Before administering a medication, what does the nurse need to know to evaluate how individual patient variability might affect the patient's response to the medication? (Select all that apply.)
a. Chemical stability of the medication
b. Ease of administration
c. Family medical history
d. Patient's age
e. Patient's diagnosis

C, D, E
The family medical history can indicate genetic factors that may affect a patient's response to a medication. Patients of different ages can respond differently to medications. The patient's illness can affect how drugs are metabolized. The chemical stability of the medication and the ease of administration are properties of drugs.

A patient is using a metered-dose inhaler containing albuterol for asthma. The medication label instructs the patient to administer "2 puffs every 4 hours as needed for coughing or wheezing." The patient reports feeling jittery sometimes when taking the medication, and she doesn't feel that the medication is always effective. Which action is outside the nurse's scope of practice?
a. Asking the patient to demonstrate use of the inhaler
b. Assessing the patient's exposure to tobacco smoke
c. Auscultating lung sounds and obtaining vital signs
d. Suggesting that the patient use one puff to reduce side effects

D
It is not within the nurse's scope of practice to change the dose of a medication without an order from a prescriber. Asking the patient to demonstrate inhaler use helps the nurse to evaluate the patient's ability to administer the medication properly and is part of the nurse's evaluation. Assessing tobacco smoke exposure helps the nurse determine whether nondrug therapies, such a smoke avoidance, can be used as an adjunct to drug therapy. Performing a physical assessment helps the nurse evaluate the patient's response to the medication.

A postoperative patient is being discharged home with acetaminophen/hydrocodone [Lortab] for pain. The patient asks the nurse about using Tylenol for fever. Which statement by the nurse is correct?
a. "It is not safe to take over-the-counter drugs with prescription medications."
b. "Taking the two medications together poses a risk of drug toxicity."
c. "There are no known drug interactions, so this will be safe."
d. "Tylenol and Lortab are different drugs, so there is no risk of overdose."

B
Tylenol is the trade name and acetaminophen is the generic name for the same medication. It is important to teach patients to be aware of the different names for the same drug to minimize the risk of overdose. Over-the-counter (OTC) medications and prescription medications may be taken together unless significant harmful drug interactions are possible. Even though no drug interactions are at play in this case, both drugs contain acetaminophen, which could lead to toxicity.

The nurse is preparing to care for a patient who will be taking an antihypertensive medication. Which action by the nurse is part of the assessment step of the nursing process?
a. Asking the prescriber for an order to monitor serum drug levels
b. Monitoring the patient for drug interactions after giving the medication
c. Questioning the patient about over-the-counter medications
d. Taking the patient's blood pressure throughout the course of treatment

C
The assessment part of the nursing process involves gathering information before beginning treatment, and this includes asking about other medications the patient may be taking. Monitoring serum drug levels, watching for drug interactions, and checking vital signs after giving the medication are all part of the evaluation phase.

A postoperative patient reports pain, which the patient rates as an 8 on a scale from 1 to 10 (10 being the most extreme pain). The prescriber has ordered acetaminophen [Tylenol] 650 mg PO every 6 hours PRN pain. What will the nurse do?
a. Ask the patient what medications have helped with pain in the past.
b. Contact the provider to request a different analgesic medication.
c. Give the pain medication and reposition the patient to promote comfort.
d. Request an order to administer the medication every 4 hours.

B
The nursing diagnosis for this patient is severe pain. Acetaminophen is given for mild to moderate pain, so the nurse should ask the prescriber to order a stronger analgesic medication. Asking the patient to tell the nurse what has helped in the past is part of an initial assessment and should be done preoperatively and not when the patient is having severe pain. Because the patient is having severe pain, acetaminophen combined with nondrug therapies will not be sufficient. Increasing the frequency of the dose of a medication for mild pain will not be effective.

A patient newly diagnosed with diabetes is to be discharged from the hospital. The nurse teaching this patient about home management should begin by doing what?
a. Asking the patient to demonstrate how to measure and administer insulin
b. Discussing methods of storing insulin and discarding syringes
c. Giving information about how diet and exercise affect insulin requirements
d. Teaching the patient about the long-term consequences of poor diabetes control

A
Because insulin must be given correctly to control symptoms and because an overdose can be fatal, it is most important for the patient to know how to administer it. Asking for a demonstration of technique is the best way to determine whether the patient has understood the teaching. When a patient is receiving a lot of new information, the information presented first is the most likely to be remembered. The other teaching points are important as well, but they are not as critical and can be taught later.

The nurse receives an order to give morphine 5 mg IV every 2 hours PRN pain. Which action is not part of the six rights of drug administration?
a. Assessing the patient's pain level 15 to 30 minutes after giving the medication
b. Checking the medication administration record to see when the last dose was administered
c. Consulting a drug manual to determine whether the amount the prescriber ordered is appropriate
d. Documenting the reason the medication was given in the patient's electronic medical record

A
Assessing the patient's pain after administering the medication is an important part of the nursing process when giving medications, but it is not part of the six rights of drug administration. Checking to see when the last dose was given helps ensure that the medication is given at the right time. Consulting a drug manual helps ensure that the medication is given in the right dose. Documenting the reason for a pain medication is an important part of the right documentation—the sixth right.

A patient tells a nurse that a medication prescribed for recurrent migraine headaches is not working. What will the nurse do?
a. Ask the patient about the number and frequency of tablets taken.
b. Assess the patient's headache pain on a scale from 1 to 10.
c. Report the patient's complaint to the prescriber.
d. Suggest biofeedback as an adjunct to drug therapy.

A
When evaluating the effectiveness of a drug, it is important to determine whether the patient is using the drug as ordered. Asking the patient to tell the nurse how many tablets are taken and how often helps the nurse determine compliance. Assessing current pain does not yield information about how well the medication is working unless the patient is currently taking it. The nurse should gather as much information about compliance, symptoms, and drug effectiveness as possible before contacting the prescriber. Biofeedback may be an effective adjunct to treatment, but it should not be recommended without complete information about drug effectiveness.

A nurse is preparing to administer medications. Which patient would the nurse consider to have the greatest predisposition to an adverse reaction?
a. A 30-year-old man with kidney disease
b. A 75-year-old woman with cystitis
c. A 50-year-old man with an upper respiratory tract infection
d. A 9-year-old boy with an ear infection

A
The individual with impaired kidney function would be at risk of having the drug accumulate to a toxic level because of potential excretion difficulties. Cystitis is an infection of the bladder and not usually the cause of excretion problems that might lead to an adverse reaction from a medication. A respiratory tract infection would not predispose a patient to an adverse reaction, because drugs are not metabolized or excreted by the lungs. A 9-year-old boy would not have the greatest predisposition to an adverse reaction simply because he is a child; nor does an ear infection put him at greater risk.

A nurse consults a drug manual before giving a medication to an 80-year-old patient. The manual states that older-adult patients are at increased risk for hepatic side effects. Which action by the nurse is correct?
a. Contact the provider to discuss an order for pretreatment laboratory work.
b. Ensure that the drug is given in the correct dose at the correct time to minimize the risk of adverse effects.
c. Notify the provider that this drug is contraindicated for this patient.
d. Request an order to give the medication intravenously so that the drug does not pass through the liver.

A
The drug manual indicates that this drug should be given with caution to elderly patients. Getting information about liver function before giving the drug establishes baseline data that can be compared with post-treatment data to determine whether the drug is affecting the liver. Giving the correct dose at the correct interval helps to minimize risk, but without baseline information, the effects cannot be determined. The drug is not contraindicated.

A patient has been receiving intravenous penicillin for pneumonia for several days and begins to complain of generalized itching. The nurse auscultates bilateral wheezing and notes a temperature of 38.5°C (101°F). Which is the correct action by the nurse?
a. Administer the next dose and continue to evaluate the patient's symptoms.
b. Ask the prescriber if an antihistamine can be given to relieve the itching.
c. Contact the prescriber to request an order for a chest radiograph.
d. Hold the next dose and notify the prescriber of the symptoms.

D
Prurient and wheezing are signs of a possible allergic reaction, which can be fatal; therefore, the medication should not be given and the prescribes should be notified. When patients are having a potentially serious reaction to a medication, the nurse should not continue giving the medication. Antihistamines may help the symptoms of an allergic reaction, but the first priority is to stop the medication. Obtaining a chest radio-graph is not helpful

A postoperative patient has orders for morphine sulfate 1 to 2 mg IV every 1 hour PRN for severe pain and acetaminophen-hydrocodone [Lortab] 7.5 mg PO every 4 to 6 hours PRN for moderate pain. The patient reports pain at a level of 8 on a scale of 1 to 10, with 10 being the worst pain. Which action by the nurse is appropriate?
a. Administer acetaminophen-hydrocodone 7.5 mg PO every 4 hours.
b. Administer acetaminophen-hydrocodone 7.5 mg PO every 6 hours and change to every 4 hours if not effective.
c. Administer morphine sulfate 1 mg IV every 1 hour until pain subsides.
d. Administer morphine sulfate 2 mg IV and evaluate the patient's pain in 15 to 30 minutes.

D
With PRN medications, the schedule is not fixed and the administration of these medications depends on the patient's condition. It is the nurse's responsibility to assess the patient's condition and then give the appropriate PRN medication. In this case, the patient has severe pain and should receive MS IV. Either 1 mg or 2 mg may be given, but the nurse must evaluate the effectiveness of the pain medication within 15 to 30 minutes to help determine subsequent doses. Acetaminophen-hydrocodone is not appropriate because it is ordered for moderate pain and this patient reports severe pain. Giving MS IV every hour is not appropriate for a PRN medication unless the patient's condition warrants it.

