddyscrasias . Hypotension . Rash The following are nursing interventions you need to be aware of when working with clients using anti-infectives (aminoglycosides): . Obtain a history of allergies. . Monitor intake and output. . Monitor vital signs during intravenous infusion. . Maintain a patent IV site. . Monitor for therapeutic levels. . Monitor for signs of nephrotoxicity. . Monitor for signs of ototoxicity. 22 Chapter 2: Simplifying Pharmacology . Teach the client to report any changes in urinary elimination. . Monitor peak and trough levels. NOTE CAUTION Benzodiazepines (Anticonvulsants/Antianxiety) These drugs are used for their antianxiety or anticonvulsant effects. Notice that all these contain the syllables pam, pate, or lam. Table 2.4 gives you a breakdown of these drug types. CAUTION TABLE 2.4 Benzodiazepines (Anticonvulsants/Sedative/Antianxiety) Drugs Action/Use DrugName* Tests on peak and trough levels are done to obtain a blood level and determine the dosage needed for the client. They should be done 30–60 minutes after the third or fourth IV dose or 60 minutes after the third or fourth IM dose. Trough levels should be drawn 30 minutes before the next dose. The client should be taught to report any change in renal function or in hearing because this category can be toxic to the kid- neys and the auditory nerve. These drugs are frequently used to treat super-infections such as methicillin-resistant staphylococcus aureus (MRSA). Clients with MRSA exhibit the following symptoms: fever, malaise, redness, pain, swelling, perineal itching, diarrhea, stomatitis, and cough. Not all the benzodiazepines contain pam; some of them contain pate and lam, as in aprazolam (Xanax); however, they all contain azo or aze. Sedative-hypnotic; also used as an anticonvulsant; has antianxiety effects Clonazepam (Klonopin) Diazepam (Valium) Chlordiazepoxide (Librium) Lorazepam (Ativan) Flurazepam (Dalmane) *The generic name is listed first with the trade name in parentheses. 23 Understanding and Identifying the Various Drugs The following list gives you some possible side effects and adverse reactions from the use of this classification: . Drowsiness . Lethargy . Ataxia . Depression . Restlessness . Slurredspeech . Bradycardia . Hypotension . Diplopia . Nystagmus . Nausea/vomiting . Constipation . Incontinence . Urinaryretention . Respiratorydepression . Rash . Urticaria The following are some nursing interventions to know when working with the client taking benzodiazepines: . Monitorrespirations. . Monitor liver function. . Monitor kidney function. . Monitor bone marrow function. . Monitor for signs of chemical abuse. 24 Chapter 2: Simplifying Pharmacology Phenothiazines (Antipsychotic/Antiemetic) These drugs are used as antiemetics or neuroleptics. These drugs are also used to treat psycho- sis in those clients with schizophrenia. Some phenothiazines such as Phenergan (prometha- zine) and Compazine (prochlorperzine), are used to treat nausea and vomiting. CAUTION Notice that all these contain the syllable zine (see Table 2.5). TABLE 2.5 Phenothiazines (Antipsychotic/Antiemetic) Drugs Action/Use DrugName* Because they are irritating to the tissue, Z-track method should be used when administering phenothi- azines by intramuscular injection. If the client is allergic to one of the phenothiazines, he probably is allergic to all of them. If the client experiences an allergic reaction or extrapyramidal effects, a more severe reaction, the client should be given Benadryl (diphenhydramine hydrochloride) or Congentin (benztropine mesylate). Used as antiemetics or major tranquilizer Chlopromazine (Thorazine) Prochlorperazine (Compazine) Trifluoperazine (Stelazine) Promethazine (Phenergan) Hydroxyzine (Vistaril) Fluphenazine (Prolixin) *The generic name is listed first with the trade name in parentheses. The following list gives you some possible side effects and adverse reactions from the use of phenothiazines: . Extrapyramidaleffects . Drowsiness . Sedation . Orthostatichypotension . Drymouth . Agranulocytosis . Photosensitivity . Neuroleptic malignant syndrome Glucocorticoids These drugs are used in the treatment of conditions requiring suppression of the immune system and in Addison’s disease. These drugs have anti-inflammatory, anti-allergenic, and anti-stress effects. They are used for replacement therapy for adrenal insufficiency (Addison’s disease); as immunosuppressive drugs in post-transplant clients; and to reduce cerebral edema associated with head trauma, neurosurgery, and brain tumors. Notice that all these contain sone or cort (see Table 2.6). TABLE 2.6 Glucocorticoid Drugs Action/Use