The nurse is teaching a patient about home administration of insulin to treat diabetes mellitus. As part of the teaching, the patient and nurse identify goals to maintain specific blood glucose ranges. This represents which aspect of the nursing process?
a. Assessment
b. Evaluation
c. Implementation
d. Planning

D
In the planning step, the nurse delineates specific interventions directed at solving or preventing problems. When creating the care plan, the nurse defines goals, sets priorities, and establishes criteria for evaluating success. The assessment step involves collecting data about the patient. The evaluation step involves evaluating the medication effectiveness. The implementation step identifies actions that are taken to administer the drug.

A nurse is reviewing a patient's medical record before administering a medication. Which factors can alter the patient's physiologic response to the drug? (Select all that apply.)
a. Ability to swallow pills
b. Age
c. Genetic factors
d. Gender
e. Height

B, C, D
Age, genetic factors, and gender influence an individual patient's ability to absorb, metabolize, and excrete drugs; therefore, these factors must be assessed before a medication is administered. A patient's ability to swallow pills, although it may determine the way a drug is administered, does not affect the physiologic response. Height does not affect response; weight and the distribution of adipose tissue can affect the distribution of drugs.

A nurse educator is conducting a continuing education class on pharmacology. To evaluate the learning of the nurses in the class, the nurse educator asks, "Which drug name gives information about the drug's pharmacologic classification?" Which is the correct response?
a. Amoxicillin
b. Tylenol
c. Cipro
d. Motrin

A
Amoxicillin is the generic name, and the suffix "-cillin" indicates that it belongs to the penicillin class of antibiotics. Tylenol, Cipro, and Motrin are all trade names without segments that indicate their pharmacologic class.

The FDA Amendments Act (FDAAA) was passed in 2007 to address which aspect of drug safety?
a. Allowing pharmaceutical companies to identify off-label uses of medications approved for other uses
b. Evaluating drug safety information that emerges after a drug has been approved and is in use
c. Expediting the approval process of the U.S. Food and Drug Administration (FDA) so that needed drugs can get to market more quickly
d. Requiring manufacturers to notify patients before removing a drug from the market

B
The FDAAA was passed to enable the Food and Drug Administration to continue oversight of a drug after granting it approval so that changes in labeling could be made as necessary and postmarketing risks could be tracked and identified. A provision of the FDA Modernization Act (FDAMA), passed in 1997, allows drug companies to promote their products for off-label uses as long as they promise to conduct studies to support their claims. Regulations to permit accelerated approval of drugs for life-threatening diseases were adopted in 1992 by the FDA. The requirement that drug companies notify patients 6 months before removing a drug from the market is a provision of the FDAMA.

A nursing student asks a nurse about pharmaceutical research and wants to know the purpose of randomization in drug trials. The nurse explains that randomization is used to do what?
a. To ensure that differences in outcomes are the result of treatment and not differences in subjects
b. To compare the outcome caused by the treatment to the outcome caused by no treatment
c. To make sure that researchers are unaware of which subjects are in which group
d. To prevent subjects from knowing which group they are in and prevent preconception bias

A
Randomization helps prevent allocation bias, which can occur when researchers place subjects with desired characteristics in the study group and other subjects in the control group so that differences in outcome are actually the result of differences in subjects and not treatment. Comparing treatment outcome to no treatment outcome is the definition of a controlled study. The last two options describe the use of blinding in studies; blinding ensures that researchers or subjects (or both) are unaware of which subjects are in which group so that preconceptions about benefits and risks cannot bias the results.

Someone asks a nurse about a new drug that is in preclinical testing and wants to know why it cannot be used to treat a friend's illness. Which statement by the nurse is correct?
a. "A drug at this stage of development can be used only in patients with serious disease."
b. "At this stage of drug development, the safety and usefulness of the medication is unknown."
c. "Clinical trials must be completed to make sure the drug is safe to use in humans."
d. "Until postmarketing surveillance data are available, the drug cannot be used."

B
Preclinical testing must be completed before drugs can be tested in humans. In this stage, drugs are evaluated for toxicities, pharmacokinetic properties, and potentially useful effects. Some drugs can be used in patients before completion of Phase III studies, but this is after preclinical testing is complete. Clinical trials proceed in stages, and each stage has guidelines defining how a new drug may be used and which patients may receive it. Postmarketing surveillance takes place after a drug is in general use.

A patient asks a nurse why drugs that have been approved by the FDA still have unknown side effects. What will the nurse tell the patient?
a. Testing for all side effects of a medication would be prohibitively expensive.
b. Patients in drug trials often are biased by their preconceptions of a drug's benefits.
c. Researchers tend to conduct studies that will prove the benefits of their new drugs.
d. Subjects in drug trials do not always represent the full spectrum of possible patients.

D
All drug trials are limited by a relatively small group of subjects who may not have all the characteristics of people who will be using the drug; therefore, some side effects go undetected until the drug is in use. Although drug trials are very expensive, this is only an indirect reason they do not detect all side effects before approval. In theory, well-designed drug trials, using blinded studies, minimize or eliminate subject bias. Designing studies to prove desired results is unethical.

A nurse is teaching nursing students about the use of nonproprietary names for drugs. The nurse tells them which fact about nonproprietary names?
a. They are approved by the FDA and are easy to remember.
b. They are assigned by the U.S. Adopted Names Council.
c. They clearly identify the drug's pharmacologic classification.
d. They imply the efficacy of the drug and are less complex.

B
Nonproprietary, or generic, names are assigned by the U.S. Adopted Names Council, which ensures that each drug has only one name. Trade names, or brand names, are approved by the FDA and are easier to remember. Some nonproprietary names contain syllables that identify the classification, although not all do. Drug names are not supposed to identify the use for the drug, although some brand names do so.

A patient tells the nurse that the oral drug that has been prescribed has caused a lot of stomach discomfort in the past. What will the nurse ask the prescriber?
a. Whether a sublingual form of the medication can be given
b. Whether the medication can be given by a parenteral route instead
c. Whether an enteric-coated form of the drug is available
d. Whether the patient can receive a sustained-release preparation of the drug

C
Enteric-coated drugs are preparations that have been coated with a material that dissolves in the intestines, not the stomach. This coating is used either to protect the drug from stomach acid and pepsin or to protect the stomach from a drug that can cause gastric upset. Sublingual forms often are used for drugs that undergo rapid inactivation during the first pass through the hepatic circulation so that the drug can be absorbed directly into the systemic circulation. Parenteral routes are more costly and less safe than oral administration and should not be used unless necessary. A sustained-release preparation is used to release the drug into the body over a specific period to reduce the number of daily doses required to sustain therapeutic drug levels.

A patient claims to get better effects with a tablet of Brand X of a drug than with a tablet of Brand Y of the same drug. Both brands contain the same amount of the active ingredient. What does the nurse know to be most likely?
a. Advertising by pharmaceutical companies can enhance patient expectations of one brand over another, leading to a placebo effect.
b. Because the drug preparations are chemically equivalent, the effects of the two brands must be identical.
c. Tablets can differ in composition and can have differing rates of disintegration and dissolution, which can alter the drug's effects in the body.
d. The bioavailability of a drug is determined by the amount of the drug in each dose.

C
Even if two brands of a drug are chemically equivalent (i.e., they have identical amounts of the same chemical compound), they can have different effects in the body if they differ in bioavailability. Tablets made by different manufacturers contain different binders and fillers, which disintegrate and dissolve at different rates and affect the bioavailability of the drug. Two brands may be chemically equivalent and still differ in bioavailability, which is not determined by the amount of drug in the dose.

A patient receives a drug that has a narrow therapeutic range. The nurse administering this medication will expect to do what?
a. Administer the drug at intervals longer than the drug half-life.
b. Administer this medication intravenously.
c. Monitor plasma drug levels.
d. Teach the patient that maximum drug effects will occur within a short period.

C
A drug with a narrow therapeutic range is more difficult to administer safely, because the difference between the minimum effective concentration and the toxic concentration is small. Patients taking these medications must have their plasma drug levels monitored closely to ensure that they are getting an effective dose that is not toxic. Administering medications at longer intervals only increases the time required to reach effective plasma drug levels. Drugs that have a narrow therapeutic range may be given by any route and do not differ from other medications in the amount of time it takes for them to take effect, which is a function of a drug's half-life and dosing frequency.

A patient is given a prescription for azithromycin [Zithromax] and asks the nurse why the dose on the first day is twice the amount of the dose on the next 4 days. Which reply by the nurse is correct?
a. "A large initial dose helps to get the drug to optimal levels in the body faster."
b. "The first dose is larger to minimize the first pass effect of the liver."
c. "The four smaller doses help the body taper the amount of drug more gradually."
d. "Tubular reabsorption is faster with initial doses, so more is needed at first."

A
A large initial dose is often used as a loading dose to help get serum drug levels to plateau levels more quickly. Larger doses do not prevent first pass effects in drugs susceptible to this type of metabolism. Tapering of doses sometimes is used to prevent rebound or withdrawal effects and is done by stepping down the amount of drug with each dose. Tubular reabsorption is a process that allows drugs to be reabsorbed from the urine into the blood

A nurse is giving an enteral medication. The patient asks why this method is preferable for this drug. How will the nurse reply?
a. "This route allows more rapid absorption of the drug."
b. "This route is safer, less expensive, and more convenient."
c. "This route is the best way to control serum drug levels."
d. "This route prevents inactivation of the drug by digestive enzymes."