DrugName* 25 Understanding and Identifying the Various Drugs These drugs are used to decrease the inflammatory response to allergies and inflammatory diseases or to decrease the possibility of organ transplant rejection. Prednisolone (Delta-Cortef, Prednisol, Prednisolone) Prednisone (Apo-Prednisone, Deltasone, Meticorten, Orasone, Panasol-S) Betamethasone (Celestone, Selestoject, Betnesol) Dexamethasone (Decadron, Deronil, Dexon, Mymethasone, Dalalone) Cortisone (Cortone) Hydrocortisone (Cortef, Hydrocortone Phosphate, Cortifoam) Methylprednisolone (Solu-cortef, Depo-Medrol, Depopred, Medrol, Rep-Pred) Triamcinolone (Amcort, Aristocort, Atolone, Kenalog, Triamolone) *The generic name is listed first with the trade name in parentheses. The following list gives you some possible side effects and adverse reactions from the use of this drug type: . Acne . Poor wound healing . Ecchymosis . Bruising . Petechiae . Depression 26 Chapter 2: Simplifying Pharmacology . Flushing . Sweating . Mood changes (depression) . Hypertension . Osteoporosis . Diarrhea . Hemorrhage NOTE The following are nursing interventions used when working with the client taking glucocorticoids: . Monitor glucose levels. . Weigh the client daily. . Monitor blood pressure. . Monitor for signs of infection. Antivirals These drugs are used for their antiviral properties. They inhibit viral growth by inhibiting an enzyme within the virus. Herpetic lesions respond to these drugs. Clients with acquired immune deficiency syndrome (AIDS) are often treated with this category of drugs either alone or in combination with other antiviral drugs. These drugs are also used to treat herpetic lesions (HSV-1, HSV-2), varicella infections (chickenpox), herpes zoster (shingles), herpes simplex (fever blisters), encephalitis, cytomegalovirus (CMV), and respiratory syncytial virus (RSV). Notice that all these drug names contain vir. Table 2.7 lists some of these drug types. These drugs can cause Cushing’s syndrome. Signs of Cushing’s syndrome include moon faces, edema, elevated blood glucose levels, purple straie, weight gain, buffalo hump, and hirsutism. TABLE 2.7 Antiviral Drugs Action/Use DrugName* 27 Understanding and Identifying the Various Drugs These drugs are used for their antiviral effects. Acyclovir (Zovirax) Ritonavir (Norvir) Saquinovir (Invirase, Fortovase) Indinavir (Crixivan) Abacavir (Ziagen) Cidofovir (Vistide) Ganciclovir (Cytovene, Vitrasert) *The generic name is listed first with the trade name in parentheses. The following list gives some side effects and adverse effects that are usually associated with this drug category: . Nausea . Vomiting . Diarrhea . Oliguria . Proteinuria . Vaginitis . Central nervous side effects (these are less common): . Tremors . Confusion . Seizures . Severe, sudden anemia The following nursing intervention are used when working with client taking antivirals: . Tell the client to report a rash because this can indicate an allergic reaction. . Watch for signs of infection. . Monitor the creatinine level frequently. . Monitor liver profile. . Monitor bowel pattern before and during treatment. 28 Chapter 2: Simplifying Pharmacology Cholesterol-Lowering Agents This drug type is used to help the client lower cholesterol and triglyceride levels and to decrease the potential for cardiovascular disease. Notice that all these contain the syllable vastatin. It should be noted that many advertisements call these “statin” drugs. These drugs should not be confused with the statin drugs used for their antifungal effects. These can include nystatin (trade name Mycostatin or Nilstat). Table 2.8 lists some of the cholesterol-lowering agents. TABLE 2.8 Cholesterol-Lowering Drugs Action/Use DrugName* These drugs are used to lower cholesterol. Atorvastatin (Lipitor) Fluvastatin (Lescol) Lovastatin (Mevacor) Pravastatin (Pravachol) Simvastatin (Zocar) Rosuvastatin (Crestor) *The generic name is listed first with the trade name in parentheses. CAUTION Here is a list of side effects and adverse reactions that could occur with the use of cholesterol- lowering agent: . Rash . Alopecia . Dyspepsia . Liverdysfunction . Muscle weakness (myalgia) . Headache CAUTION This category should not be taken with grapefruit juice and should be taken at night. The client should have regular liver studies to determine the presence of liver disease. Rhabdomyolysis, a muscle-wasting syndrome, has been linked with the use of cholesterol-lowering agents. The client should be instructed to report unexplained muscle soreness and weakness to the physi- cian because these may be signs of rhabdomyolysis. 29 Understanding and Identifying the Various Drugs The following nursing interventions are used when working with the client taking cholesterol lowering agents: . A diet low in cholesterol and fat should be included in therapy. . Monitor cholesterol levels. . Monitor liver profile. . Monitor renal function. . Tell the client to report visual changes because cataracts can occur in clients taking vastatins. . Monitor for muscle pain and weakness. Angiotensin Receptor Blockers These drugs block vasoconstrictor- and aldosterone-secreting angiotensin II. They are used to treat primary or secondary hypertension and are an excellent choice for clients who complain of the coughing associated with ACE inhibitors. Notice that all these contain sartan. Table 2.9 lists some of these drugs. TABLE 2.9 Angiotensin Receptor Blocker Drugs Action/Use DrugName* These drugs are used to lower blood pressure and Valsartan (Diovan) increase cardiac output. Candesartan (Altacand) Losartan (Cozaar) Telmisartan (Micardis) *The generic name is listed first with the trade name in parentheses. The following list gives some side effects and adverse effects for the use of angiotensin recep- tor blockers: . Dizziness . Insomnia . Depression . Anginapectoris . Second-degree AV block . Conjunctivitis 30 Chapter 2: Simplifying Pharmacology . Diarrhea . Nausea/vomiting . Impotence . Musclecramps . Neutropenia . Cough The following nursing interventions are used when working with a client taking an angiotensin receptor blocker agent: . Monitor blood pressure and pulse. . MonitorBUN. . Monitorcreatinine. . Monitorelectrolytes. . Tell the client to report edema in feet and legs daily. . Monitor hydration status. Histamine 2 Antagonists These drugs are used in the treatment of gastroesophageal reflux disease (GERD), acid reflux, and gastric ulcers. They inhibit histamine 2 (H2) release in the gastric parietal cells, therefore inhibiting gastric acids. Notice that all these contain the syllable tidine (see Table 2.10). TABLE 2.10 Histamine 2 Antagonist Drugs Action/Use DrugName* Block histamine 2 receptor sites, decreasing acid Cimetidine (Tagamet) production; used to treat gastric ulcers and GERD Famotidine (Pepcid) Nizatidine (Axid) Rantidine (Zantac) *The generic name is listed first with the trade name in parentheses. 31 Understanding and Identifying the Various Drugs The following list gives some side effects and adverse effects associated with histamine 2 antagonist: . Confusion . Bradycardia/tachycardia . Diarrhea . Psychosis . Seizures . Agranulocytosis . Rash . Alopecia . Gynecomastia . Galactorrhea Following are some nursing interventions taking H2 antagonist: . Monitor the blood urea nitrogen levels. . Administer the medication with meals. . If taking the medication with antacids, take antacids one hour before or after taking these drugs. . Cimetidine may be prescribed in one large dose at bedtime. . Sucralfate decreases the effects of histamine 2 receptor blockers. Proton Pump Inhibitors These drugs suppress gastric secretion by inhibiting the hydrogen/potassium ATPase enzyme system. They are used in the treatment of gastric ulcers, indigestion, and GERD (gastro- esophageal reflux disease). Notice that all these drugs contain the syllable prazole and should be given prior to meals. Table 2.11 highlights proton pump inhibitor drugs. 32 Chapter 2: Simplifying Pharmacology TABLE 2.11 Proton Pump Inhibitors Action/Use DrugName* Used in the treatment of GERD, gastric ulcers, Esomeprazole (Nexium) and esophagitis Lansoprazole (Prevacid) Pantoprazole (Protonix) Rabeprazole (AciPhex) *The generic name is listed first with the trade name in parentheses. The following list gives some side effects and adverse effects associated with proton pump inhibitors: . Headache . Insomnia . Diarrhea . Flatulence . Rash . Hyperglycemia Some nursing interventions to use when working with the client taking proton pump inhibi- tors are as follows: . Do not crush pantoprazole (Protonix). Use a filter when administering IV pantopra- zole. . May take before meals for best absorption. . Monitor liver function. Anticoagulants These drugs are used in the treatment of thrombolytic disease. These drugs are used to treat pulmonary emboli, myocardial infarction, deep-vein thrombosis, after coronary artery bypass surgery, and for other conditions requiring anticoagulation. Notice that all these drugs contain the syllable parin and are heparin derivatives. The client should have a PTT checked to evaluate the bleeding time when giving heparin. The antidote for heparin is protamine sulfate. Table 2.12 lists these. TABLE 2.12 Anticoagulant Drugs 33 Understanding and