B
Parenteral routes include the intravenous, intramuscular, and subcutaneous routes. Enteral routes include oral administration, including pills and liquid suspensions. Enteral routes are safer, cheaper, and easier to use. Parenteral routes are used when rapid absorption, precise control of plasma drug levels, and prevention of digestive inactivation are important.

The nurse is preparing to administer penicillin G intramuscularly to a child. The child's parents ask why the drug cannot be given in an oral liquid form. What is the nurse's reply?
a. "This drug causes severe gastric upset if given orally."
b. "This drug has a narrow therapeutic range, and the dose must be tightly controlled."
c. "This drug is absorbed much too quickly in an oral form."
d. "This drug would be inactivated by enzymes in the stomach."

D
Penicillin G is inactivated by digestive enzymes in the stomach and cannot be given orally. It does not have a narrow therapeutic range.

A provider has written an order for a medication: drug 100 mg PO every 6 hours. The half-life for the drug is approximately 6 hours. The nurse is preparing to administer the first dose at 8:00 AM on Tuesday. On Wednesday, when will the serum drug level reach plateau?
a. 2:00 AM
b. 8:00 AM
c. 2:00 PM
d. 8:00 PM

B
It takes four half-lives for a drug to reach plateau. Total body stores reach their peak at the beginning of the fifth dose of a drug if all doses are equal in amount; in this case, this will be at 8:00 AM the following day.

An adult male patient is 1 day postoperative from a total hip replacement. On a pain scale of 0 to 10, with 10 being the greatest pain, the patient reports a pain level of 10. Which medication would be most appropriate for the nurse to administer to this patient?
a. 60 mg morphine sulfate PO
b. 75 mg meperidine [Demerol] intramuscularly
c. 6 mg morphine sulfate intravenously
d. Fentanyl [Duragesic] patch 50 mcg transdermally

C
The intravenous route is the fastest route of absorption and the one most appropriate for a patient in extreme pain. With the oral route, the medication would take at least 45 minutes to be effective, too long for a patient in extreme pain. With the intramuscular route, the medication would take at least 15 minutes to be effective; although faster than the oral route, this is not as fast as the intravenous route. A Duragesic patch would be the most inappropriate route because of the long drug half-life. This is a more appropriate route for long-term use.

A nurse is explaining drug metabolism to a nursing student who asks about glucuronidation. The nurse knows that this is a process that allows drugs to be:
a. excreted in hydrolyzed form in the feces to reduce drug toxicity.
b. reabsorbed from the urine into the renal circulation to minimize drug loss.
c. recycled via the enterohepatic recirculation to remain in the body longer.
d. transported across the renal tubules to be excreted in the urine.

C
Glucuronidation of some drugs in the liver allows drugs to enter the bile, pass into the duodenum, and then be hydrolyzed to release the free drug. This is a repeating cycle of enterohepatic recirculation, which allows drugs to remain in the body longer. Glucuronidated drugs that are more resistant to hydrolysis are excreted in the feces. Glucuronidation occurs in the enterohepatic circulation and not in the renal circulation.

A patient is receiving intravenous gentamicin. A serum drug test reveals toxic levels. The dosing is correct, and this medication has been tolerated by this patient in the past. Which could be a probable cause of the test result?
a. A loading dose was not given.
b. The drug was not completely dissolved in the IV solution.
c. The patient is taking another medication that binds to serum albumin.
d. The medication is being given at a frequency that is longer than its half-life.

C
Gentamicin binds to albumin, but only weakly, and in the presence of another drug that binds to albumin, it can rise to toxic levels in blood serum. A loading dose increases the initial amount of a drug and is used to bring drug levels to the desired plateau more quickly. A drug that is not completely dissolved carries a risk of causing embolism. A drug given at a frequency longer than the drug half-life will likely be at subtherapeutic levels and not at toxic levels.

The nurse is caring for a child who has ingested a toxic amount of aspirin. The provider orders an intravenous drug that will increase pH in the blood and urine. The nurse understands that this effect is necessary to:
a. decrease the gastric absorption of aspirin.
b. decrease the lipid solubility of aspirin.
c. increase the serum protein binding of aspirin.
d. increase the urinary excretion of aspirin.

D
The phenomenon of pH-dependent ionization can be used to accelerate renal excretion of drugs. When children have been exposed to toxic amounts of aspirin, they can be treated, in part, by giving an agent that elevates urinary pH, leading to less passive reabsorption of the now ionized molecules of aspirin and, hence, more excretion. Elevating the pH of the blood and urine does not affect absorption in the stomach. Ionization of aspirin does not affect lipid solubility or protein binding.

A patient is taking a drug that does not bind to albumin. Which aspect of renal drug excretion is affected by this characteristic?
a. Active tubular secretion
b. Glomerular filtration
c. Passive tubular reabsorption
d. pH-dependent ionization

B
As blood flows through the glomerular capillaries, fluids and small molecules are forced through the pores of the capillary wall. Large molecules, such as drugs bound to albumin, remain behind in the blood. Active tubular secretion requires active transport systems to pump molecules from one side of the membrane to another. Passive tubular reabsorption allows substances in high concentrations in the tubule to be reabsorbed into the blood, and lipid-soluble drugs readily cross this membrane by passive reabsorption. pH-dependent ionization affects drugs that ionize in either acid or alkaline environments.

When administering medications to infants, it is important to remember which of the following? (Select all that apply.)
a. Breast-feeding infants are more likely to develop toxicity when given lipid-soluble drugs.
b. Immaturity of renal function in infancy causes infants to excrete drugs less efficiently.
c. Infants have immature livers, which slows drug metabolism.
d. Infants are more sensitive to medications that act on the central nervous system (CNS).
e. Oral medications are contraindicated in infants, because PO administration requires a cooperative patient.

B, C, D
Immature renal function causes infants to excrete drugs more slowly, and infants are at risk for toxicity until renal function is well developed. Infants' livers are not completely developed, and they are less able to metabolize drugs efficiently. Because the blood-brain barrier is not well developed in infants, caution must be used when administering CNS drugs. Lipid-soluble drugs may be excreted in breast milk if the mother is taking them, but breast-feeding does not affect medications given directly to the infant. Oral medications may be given safely to infants as long as they are awake and can swallow the drug.

A patient is receiving digoxin twice daily. When assessing the patient before giving a dose, the nurse counts a pulse of 60 beats per minute and learns that the patient is experiencing nausea. The nurse consults a drug manual and verifies that the ordered dose is correct. What should the nurse do?
a. Contact the prescriber to report the symptoms.
b. Delay the dose so the drug can clear from receptor sites.
c. Give the medication as ordered, because the dose is correct.
d. Request an antinausea medication from the prescriber.

A
The symptoms indicate toxicity, and even though the dose is safe and effective in most cases, an individual patient may have toxic effects with a standard dose. The nurse should contact the prescriber to discuss the next steps. Delaying a dose without a change in order is not within the scope of practice for a nurse. The nurse should not give a dose of a medication when toxicity is suspected, because additional drug will compound the symptoms. Antiemetics are useful for counteracting drug side effects, but they should not be used when the patient's symptoms indicate toxicity.

A patient reports becoming "immune" to a medication because it no longer works to alleviate symptoms. The nurse recognizes that this decreased effectiveness is likely caused by:
a. antagonists produced by the body that compete with the drug for receptor sites.
b. decreased selectivity of receptor sites, resulting in a variety of effects.
c. desensitization of receptor sites by continual exposure to the drug.
d. synthesis of more receptor sites in response to the medication.

C
Continual exposure to an agonist would cause the cell to become less responsive or desensitized. The body does not produce antagonists as a response to a medication. Receptor site selectivity is determined by physiologic factors and not by the substances that bind to them. Medications do not cause more receptors to be produced.

A patient has been receiving an antibiotic with a small therapeutic index for 10 days. Upon assessment, the nurse notes an increase in the drug's side effects. What would be the nurse's priority action?
a. Call the prescriber and have the antibiotic changed.
b. Suspect an allergic reaction and administer a PRN antihistamine.
c. Ask the prescriber to order a plasma drug level test.
d. Set up oxygen and obtain an order for an antagonist.

C
A narrow therapeutic index indicates that a drug is relatively unsafe and should be monitored closely. The nurse should have a blood level drawn to confirm suspicions of toxicity. The nurse would not have the antibiotic changed, because there is no cause at this time. The patient is unlikely to be experiencing an allergic reaction, because the antibiotic has been in the system for 10 days. The patient shows no signs of anaphylaxis, so oxygen and an antagonist are not indicated.

A patient who is taking morphine for pain asks the nurse how a pain medication can also cause constipation. What does the nurse know about morphine?
a. It binds to different types of receptors in the body.
b. It can cause constipation in toxic doses.
c. It causes only one type of response, and the constipation is coincidental.
d. It is selective to receptors that regulate more than one body process.

D
Morphine is a medication that is selective to receptor type that regulates more than one process. Because it is selective to receptor type, it does not bind to different types of receptors. Constipation is a normal side effect and is not significant for toxicity.