Identifying the Various Drugs Action/Use DrugName* These drugs are used to treat clotting disorders and Heparin sodium (Hepalean) to thin the blood. Enoxaparin sodium (Lovenox) Dalteparin sodium (Fragmin) *The generic name is listed first with the trade name in parentheses. The following list gives side effects and adverse effects of heparin derivatives: . Fever . Diarrhea . Stomatitis . Bleeding . Hematuria . Dermatitis . Alopecia . Pruritus Nursing intervention to use in caring for the client taking an anticoagulant (heparin derivative) consists of the following: . Blood studies (hematocrit and occult blood in stool) should be checked every three months. . Monitor PTT often for heparin (therapeutic levels are 1.5–2.0 times the control). There is no specific bleeding time done for enoxaparin (Lovenox). . Monitor platelet count. . Monitor for signs of bleeding. . Monitor for signs of infection. More Drug Identification Helpers These are some of the commonly given medications that allow you to utilize the testing tech- nique of commonalities. Looking at these similarities will help you manage the knowledge needed to pass the NCLEX and better care for your clients. 34 Chapter 2: Simplifying Pharmacology Here are some other clues that may help you in identifying drug types: . Caine = anesthetics (Lidocaine) . Mab = monoclonal antibodies (Palivazumab) . Ceph or cef = cephalosporins (Cefatazime) . Cillin = penicillins (Ampicillin) . Cycline = tetracycline (Tetracycline) . Stigmine = cholinergics (Phyostigmine) . Phylline = bronchodilators (Aminophylline) . Cal = calciums (Calcimar) . Done = opioids CAUTION Herbals Herbals are not considered by some to be medications. They are not regulated by the FDA and can be obtained without a prescription. They do, however, have medicinal properties. Herbals are included on the NCLEX in the category of pharmacology. . Feverfew—Thisisusedtopreventandtreatmigraines,arthritis,andfever.Thisherbal should not be taken with Coumadin, aspirin, NSAIDs, thrombolytics, or antiplatelet medications because it will prolong the bleeding time. . Ginseng—This is used as an anti-inflammatory. It has estrogen effects, enhances the immune system, and improves mental and physical abilities. This herbal decreases the effects of anticoagulants and NSAIDs. This herbal also should not be taken by clients taking corticosteroids because the combination of these two can result in extremely high levels of corticosteroids. High doses cause liver problems. . Ginkgo—This improves memory and can be used to treat depression. It also improves peripheral circulation. Ginkgo should not be taken with MAO inhibitors, anticoagu- lants, or antiplatelets. It increases the bleeding time in clients taking NSAIDs, cephalo- sporins, and valproic acid. . Echinacea—This is used to treat colds, fevers, and urinary tract infections. This herbal may interfere with immunosuppressive agents, methotrexate, and ketoconizole. Do not give tetracycline to pregnant women or small children. It stains the teeth dark and stunts the growth of small children. 35 Pregnancy Categories for Drugs . Kava-kava—This herb is used to treat insomnia and mild muscle aches and pains. This herbal increases the effects of central nervous system (CNS) suppressants and decreases the effects of levodopa. It can also increase the effect of MAOIs. . St. John’s Wort—This is used to treat mild to moderate depression. This herbal increases adverse CNS effects when used with alcohol or antidepressant medications. . Ma Huang—This is used to treat asthma and hay fever, for weight loss, and to increase energy levels. This herbal increases the effect of MAOIs, sympathomimetics, theophylline, and cardiac glycosides. Drug Schedules It is important for the nurse to be aware of the drug schedules; several questions might be asked on the NCLEX regarding safety. . Schedule I—Research use only (for example, LSD). . Schedule II—Requires a written prescription for each refill. No telephone renewals are allowed (for example, narcotics, stimulants, and barbiturates). . Schedule III—Requires a new prescription after six months or five refills; it can be a telephone order (for example, codeine, steroids, and antidepressants). . Schedule IV—Requires a new prescription after six months (for example, benzodi- azepines). . Schedule V—Dispensed as any other prescription or without prescription if state law allows (for example, antidiarrheals and antitussives). Pregnancy Categories for Drugs These drug categories might also be included on the NCLEX exam. It is important for the nurse to know which categories the pregnant client should avoid: . Category A—No risk to fetus. . Category B—Insufficient data to use in pregnancy. . Category C—Benefits of medication could outweigh the risks. . Category D—Risk to fetus exists, but the benefits of the medication could outweigh the probable risks. . Category X—Avoid use in pregnancy or in those who may become pregnant. Potential risks to the fetus outweigh the potential benefits. 