What occurs when a drug binds to a receptor in the body?
a. It alters the receptor to become nonresponsive to its usual endogenous molecules.
b. It increases or decreases the activity of that receptor.
c. It gives the receptor a new function.
d. It prevents the action of the receptor by altering its response to chemical mediators.

B
When a drug binds to a receptor, it mimics or blocks the actions of the usual endogenous regulatory molecules, either increasing or decreasing the rate of the physiologic activity normally controlled by that receptor. It does not alter the activity of the receptor and does not give the receptor a new function

The nurse administers naloxone [Narcan] to a patient who has received a toxic dose of morphine sulfate. The nurse understands that the naloxone is effective because of which action?
a. Countering the effects of morphine sulfate by agonist actions
b. Increasing the excretion of morphine sulfate by altering serum pH
c. Preventing activation of opioid receptors through antagonist actions
d. Regulating the sensitivity of opioid receptors by neurochemical alterations

C
Naloxone acts by blocking the action of opioids at opioid receptors. An opioid agonist would increase the effects of morphine. Naloxone does not affect serum pH or excretion of opioids. Naloxone does not alter the sensitivity of opioid receptors.

Two nurses are discussing theories of drug-receptor interaction. Which statements are true regarding the affinity of a drug and its receptor? (Select all that apply.)
a. Affinity and intrinsic activity are dependent properties.
b. Affinity refers to the strength of the attraction between a drug and its receptor.
c. Drugs with high affinity are strongly attracted to their receptors.
d. Drugs with low affinity are strongly attracted to their receptors.
e. The affinity of a drug for its receptors is reflected in its potency.

B, C, E
Affinity refers to the strength of the attraction between a drug and its receptor. Drugs with high affinity are strongly attracted to their receptors, and the affinity of a drug and its receptors is reflected in its potency. Affinity and intrinsic activity are independent properties. Drugs with low affinity are weakly attracted to their receptors.

Which drugs will not be affected by interpatient variability? (Select all that apply.)
a. Antiseptics applied to the skin to slow bacterial growth
b. Antacids to help with the discomfort of heartburn
c. Broad-spectrum antibiotics that are effective against many organisms
d. Chelating agents that remove metal compounds from the body
e. Topical analgesics used to treat localized pain

A, B, D
Antiseptics, antacids, and chelating agents are all receptorless drugs that do not depend on the body's processes for effects; these agents react with other molecules. Broad-spectrum antibiotics and topical analgesics bind with receptors to produce desired effects, and these processes can be influenced by individual patient variables.

The nurse is teaching a patient about taking warfarin and asks if the patient takes aspirin. This assessment by the nurse reflects a knowledge of which type of drug interaction?
a. Creation of unique effects
b. Increased therapeutic effects
c. Inhibitory effects
d. Potentiative effects

D
A potentiative effect is one in which one drug intensifies the effects of another. Both warfarin and aspirin suppress blood clotting, and the combination may increase the risk of bleeding, which is an intensified adverse effect. Creation of a unique effect is a rare occurrence in which the combination of two drugs creates a response not seen with either drug when given alone. Increased therapeutic effects are a type of potentiative effect; however, in this case the combination of two drugs would increase the desired effects. An inhibitory effect is a type of pharmacodynamic effect that occurs when an antagonist drug inhibits the action of an agonist drug at the same receptor site.

A young adult postoperative patient is receiving morphine 2 to 4 mg IV every 2 hours PRN pain. The last dose was 3 mg given 2 hours ago. The patient is asleep, and the nurse notes a heart rate of 86 beats per minute and a respiratory rate of 8 breaths per minute. Which PRN medication will the nurse give this patient?
a. Diphenhydramine [Benadryl] to counter morphine side effects
b. Morphine 4 mg for increased pain, as indicated by tachycardia
c. Naloxone [Narcan] to block the effects of the morphine
d. Nothing at this time, because the patient is resting comfortably

C
A respiratory rate of 8 breaths per minute indicates respiratory depression, which is a significant adverse effect indicating morphine toxicity. Naloxone blocks the actions of morphine at cell receptor sites and is given to quickly reverse the effects. This patient does not have signs of an allergic response, which would include shortness of breath, a rapid respiratory rate, and wheezing. The tachycardia might be a sign of worsening pain, but the toxic effects must be treated first. Patients who are sleeping are not always pain free.

In a discussion of drug-drug interactions, which would be the best example of a beneficial inhibitory interaction?
a. Naloxone [Narcan] blocking morphine sulfate's actions
b. Antacids blocking the action of tetracycline [Sumycin]
c. Propanolol [Inderal] blocking the effects of albuterol
d. Cholestyramine blocking the actions of antihypertensive drugs

A
Naloxone is used when a narcotic overdose has occurred. As a narcotic antagonist, it provides a beneficial inhibitory interaction. An antacid blocking tetracycline's antibiotic effects would not be beneficial, but rather detrimental to the desired effects of the tetracycline. Alcohol would not block the effects of opiates, but would contribute to CNS depression. Cholestyramine and certain other adsorbent drugs, which are administered orally but do not undergo absorption, can adsorb other drugs onto themselves, thereby preventing absorption of the other drugs into the blood.

A patient is taking drug X and receives a new prescription for drug Y, which is listed as an inducing agent. The nurse caring for this patient understands that this patient may require ____ doses of drug ____.
a. lower; X
b. lower; Y
c. higher; X
d. higher; Y

C
An inducing agent stimulates the synthesis of CYP isoenzymes, which may increase the metabolism of other drugs as much as two- to threefold, thereby lowering the level of those drugs in the body and requiring higher doses to maintain drug effectiveness.

A patient taking oral contraceptives thinks she may be pregnant. As part of this patient's history, what will the nurse ask the patient?
a. "Do you drink grapefruit juice?"
b. "Do you take seizure medication?"
c. "Do you take your contraception with milk?"
d. "Do you use laxatives regularly?"

B
Patients taking oral contraceptives along with phenobarbital, which is used to treat seizures, will have lower levels of the contraceptive, because phenobarbital is an inducing agent, which causes an increase in the metabolism of oral contraceptives. Grapefruit juice inhibits the metabolism of some drugs, leading to toxic effects. Dairy products interfere with the absorption of tetracyclines, because the calcium binds with the drug to form an insoluble complex. Laxatives reduce the absorption of some drugs by speeding up the transit time through the gut.

A child ingests a parent's aspirin tablets, and the prescriber orders sodium bicarbonate to block the toxic effects of the aspirin. The nurse caring for this patient knows that sodium bicarbonate is effective against the aspirin because it:
a. accelerates its passage through the intestine.
b. alters urinary pH to enhance renal excretion.
c. induces CYP isoenzymes to increase drug metabolism.
d. raises the pH of the interstitial fluid to facilitate passage out of the cells.

D
Sodium bicarbonate increases the pH of interstitial fluid and plasma, allowing the acidic aspirin ions to move outside the cells and thus removing them from the site where they have toxic effects. It does not have laxative effects and does not alter the rate of passage through the gut. It is not a CYP isoenzyme inducer and therefore has no effect on drug metabolism. It does not alter renal excretion of aspirin.

Which statement about food and drug interactions is true?
a. Foods alter drug absorption and metabolism but not drug action.
b. Medications are best absorbed on an empty stomach.
c. Patient discomfort is the food and drug interaction of most concern.
d. Some foods can inhibit CYP isoenzymes and alter drug metabolism.

D
Grapefruit juice inhibits CYP3A4, which lowers the metabolism of some drugs, leading to toxic effects of drugs affected by these isoenzymes. Foods can alter all pharmacokinetic and pharmacodynamic processes. Not all medications are absorbed better on an empty stomach; some require certain foods to enhance absorption. Patient comfort is a concern, but it is not as important as more severe and possibly life-threatening food and drug interactions.

A nurse is teaching a patient about a prescription for a monoamine oxidase (MAO) inhibitor for depression. What will the nurse teach the patient to avoid while taking this drug?
a. Alcoholic beverages
b. Aged cheeses
c. Brussels sprouts and cabbage
d. Grapefruit juice

B
Aged cheeses are rich in tyramine, which interacts with MAO inhibitors to raise blood pressure to life-threatening levels. Patients taking MAO inhibitors should be taught to avoid tyramine-rich foods. Chianti wine contains tyramine, but other alcoholic beverages do not. Brussels sprouts and cabbage are foods rich in vitamin K, which can interfere with the effects of warfarin. Grapefruit juice inhibits CYP3A4 and interferes with the metabolism of many medications.

A nurse is teaching a patient about a drug that induces P-glycoprotein. The nurse will explain that this drug may cause which effect on other drugs?
a. Decreased absorption in the intestines
b. Decreased elimination through the kidneys
c. Increased brain exposure
d. Increased fetal absorption

B
Drugs that induce PGP can increase drug export from cells of the intestinal epithelium into the intestinal lumen, thus decreasing absorption of the drug. PGP inducers also increase drug elimination and decrease brain and fetal drug exposure.

The nurse is providing multiple medications to a patient whose spouse brings grapefruit juice every morning. The nurse will be concerned about which classes of drugs? (Select all that apply.)
a. Calcium channel blockers
b. Selective serotonin reuptake inhibitors
c. Aminoglycosides
d. Beta blockers
e. Penicillins

A, B
Calcium channel blockers and selective serotonin reuptake inhibitors have been shown to reach increased and/or toxic levels when taken with grapefruit juice. Grapefruit juice is not contraindicated with aminoglycosides, beta blockers, or penicillins.