36 Chapter 2: Simplifying Pharmacology Exam Prep Questions 1. Which instruction should be given to the client taking alendronate sodium (Fosamax)? A. B. C. D. Take the medication in conjunction with estrogen. Take the medication before arising. Force fluids while taking this medication. Remain upright for 30 minutes after taking this medication. 2. The client is discharged from the unit with a prescription for Evista (raloxifene HCl). Which of the following is a side effect of this medication? A. B. C. D. Cold extremities Leg cramps Hot flashes Urinary frequency 3. An elderly diabetic who has been maintained on metformin (Glucophage) is scheduled for a cardiac catheterization. Which instruction should be given to the client? A. B. C. D. Take the medication with only water prior to the exam. Take the medication as ordered prior to the exam. Limit the amount of protein in the diet prior to the exam. Discontinue the medication prior to the exam. 4. The client’s mother contacts the clinic regarding medication administration stating, “My daughter can’t swallow this capsule. It’s too large.” Investigation reveals that the medication is a capsule marked SR. The nurse should instruct the mother to: A. B. C. D. Stop the medication and inform the physician at the follow-up visit. Open the capsule and mix the medication with ice cream. Crush the medication and administer it with 8 oz. of liquid. Call the pharmacist and request an alternative preparation of the medication. 37 Exam Prep Questions 5. A 5-year-old is being treated for an acute attack of asthma using racemic epinephrine (epinephrine hydrochloride) nebulizer stat. Which finding indicates an adverse effect of this medication? A. B. C. D. Excitability Tremors Heart rate 150 Nausea 6. The client is being treated with intravenous Vancomycin for MRSA when the nurse notes redness of the client’s neck and chest. Place in ordered sequence the actions to be taken by the nurse: A. B. C. D. Call the doctor. Stop the IV infusion of Vancomycin. Administer Benadryl as ordered. Take the vital signs. 7. A client with leukemia is receiving oral prednisolone (Prednisone). An expected side effect of the prolonged use of prednisoline is: A. B. C. D. Weight loss Decreased appetite Hirsutism Integumentary bronzing 8. Which laboratory result would concern the nurse caring for a client who is receiving furosemide (Lasix)? A. B. C. D. Potassium of 2.5 Sodium 140 Glucose 110 Calcium of 8 9. Which instruction should be given to a client taking Lugol’s solution prior to a thyroidectomy? A. B. C. D. Take at bedtime. Take the medication with juice. Report changes in appetite. Avoid the sunshine while taking the medication. 38 Chapter 2: Simplifying Pharmacology 10. A client is admitted to the recovery room following an exploratory laparotomy. Which medication should be kept nearby? A. B. C. D. Diphenhydramine (Benadryl) A. B. C. D. Severe headache Slight nausea Decreased urination Itching Nitroprusside (Nipride) Naloxone hydrochloride (Narcan) Flumazenil (Romazicon) 11. A client with renal failure has an order for erythropoietin (Epogen) to be given subcutaneously. The nurse should teach the client to report: Answer Rationales 1. Answer C is correct. Alendronate sodium is a drug used to treat osteoporosis. Let’s use testing strategies for this question. Look at answers A and C; these are opposites. When you are in the bed, you are lying down. The drug should not be given while lying down nor should it be taken with medication or with estrogen. In answer C, you are upright. This drug causes gastric reflux, so you should remain upright and take it with only water. Notice the clue in the name of the drug: fosa, as in fossils. All the drugs in this category contain the syllable dronate. 2. Answer B is correct. This drug is in the same category as the chemotherapeutic agent tamoxifene (Novaldex) used for breast cancer. In the case of Evista, this drug is used to treat osteoporosis. Notice that the E stands for estrogen. This drug has an agonist effect, so it binds with estrogen and can cause hot flashes. This drug does not cause leg cramps, urinary frequency, or cold extremites, so answers A, C, and D are incorrect. 3. Answer C is correct. Glucophage can cause renal problems. The dye used in cardiac catheteriza- tions is also detrimental to the kidneys. The client should be placed on sliding scale insulin for 48 hours after the dye procedure or until renal function returns. Note the syllable phage, as seen in the syllable phagia, which means eating. Also note that answers A and C are opposites. Answer A is incorrect because the medication should be withheld; answer B is incorrect because limiting the amount of protein in the diet prior to the exam has no correlation to the medication. Taking the medication with water is not necessary, so answer D is incorrect. 4. Answer C is correct. SR means sustained release. These medications cannot be altered. In answers A and B, crushing or opening the capsule is not allowed. In answer D, the doctor should be noti- fied immediately. 39 Answer Rationales 5. Answer C is correct. Adverse effects of epinephrine include hypertension and tachycardia. Answers A, B, and D are expected side effects of racemic epinephrine. 6. The correct order is B, D, A, and C. 7. Answer C is correct. Notice that the testing strategy “odd item out” can be used in this question. Answers A, B, and D are symptoms of Addison’s disease. Answer C is the answer that is different from the rest. Hirsutism, or facial hair, is a side effect of cortisone therapy. 8. Answer A is correct. Furosemide (Lasix) is a loop diuretic. Note that most of the loop diuretics end in ide. In answers B, C, and D, the findings are all within normal limits. 9. Answer B is correct. Lugol’s solution is a soluble solution of potassium iodine and should be given with juice because it is bitter to taste. In answer A the medication can be taken at another time, so it is incorrect. Reporting changes in appetite is unnecessary, so answer C is incorrect. Answer D is incorrect because it is also unnecessary. 10. Answer B is correct. During the post-operative period, narcotics are given. Narcan is the antidote to narcotics, so answer B is correct. Nipride is utilized to lower blood pressure, so answer A is incorrect. Romazicon is the antidote for the benzodiazepines, so answer C is incorrect. Benadryl is an antihistamine, so answer D is incorrect. 11. Answer A is correct. Severe headache can indicate impending seizure activity. Slight nausea is expected when beginning the therapy, so answer B is incorrect. The client with renal failure already has itching and decreased urination, so answers C and D are incorrect. 40 Chapter 2: Simplifying Pharmacology Suggested Reading and Resources . Whalen, K. Lippincott’s Illustrated Reviews: Pharmacology, 6th Edition. Philadelphia: Lippincott Williams, and Wilkins, 2014. . Lehne, R. Pharmacology For Nursing Care, 9th Edition. St. Louis: Elsevier, 2016. CHAPT3ER THREE Caring for the Client with Disorders of the Respiratory System Terms you’ll need to understand: Acute respiratory failure Apnea Asthma Atelectasis Bronchitis Continuous positive airway pressure (CPAP) Cor pulmonale Cyanosis Dyspnea Nursing skills you’ll need to master: Assessing breath sounds Providing tracheostomy care Collecting sputum Teaching proper use of an inhaler Performing postural drainage Assisting with thoracentesis Emphysema Empyema Hemoptysis Hypoxemia Hypoxia Pleural effusion Pleurisy Pneumonia Pulmonary embolus Tachypnea Obtaining a throat culture Performing venopuncture Administering medication Managing chest tubes Maintaining oxygen therapy Teaching pursed lip breathing exercises 42 Chapter 3: Caring for the Client with Disorders of the Respiratory System Chronic Obstructive Pulmonary Disease Chronic obstructive pulmonary disease (COPD) exists when prolonged disease or injury has made the lungs less capable of meeting the body’s oxygen needs. Cigarette smoking, exposure to inhaled particles in wood smoke and biomass fuels, and deficiency in alpha antitrypsin are all risk factors for COPD. Examples of COPD include chronic bronchitis, emphysema, and asthma. Chronic Bronchitis Chronic bronchitis, an inflammation of the bronchi and bronchioles, is caused by continous exposure to infection and non-infectious irritants, such as cigarette smoke. The condition is most common in those ages 40 to 55. Chronic bronchitis might be reversed with the removal of noxious irritants, although it is often complicated by chronic lung infections. These infec- tions, which are characterized by productive cough and dyspnea, can progress to right-sided heart failure and pulmonary hypertension. Chronic bronchitis and emphysema have similar symptoms that require similar interventions. Emphysema Emphysema is the irreversible overdistention of the airspaces of the lungs, which results in destruction of