The nurse is administering morning medications. The nurse gives a patient multiple medications, two of which compete for plasma albumin receptor sites. As a result of this concurrent administration, the nurse can anticipate that what might occur? (Select all that apply.)
a. Binding of one or both agents will be reduced.
b. Plasma levels of free drug will rise.
c. Plasma levels of free drug will fall.
d. The increase in free drug will intensify effects.
e. The increase in bound drug will intensify effects.

A, B, D
When two drugs bind to the same site on plasma albumin, coadministration of those drugs produces competition for binding. As a result, binding of one or both agents is reduced, causing plasma levels of free drug to rise. The increase in free drug can intensify the effect, but it usually undergoes rapid elimination. The increase in plasma levels of free drug is rarely sustained.

A nurse is caring for a patient who is taking multiple medications. To help ensure that adverse drug reactions are prevented or minimized, the nurse will do which of the following? (Select all that apply.)
a. Ask the patient about over-the-counter medications used.
b. Contact the prescriber to request cytochrome P450 levels.
c. Limit the patient's calcium intake.
d. Obtain a thorough diet history.
e. Request orders for PRN medications to treat any anticipated symptoms of drug interactions.

A, B, D
Over-the-counter medications add to drug interactions, and a thorough history of all medications taken by the patient is essential to minimize adverse drug reactions. Cytochrome P450 levels yield important information about a patient's ability to metabolize drugs and can help predict whether drugs will reach toxic levels or be ineffective. A diet history allows providers to anticipate significant known food-drug interactions. Limiting calcium intake is necessary only if the patient is taking drugs known to interact with calcium, such as tetracycline. Asking for PRN medications to treat drug reactions may only compound the risk, because the risk of drug interactions increases with the number of medications taken.

The prescriber has ordered an antibiotic for a patient with a bacterial infection. The nurse provides patient education at discharge and instructs the patient to take the drug on an empty stomach. When should the patient take the drug? (Select all that apply.)
a. 1 hour or more before a meal
b. Only after an 8-hour fast
c. Only after the patient has missed a meal
d. At least 2 hours after a meal
e. Shortly before a meal

A, D
The absorption of some drugs can be significantly reduced by food; these drugs should be taken on an empty stomach, which is 1 hour or more before a meal or at least 2 hours after a meal. An 8-hour fast is not necessary; the patient does not need to miss a meal to take the medication; and it is not reasonable to have the patient on thin liquids for 12 hours.

A patient is given a new medication and reports nausea within an hour after taking the drug. The nurse consults the drug information manual and learns that nausea is not an expected adverse effect of this drug. When the next dose is due, what will the nurse do?
a. Administer the drug and tell the patient to report further nausea.
b. Hold the drug and notify the provider of the patient's symptoms.
c. Report the symptoms of nausea to the MEDWATCH program.
d. Request an order for an antiemetic to counter this drug's effects.

A
Not all adverse drug reactions (ADRs) can be detected during clinical trials, and nurses should be alert to any effects that may result from drug administration. Because nausea is not a serious effect and because it is not yet known whether the drug is the cause of this patient's nausea, the nurse should administer the medication and observe the patient for recurrence of the symptom. It is not necessary to hold the drug, because nausea is not a serious side effect. The MEDWATCH program should be notified when there is a greater suspicion that the drug may have caused the nausea if the nausea occurs with subsequent doses. Until there is greater suspicion that the drug actually caused this patient's nausea, giving an antiemetic is not indicated.

A patient is being discharged after surgery. During the admission history, the nurse learned that the patient normally consumes two or three glasses of wine each day. The prescriber has ordered hydrocodone with acetaminophen [Lortab] for pain. What will the nurse do?
a. Request an order for acetaminophen without hydrocodone for pain.
b. Suggest that the patient use ibuprofen for pain.
c. Tell the patient not to drink wine while taking Lortab.
d. Tell the patient to limit wine intake to one or two glasses per day.

C
Combining a hepatotoxic drug with certain other drugs may increase the risk of hepatotoxicity. When even therapeutic doses of acetaminophen are taken with alcohol, the acetaminophen can cause liver damage. Patients should be cautioned not to drink alcohol; even two drinks with acetaminophen can produce this effect. Hydrocodone does not contribute to hepatotoxicity. Ibuprofen is not indicated for postoperative pain unless the pain is mild. Limiting wine to one or two glasses per day still increases the risk of hepatotoxicity.

A nurse is reviewing a medication administration record before administering medications. Which order will the nurse implement?
a. Furosemide [Lasix] 20 mg QD PO
b. Furosemide [Lasix] 20 mg qd PO
c. Furosemide [Lasix] 20 mg daily
d. Furosemide [Lasix] 20 mg PO daily

D
The correct answer is a complete order; it contains the medication, dose, route, and time. "qd" is no longer an accepted abbreviation; it should be written out as "daily" or "every day." The order of "20 mg daily" does not specify the route to be used.

A patient is given a drug for the first time and develops shortness of breath. The patient's heart rate is 76 beats per minute, the respiratory rate is 20 breaths per minute, and the blood pressure is 120/70 mm Hg. The nurse checks a drug administration manual to make sure the correct dose was given and learns that some patients taking the drug experience shortness of breath. The nurse will contact the provider to report what?
a. An allergic reaction
b. An idiosyncratic effect
c. An iatrogenic response
d. A side effect

D
A side effect is a secondary drug effect produced at therapeutic doses. This patient received the correct dose of the drug and developed shortness of breath, which, in this case, is a drug side effect. To experience an allergic reaction, a patient must have prior exposure to a drug and sensitization of the immune response. An idiosyncratic effect results from a genetic predisposition to an uncommon drug response. An iatrogenic response occurs when a drug causes symptoms of a disease.

A nurse is preparing to give an antibiotic to a patient who reports being allergic to antibiotics. Before giving the medication, what will the nurse do first?
a. Ask whether the patient has taken this antibiotic for other infections
b. Question the patient about allergies to other medications
c. Request an order for a lower dose of the antibiotic
d. Request an order for an antihistamine

B
A drug that causes disease-like symptoms is known to be iatrogenic. Nurses should be prepared for this possibility and be prepared to withdraw the drug if necessary and treat the symptoms. Such effects are not teratogenic. Patients with a genetic predisposition to respond differently to drugs are known to have idiosyncratic effects. Iatrogenic effects, even when known, are not typically expected side effects.

A nurse provides teaching to a patient who will begin taking a drug with a known risk of hepatotoxicity. Which statement by the patient indicates a need for further teaching?
a. "I should avoid taking acetaminophen while taking this drug."
b. "I will need periodic evaluation of aspartate aminotransferase and alanine aminotransferase levels."
c. "If I experience nausea, vomiting, or abdominal pain, I should call my provider."
d. "Routine testing and early detection of problems will prevent liver failure."

D
Drug-induced liver injury can progress from undetectable to advanced between routine tests; therefore, routine testing does not always prevent liver failure. Patients taking known hepatotoxic drugs should avoid other drugs, such as acetaminophen, that can cause liver damage. Aspartate aminotransferase (AST) and alanine aminotransferase (ALT) are liver enzymes that are routinely monitored when a patient is taking hepatotoxic drugs. Nausea, vomiting, and abdominal pain are signs of liver injury and should be reported.

A patient is taking sertraline [Zoloft] for depression, and the provider orders azithromycin [Zithromax] to treat an infection. What will the nurse do?
a. Contact the provider to discuss an alternative to azithromycin.
b. Request an order for a different antidepressant medication.
c. Request an order to reduce the dose of sertraline.
d. Withhold the sertraline while giving the azithromycin.

A
Both sertraline and azithromycin prolong the QT interval, and when taken together, they increase the risk of fatal dysrhythmias. Because the antibiotic is used for a short time, it is correct to consider using a different antibiotic. Reducing the dose of sertraline does not alter the combined effects of two drugs that lengthen the QT interval. Sertraline should not be stopped abruptly, so withholding it during antibiotic therapy is not indicated.

A patient is taking a drug that has known toxic side effects. What will the nurse do?
a. Discontinue the drug at the first signs of toxicity.
b. Ensure that complete blood counts are ordered periodically.
c. Monitor the function of all organs potentially affected by the drug.
d. Teach the patient how to treat the symptoms if they develop.

C
When a drug is administered that has known toxic side effects, the nurse is responsible for monitoring all organ systems potentially affected by the drug. Not all toxic side effects warrant discontinuation of the drug, and a nurse cannot discontinue a drug without an order from the provider. Complete blood counts are indicated only for drugs that affect the blood. Some drugs need to be discontinued, so teaching a patient to treat symptoms is not correct in all cases.

A nursing student is preparing to give a medication that has a boxed warning. The student asks the nurse what this means. What will the nurse explain about boxed warnings?
a. They indicate that a drug should not be given except in life-threatening circumstances.
b. They provide detailed information about the adverse effects of the drug.
c. They alert prescribers to measures to mitigate potential harm from side effects.
d. They provide information about antidotes in the event that toxicity occurs.

C
Boxed warnings (also known as black box warnings) are used to alert providers to potential side effects and to ways to prevent or reduce harm from these side effects. A boxed warning is placed on any drug that, although useful, has serious side effects; this is a way to keep drugs on the market while protecting patients. Many of these drugs are used in situations that are not life threatening. The boxed warning provides a concise summary and not a detailed explanation of drug side effects. The boxed warning does not include antidotes to toxicity.

Which actions occur in 90% of fatal medication errors? (Select all that apply.)
a. Confusing drugs with similar packaging
b. Giving a drug intravenously instead of intramuscularly
c. Giving Nasarel instead of Nizoral
d. Using an infusion device that malfunctions
e. Writing a prescription illegibly

B, C, E
Ninety percent of fatal medication errors fall into three categories: human factors, communication mistakes, and name confusion. Giving a drug IV (intravenously) instead of IM (intramuscularly) is an example of a human factor; writing a prescription so that it is illegible is an example of a communication mistake; and giving a drug with a name that sounds like the name of another drug is an example of name confusion. Confusion of drugs with similar packaging and using a faulty device also can cause fatal drug errors, but these factors do not fall into the categories that account for 90% of fatal errors.

Which are effective ways to help prevent medication errors? (Select all that apply.)
a. Developing nonpunitive approaches to track errors
b. Focusing on caregivers who make errors
c. Helping patients to be active, informed members of the healthcare team
d. Naming, blaming, and shaming those who make errors
e. Using electronic medical order entry systems

A, C, E
To help prevent medication errors, it is important to create an environment for tracking errors that is nonpunitive so that caregivers can learn from mistakes and work together to change systems appropriately. Helping patients be active, informed members of the healthcare team is a useful tool in this process. Using electronic order entry helps eliminate confusion from poor handwriting and allows built-in systems to warn caregivers about possible overdoses, side effects, and drug interactions; it also helps ensure the right dose at the right time to the right patient. An approach that focuses on those who make mistakes by naming, blaming, and shaming is not productive and often results in personnel who cover up mistakes instead of working to make things better.

Which patients are at increased risk for adverse drug events? (Select all that apply.)
a. A 2-month-old infant taking a medication for gastroesophageal reflux disease
b. A 23-year-old female taking an antibiotic for the first time
c. A 40-year-old male who is intubated in the intensive care unit and taking antibiotics and cardiac medications
d. A 7-year-old female receiving insulin for diabetes
e. An 80-year-old male taking medications for COPD

A, C, E
Patients at increased risk for adverse drug events include the very young, the very old, and those who have serious illnesses. Females, children, and young adults taking single medications do not have increased risks for adverse events.

A postoperative patient who is worried about pain control will be discharged several days after surgery. The nurse providing discharge teaching tells the patient that the prescribed Lortab is not as strong as the morphine the patient was given in the immediate postoperative period. Which response is the patient likely to experience?
a. A decreased likelihood of filling the prescription for the drug
b. A negative placebo effect when taking the medication
c. An increased compliance with the drug regimen
d. Optimistic, realistic expectations about the drug

B
The full extent of placebo effects, if they truly occur, is not well documented or understood, although a decrease in pain as a placebo effect has been demonstrated to some extent. To foster a beneficial placebo effect, it is important for all members of the healthcare team to present an optimistic and realistic assessment of the effects of the drug the patient is taking. If the nurse tells an anxious patient that the medication being given is not as strong as what has been given, the patient is likely to have lowered expectations of the effectiveness of the drug, causing a negative placebo effect. Lowered expectations do not mean that the patient will give up on the drug entirely; in fact, the patient may actually fill the prescription and then take more drug than what is prescribed to get a better effect.

A nurse administers the same medication in the same preparation in the same dose to several patients and notes that some patients have a better response to the drug than others. What is the most likely explanation for this phenomenon?
a. Altered bioavailability of the drug
b. Patient compliance with the therapeutic regimen
c. Pharmacogenomic differences among individuals
d. Placebo effects enhancing expectations of drug efficacy

C
Each patient's genetic makeup can determine how that patient responds to drugs quantitatively and qualitatively, and this is the most likely cause of individual variation when the same drug is given at the same dose. The bioavailability of a drug is determined by the drug's composition and varies across formulations of the drug. The patients in this example were given the same drug. The nurse was administering the medication to the patients, so compliance is not an issue. Nothing in this example indicates that a placebo effect was in play.

The U.S. Food and Drug Administration (FDA) recommends genetic testing of patients receiving certain medications. Genetic testing helps prescribers:
a. better establish a drug's therapeutic index.
b. determine whether a patient is a rapid or slow metabolizer of the drug.
c. identify racial characteristics that affect psychosocial variation in drug response.
d. produce a drug that is tailored to an individual patient's genetic makeup.

B
Pharmacogenomics is the study of the ways genetic variations affect individual responses to drugs through alterations in genes that code for drug-metabolizing enzymes and drug receptors. For some drugs, the FDA requires genetic testing, and for others, this testing is recommended but not required. Genetic testing does not determine a drug's therapeutic index; this is a measure of a drug's safety based on statistics of the drug's use in the general population (see Chapter 5). Any distinct physiologic differences in drug response among various racial populations are related to genetic differences and do not affect psychosocial differences in drug responses. Genetic testing is recommended to identify how a patient will respond to a drug and not to design a drug specific to an individual.

A patient asks a nurse why a friend who is taking the same drug responds differently to that drug. The nurse knows that the most common variation in drug response is due to differences in each patient's:
a. drug receptor sites.
b. hypersensitivity potential.
c. metabolism of drugs.
d. psychosocial response.

C
The most common source of genetic variation in drug response is related to alterations in drug metabolism and is determined by genetic codes for various drug-metabolizing isoenzymes. There are known genetic differences in codes for drug target sites, but these are not as numerous as those for metabolic isoenzymes. Hypersensitivity potential is also genetically determined, but variations produce differences in adverse reactions to drugs and not in drug effectiveness. Psychosocial responses vary for many less measurable reasons, such as individual personalities and variations in cultures.

A nurse is preparing to care for a patient who is receiving digoxin. When screening for potential adverse effects from this drug, the nurse will review which of this patient's laboratory results?
a. Albumin
b. Blood urea nitrogen (BUN) and creatinine
c. Hepatic enzymes
d. Serum electrolytes

C
Pharmacodynamic tolerance results when a patient takes a drug over a period of time. Adaptive processes occur in response to chronic receptor occupation. The result is that the body requires increased drug, or an increased MEC, to achieve the same effect. This patient is getting adequate pain relief, so there is no negative placebo effect. Tachyphylaxis is a form of tolerance that can be defined as a reduction in drug responsiveness brought on by repeated dosing over a short time; this occurs over several months. Barbiturates induce synthesis of hepatic enzymes that cause increased metabolism of the drug, but it does not increase the MEC.

A nurse is caring for a woman with breast cancer who is receiving tamoxifen. A review of this patient's chart reveals a deficiency of the CYP2D6 gene. The nurse will contact the provider to suggest:
a. a different medication.
b. an increased dose.
c. a reduced dose.
d. serum drug levels.

A
Women with a deficiency of the CYP2D6 gene lack the ability to convert tamoxifen to its active form, endoxifen, and will not benefit from this drug. Another drug should be used to treat this patient's breast cancer. Increasing the dose, reducing the dose, or monitoring serum drug levels will not make this drug more effective in these women.

A nurse is teaching a group of women about medications. The women want to know why so many drugs have unpredictable effects in women. The nurse will tell them that:
a. drugs usually have more toxic effects in women.
b. most known drug effects are based on drug trials in men.
c. women have varying responses to drugs during menstrual cycles.
d. women metabolize drugs more slowly.

B
Until 1997 almost all clinical drug trials were performed in men. Women may have more toxic effects with some drugs and fewer toxic effects with others. Not all drugs are influenced by hormonal changes. Women metabolize some drugs more slowly and other drugs more quickly. Unless drug trials are performed in both women and men, the effects of drugs in women will not be clear.

The nurse is assessing a newly admitted older patient who has recently lost 15 pounds. The nurse notes that the patient is taking warfarin (Coumadin). Which laboratory tests will the nurse discuss with this patient's provider?
a. Blood glucose and C-reactive protein
b. Complete blood count and hepatic function tests
c. Renal function tests and serum electrolytes
d. Serum albumin and coagulation studies

D
Older patients and those who are malnourished are at increased risk for low serum albumin. Since warfarin binds to albumin, such patients are at increased risk for elevated warfarin levels, which can cause increased bleeding. The nurse should request albumin levels and coagulation studies.

Which groups of people are especially sensitive to medication effects? (Select all that apply.)
a. Older adults
b. Caucasians
c. Infants
d. Minorities
e. Women

A, C
Older adults and infants are the two groups most sensitive to drugs because of differences in organs that absorb, metabolize, and excrete drugs. In the older adult, organ degeneration accounts for these differences, whereas in infants the differences are related to organ immaturity. Racial and gender differences tend to be related to genetic differences and not race and gender per se. These groups are more sensitive to drug effects in some cases and less sensitive in other cases.

A patient receives morphine and shows signs of toxicity. The prescriber orders naloxone [Narcan] to reverse the effects of the morphine. The nurse understands that the naloxone reverses morphine toxicity by which action on morphine receptor sites?
a. Blocking transmitter reuptake
b. Inhibiting transmitter release
c. Interfering with transmitter storage
d. Preventing activation of receptors

D
Morphine and its antagonist, naloxone, act directly at the same receptors. Morphine causes activation, and naloxone prevents activation. Neither morphine nor naloxone acts to alter transmitter reuptake, release, or storage.

A nurse is teaching a group of nursing students about neuropharmacology. Which statement by a student about peripheral nervous system (PNS) drugs indicates a need for further teaching?
a. "Drugs affecting axonal conduction have a variety of uses."
b. "Drugs that alter synaptic transmission can be highly selective."
c. "Many PNS drugs act by altering synaptic transmission."
d. "These drugs work by influencing receptor activity."