the alveolar walls. Although some alveoli are destroyed others could enlarge or loose elasticity to the point of becoming flabby with less area available for gas exchange. Clients with early emphysematous changes might complain of exertional dyspnea without cyanosis. As the disease progresses the client might develop chronic hypoxia, cyanosis, poly- cythemia, cor pulmonale, pulmonary edema, or respiratory failure. Cigarette smoking is the primary cause of both chronic bronchitis and emphysema. Physical assessment of the client with emphysema reveals the presence of a barrel chest, use of accessory muscles, coughing with the production of thick mucoid sputum, prolonged expira- tory phase with grunting respirations, peripheral cyanosis, and digital clubbing. In identifying emphysema, a chest x-ray reveals hyperinflation of the lungs with flattened diaphragm. Pulmonary studies show that the residual volume is increased while vital capacity is decreased. Arterial blood gases reveal hypoxemia and in advanced emphysema the presence of hypercarbia. Lab studies reveal an increase in the number of RBCs, as well as electrolyte imbalances due to respiratory acidosis. Many symptoms of chronic bronchitis and emphysema are the same; therefore, medications for the client with chronic bronchitis and emphysema include bronchodilators, corticosteroids, antibiotics, and expectorants. Oxygen may be administered via nasal cannula at 2–4 liters/ minute as well as by Venturi mask up to 40%. Close attention should be given to nutritional needs, avoidance of respiratory irritants, prevention and treatment of respiratory infections, providing oral hygiene, and client teaching regarding medications and effective means of coughing and breathing. NOTE CAUTION 43 Chronic Obstructive Pulmonary Disease Oxygen therapy is prescribed at the lowest flow rate needed to manage hypoxemia. Clients with chronic obstructive lung disease are at risk for oxygen-induced hypercapnia. The Venturi mask is preferred over the nasal cannula, because it delivers more precise oxygen levels; however some clients do not tolerate having a facemask. Methylxanthines such as theophylline and aminophylline are no longer considered the first class of medications to treat COPD due to their serious side effects, interactions with other medications, and narrow margin for safety. In most cases they have been replaced by short acting beta 2 agonists and long acting beta 2 agonists. Toxic symptoms associated with methylxanthines (theophylline and aminophylline) include nausea, vomiting, tachycardia, palpitations, hypotension, shock, coma, and death. The therapeutic range for aminophylline is as follows: 10–20 mcg/mL. Asthma Asthma is a chronic condition with intermittent reversible airflow obstruction. Although it can occur at any age, it is the most common respiratory condition of childhood. About half of adult asthmatics had the disorder as children. Intrinsic (nonallergenic) asthma is precipitated by exposure to cold temperatures or infection. Extrinsic (allergenic or atopic) asthma is often associated with childhood eczema. Both asthma and eczema are triggered by allergies to cer- tain foods or food additives. Introducing new foods to the infant one at a time helps decrease the development of these allergic responses. Easily digested, hypoallergenic foods and juices should be introduced first. These include rice cereal and apple juice, which may be given at six months of age. Other triggers include dry air, fine airborne particles, microorganisms, as well as ingestion of aspirin or NSAIDS. Hyperresponsiveness can occur with exercise and upper respiratory infection. Symptoms of asthma include expiratory wheeze; shortness of breath; and a dry, hacking cough, which eventually produces thick, white, tenacious sputum. In some instances an attack may progress to status asthmaticus, leading to respiratory collapse and death. Management of the client with asthma includes medications to prevent and treat asthma attacks. Medications include bronchodilators, corticosteroids, short acting beta 2 agonists, long acting beta 2 agonists, cholinergic antagonists, chromones, and leukotriene modifiers. Treatment of acute asthmatic attacks includes the administration of oral or inhaled short-term or long-term B2 agonist and anti-inflammatories as well as supplemental oxygen. Methylxanthines, such as aminophylline, are rarely used for the treatment of asthma. These drugs, which can cause tachycardia and dysrhythmias, are administered as a last resort. Antibiotics are frequently ordered when a respiratory infection is present. 44 Chapter 3: Caring for the Cl