A
Local anesthetics are drugs that work by altering axonal conduction. Any drug affecting axonal conduction would be nonselective, because axonal conduction of impulses is essentially the same in all neurons. In contrast, drugs that affect synaptic transmission can be highly selective, because each transmitter has different effects on receptor sites. Most PNS drugs work on synaptic transmission processes. Through their effects on transmitters, they influence receptor activity.

A nurse is preparing to administer a medication and learns that it is a nonselective agonist drug. What does the nurse understand about this drug?
a. It directly activates receptors to affect many physiologic processes.
b. It directly activates receptors to affect a specific physiologic process.
c. It prevents receptor activation to affect many physiologic processes.
d. It prevents receptor activation to affect a specific physiologic processes.

A
Drugs that directly activate receptors are called agonists, so this drug will directly activate the receptor site. Drugs that are nonselective activate a variety of receptor sites. A selective agonist would directly activate specific receptors to affect a specific process. An antagonist would prevent receptor activatio

A nurse is administering drug X to a patient. The drug information states that the drug acts by activating receptors in the peripheral nervous system by increasing transmitter synthesis. The nurse understands that the effect of this drug is to:
a. activate axonal conduction.
b. enhance transmitter storage.
c. increase receptor activation.
d. synthesize supertransmitters.

C
Drugs that increase transmitter synthesis increase receptor activation. Other drugs that alter transmitter synthesis can decrease synthesis and would cause decreased receptor activation. Drugs that affect transmitter production do not exert their effects on axonal conduction. The amount of transmitter produced does not directly affect transmitter storage. Some drugs that alter transmitter synthesis cause the synthesis of transmitter molecules that are more effective than the transmitter itself.

A nurse learns about a drug that interferes with transmitter storage in the PNS. The transmitter affected by this drug causes an increased heart rate. What response will the nurse expect to see when this drug is administered?
a. Bradycardia
b. Positive inotropic effects
c. Prolonged receptor activation
d. Tachycardia

A
Drugs that interfere with transmitter storage reduce receptor activation, because disruption of storage decreases the amount of transmitter available for release. Because this transmitter increases the heart rate, the result will be a decrease in the heart rate. Inotropic effects control the force of contraction, not the rate of contraction. Decreased transmitter storage would result in decreased receptor activation. Tachycardia would occur if transmitter availability were increased.

A patient receiving botulinum toxin injections to control muscle spasticity asks how the drug works. The nurse knows that this drug affects the transmitter acetylcholine by:
a. inhibiting its release.
b. interfering with its storage.
c. preventing its reuptake.
d. promoting its synthesis.

A
Acetylcholine is a neurotransmitter that activates receptors that increase skeletal muscle contraction. Botulinum toxin inhibits the release of this transmitter. It does not interfere with storage, reuptake, or synthesis of acetylcholine.

A patient has allergies and takes an antihistamine. The patient wants to know how the drug works. The nurse understands that antihistamines work because they are what?
a. Activators
b. Agonists
c. Antagonists
d. Antidotes

C
Antihistamines bind to receptors to prevent activation by histamine; this makes antihistamines antagonist drugs. Antihistamines do not activate receptors. Agonist drugs activate receptors; they are not antidotes.

A nursing student asks about drugs that interfere with the termination of transmitter action. Which statement by the nurse is correct?
a. "Drugs act on this process by altering the diffusion of the transmitter away from the synaptic gap."
b. "Drugs can interfere with termination by either increasing or decreasing reuptake of the transmitter."
c. "Drugs in this category lead to decreased activation by the transmitter in the synapse."
d. "These drugs reduce either reuptake or degradation of the transmitter, causing an increase in receptor activation."

D
Drugs that interfere with termination of transmitter action do so by blocking transmitter reuptake or inhibiting transmitter degradation, resulting in increased receptor activation, because more of the transmitter remains available. Diffusion of the transmitter occurs naturally, but it is a slow process with little clinical significance. Drugs that alter this process cause a decrease in reuptake, not an increase. The effect of drugs that interfere with termination of transmitter action is increased activation.

What is the target organ when a beta1 agonist is administered?
a. heart
b. kidney
c. respiratory
d. liver

A
A beta1 agonist increases the patient's heart rate and blood pressure and is used in heart failure. Beta1 agonists would not be used for kidney, respiratory, or liver failure.

A nurse is teaching a patient about a medication that alters sympathetic nervous system functions. To evaluate understanding, the nurse asks the patient to describe which functions the sympathetic nervous system regulates. Which answer indicates the need for further teaching?
a. "The digestive functions of the body"
b. "The cardiovascular system"
c. "The fight-or-flight response"
d. "Body temperature"

B
The sympathetic nervous system does not regulate digestive functions of the body—the parasympathetic nervous system does; further education is needed. The sympathetic nervous system regulates the cardiovascular system, the fight-or-flight response, and the body temperature; no further education is needed.

A patient is wheezing and short of breath. The nurse assesses a heart rate of 88 beats per minute, a respiratory rate of 24 breaths per minute, and a blood pressure of 124/78 mm Hg. The prescriber orders a nonspecific beta agonist medication. Besides evaluating the patient for a reduction in respiratory distress, the nurse will monitor for which side effect?
a. Hypotension
b. Tachycardia
c. Tachypnea
d. Urinary retention

B
Beta agonists are used for asthma because of their beta2 effects on bronchial smooth muscle, causing dilation. Beta1 effects cause tachycardia and hypertension. Beta receptors do not exert effects on the bladder.

A nurse is teaching a group of nursing students about neurotransmitters. Which statement by a student about acetylcholine indicates a need for further teaching?
a. "It activates three cholinergic receptor subtypes."
b. "It has effects in the parasympathetic, sympathetic, and somatic nervous systems."
c. "It is used at most junctions of the peripheral nervous system."
d. "Its transmission is terminated by reuptake into the cholinergic nerve terminal."

D
Acetylcholine (ACh) is destroyed by acetylcholinesterase, an enzyme that degrades ACh into two inactive products: acetate and choline. Choline is taken up into the nerve terminal. ACh activates three receptor sites: nicotinicN, nicotinicM, and muscarinic. ACh has effects throughout the peripheral nervous system (PNS) and is used at most junctions in the PNS.

A nurse is administering an agonist drug that acts on postganglionic neurons of the sympathetic nervous system. Which response will the nurse expect to see?
a. Decreased sweating
b. Bronchodilation
c. Increased cardiac output
d. Pinpoint pupils

C
Norepinephrine (NE) is the most common neurotransmitter released by all postganglionic neurons of the sympathetic nervous system except those going to sweat glands where ACh is the neurotransmitter. NE acts on alpha1, alpha2, and beta1 receptors to increase the force and rate of cardiac contraction, thus increasing cardiac output. ACh would increase sweating. Bronchodilation occurs when epinephrine activates beta2 receptors on bronchial smooth muscle. NE affects alpha1 receptors to dilate the pupils.

Many medications list side effects that include dry mouth, constipation, and urinary retention. What kinds of effects are these?
a. Alpha adrenergic
b. Anticholinergic
c. Beta adrenergic
d. Sympathetic

B
Cholinergic stimulation by ACh causes increased salivation, increased gastrointestinal (GI) motility, and relaxation of the bladder trigone and sphincter. Anticholinergic medications inhibit these responses, causing dry mouth, constipation, and urinary retention. Alpha-adrenergic agents effect processes in the sympathetic nervous system, causing peripheral vasoconstriction and pupil dilation, among other effects. The effects of beta-adrenergic medications are seen mostly in the heart and blood vessels. The sympathetic nervous system has both cholinergic and adrenergic transmitters.

A nurse is explaining activation of beta2 receptors to nursing students during a clinical rotation at the hospital. Which statement by a student demonstrates a need for further teaching?
a. "Beta2 activation results in bronchodilation."
b. "Beta2 activation results in contraction of uterine muscle."
c. "Beta2 activation results in glycogenolysis."
d. "Beta2 activation results in vasodilation of skeletal muscles."

B
Beta2 activation would result in relaxation of uterine smooth muscle, not contraction; this statement indicates a need for further teaching. Bronchodilation is an effect of beta2 activation; no further teaching is needed. Beta2 activation does result in glycogenolysis; no further teaching is needed. Beta2 activation does result in vasodilation of skeletal muscle; no further teaching is needed.

A pregnant patient is in premature labor. Which class of drug will she be given?
a. Alpha1 agonist
b. Anticholinergic
c. Beta2 agonist
d. Beta2 antagonist

C
Beta2 agonists cause relaxation of uterine muscle, slowing or stopping the contractions that precipitate labor. An alpha1 agonist would have effects on the heart and arterioles. Anticholinergic drugs generally are given for their effects on the urinary and GI tracts and do not affect uterine muscle. A beta2 antagonist would cause increased constriction of uterine muscle.

A patient is to receive a beta agonist. Before administration of this medication, which assessment finding would most concern the nurse?
a. Pulse oximetry reading of 88%
b. Blood pressure of 100/60 mm Hg
c. Respiratory rate of 28 breaths per minute
d. Heart rate of 110 beats per minute

D
A beta agonist dilates respiratory smooth muscle, but as a side effect, it can stimulate the heart. A heart rate of 110 beats per minute is a concern, because this medication may further increase the already elevated heart rate. A pulse oximetry reading of 88% is a concern, but the medication causes bronchodilation and increased oxygenation; this should increase the pulse oximetry reading. A blood pressure of 100/60 mm Hg is on the low side, but this medication may actually cause an increase in blood pressure as a side effect; this should not concern the nurse before administration of the medication. A respiratory rate of 28 breaths per minute is elevated; however, this medication should increase oxygenation by bronchodilation, and the patient's respiratory rate should decrease once oxygenation has improved. Therefore, this should not concern the nurse.

A prescriber has ordered pilocarpine [Pilocar]. A nurse understands that the drug stimulates muscarinic receptors and would expect the drug to have which action?
a. Reduction of excessive secretions in a postoperative patient
b. Lowering of intraocular pressure in patients with glaucoma
c. Inhibition of muscular activity in the bladder
d. Prevention of hypertensive crisis

B
Pilocarpine is a muscarinic agonist used mainly for topical therapy of glaucoma to reduce intraocular pressure. Pilocarpine is not indicated for the treatment of excessive secretions and mucus; in fact, pilocarpine is used to treat dry mouth. Pilocarpine does not inhibit muscular activity in the bladder. Pilocarpine is not used to prevent hypertensive crisis.

A patient has developed muscarinic antagonist toxicity from ingestion of an unknown chemical. The nurse should prepare to administer which medication?
a. Atropine [Sal-Tropine] IV
b. Physostigmine [Antilirium]
c. An acetylcholinesterase activator
d. Pseudoephedrine [Ephedrine]

B
Physostigmine is indicated for muscarinic antagonist toxicity. Atropine is a drying agent and would only complicate the drying action that arises from the muscarinic antagonist. An acetylcholinesterase activator would only contribute to dryness that arises from the muscarinic antagonist. Ephedrine is not indicated for muscarinic antagonist toxicity.

A prescriber has ordered bethanechol [Urecholine] for a postoperative patient who has urinary retention. The nurse reviews the patient's chart before giving the drug. Which part of the patient's history would be a contraindication to using this drug?
a. Asthma as a child
b. Gastroesophageal reflux
c. Hypertension
d. Hypothyroidism

A
Bethanechol is contraindicated in patients with active or latent asthma, because activation of muscarinic receptors in the lungs causes bronchoconstriction. It increases the tone and motility of the gastrointestinal (GI) tract and is not contraindicated in patients with reflux. It causes vasodilation and would actually lower blood pressure in a hypertensive patient. It causes dysrhythmias in hyperthyroid patients.

A patient will begin using a transdermal preparation of a muscarinic antagonist for overactive bladder (OAB). The nurse teaches the patient what to do if side effects occur. Which statement by the patient indicates the need for further teaching?
a. "I can use sugar-free gum for dry mouth."
b. "I may need laxatives for constipation."
c. "I should keep the site covered to prevent other people from getting the medicine."
d. "I will take Benadryl for any itching caused by a local reaction to the patch."

D
Benadryl is an antihistamine, and even though it is not classified as a muscarinic antagonist, it has anticholinergic effects. Giving it with a muscarinic antagonist greatly enhances these effects, so it should not be used. Muscarinic antagonists cause dry mouth, and patients should be taught to use sugar-free gum or candies to help with this. Muscarinic antagonists can cause constipation, and laxatives may be used. Medication applied topically can be transferred to others who come in contact with the skin, so the site should be covered.

An older adult patient who lives alone and is somewhat forgetful has an overactive bladder (OAB) and reports occasional constipation. The patient has tried behavioral therapy to treat the OAB without adequate results. Which treatment will the nurse anticipate for this patient?
a. Oxybutynin short-acting syrup
b. Oxybutynin [Ditropan XL] extended-release tablets
c. Oxybutynin [Oxytrol] transdermal patch
d. Percutaneous tibial nerve stimulation (PTNS)

C
The transdermal patch is applied weekly and may be the best option for a patient who is more likely to forget to take a daily medication. The transdermal preparation has fewer side effects than the systemic dose, so it is less likely to increase this patient's constipation. The syrup has a high incidence of dry mouth and other anticholinergic side effects. The extended-release tablets must be given daily, and this patient may not remember to take them. PTNS is used after behavioral and drug therapies have failed.

A patient received atropine intravenously before surgery. The recovery room nurse notes that the patient is delirious upon awakening and has a heart rate of 96 beats per minute, a respiratory rate of 22 breaths per minute, and a blood pressure of 110/78 mm Hg. The nurse notifies the anesthesiologist, who will order:
a. activated charcoal to minimize intestinal absorption of the antimuscarinic agent.
b. an acetylcholinesterase inhibitor to compete with the antimuscarinic agent at receptors.
c. an antipsychotic medication to treat the patient's central nervous system symptoms.
d. ipratropium bromide [Atrovent] to counter the respiratory effects of the antimuscarinic agent.

B
This patient is showing signs of antimuscarinic toxicity, caused by the atropine given during surgery. The most effective antidote is physostigmine, which inhibits acetylcholinesterase, allowing acetylcholine to build up at cholinergic junctions and compete with the antimuscarinic agent for receptor binding. Activated charcoal is useful only if an antimuscarinic agent has been ingested, because it impedes absorption from the GI tract. Because this patient's psychotic symptoms are caused by an antimuscarinic agent, physostigmine should be given to treat the cause; an antipsychotic medication would only treat the symptom. Ipratropium bromide is an antimuscarinic agent and would only compound the effects. This patient's respiratory rate is only mildly elevated.

Bethanechol [Urecholine] is used to treat urinary retention but is being investigated for use in which other condition?
a. Gastric ulcers
b. Gastroesophageal reflux
c. Hypotension
d. Intestinal obstruction

B
Bethanechol is being investigated for treatment for gastroesophageal reflux disease (GERD) because of its effects on esophageal motility and the lower esophageal sphincter. Bethanechol stimulates acid secretion and could intensify ulcer formation. Bethanechol can cause hypotension. Because bethanechol increases the motility and tone of intestinal smooth muscle, the presence of an obstruction could lead to bowel rupture.

A patient receives topical atropine to facilitate an eye examination. The nurse will tell the patient to remain in a darkened room or to wear sunglasses for several hours until the effects of the medication wear off. This teaching is based on the nurse's knowledge that muscarinic antagonists cause:
a. elevation of intraocular pressure.
b. miosis and ciliary muscle contraction.
c. paralysis of the iris sphincter.
d. relaxation of ciliary muscles.

C
By blocking muscarinic receptors in the eye, atropine causes paralysis of the iris sphincter, which prevents constriction of the pupil; consequently, the eye cannot adapt to bright light. This also causes an elevation in intraocular pressure, which increases the risk of glaucoma. However, it is not an indication for wearing darkened glasses. Muscarinic agonists cause miosis; atropine causes mydriasis. The effect of relaxing ciliary muscles focuses the eye for far vision, causing blurred vision

A patient who has esophageal cancer is experiencing dry mouth and the provider orders oral pilocarpine to treat this symptom. What will the nurse expect to teach this patient about this medication?
a. "This medication may cause rapid heart rate and elevated blood pressure."
b. "This medication may cause constipation and gastric discomfort in large doses."
c. "You should experience sweating with this medication and should not have other side effects."
d. "You will begin taking 5 mg three times daily and may increase the dose to 10 mg."

D
The dosing for pilocarpine, when used for dry mouth associated with head and neck cancers, is 5 mg three times daily, which may be titrated up to 10 mg three times daily. Tachycardia and constipation are side effects of atropine. Sweating occurs with low doses of pilocarpine. Higher doses, such as this, are associated with the full range of muscarinic effects.

A nurse is teaching a nursing student about the two classes of adrenergic agonist drugs. Which statement by the nursing student indicates understanding of the teaching?
a. "Catecholamines may be given orally."
b. "Catecholamines often require continuous infusion to be effective."
c. "Noncatecholamines do not cross the blood-brain barrier."
d. "Noncatecholamines undergo rapid degradation by monoamine oxidase."

B
Catecholamines undergo rapid degradation by monoamine oxidase (MAO) and catechol-O-methyltransferase (COMT). Consequently, they have a brief duration of action, and continuous infusion often is required to maintain the drug's effects. Catecholamines cannot be used orally. Catecholamines do not cross the blood-brain barrier; noncatecholamines do. Noncatecholamines are not degraded by MAO.

Dopamine is administered to a patient who has been experiencing hypotensive episodes. Other than an increase in blood pressure, which indicator would the nurse use to evaluate a successful response?
a. Decrease in pulse
b. Increase in urine output
c. Weight gain
d. Improved gastric motilit

B
Dopamine would cause an increase in urine output, because cardiac output is increased as a result of the increase in blood pressure. The effectiveness of dopamine would not be measured by a decrease in pulse, because dopamine's primary effect is to increase blood pressure. Dopamine's effectiveness would not be evaluated by a weight gain. Dopamine's effectiveness would not be evaluated by improved gastric motility.

A nursing student asks the nurse about receptor specificity of adrenergic agonist medications. What will the nurse say?
a. "As the dosage of these medications increases, drugs in this class are more selective."
b. "Dopamine is selective for dopamine receptors and has no effects on alpha or beta receptors."
c. "Epinephrine is the most selective alpha-adrenergic agonist medication."
d. "Specificity is relative and is dose dependent."

D
Receptor specificity is relative, not absolute, and is dose dependent. At low doses, selectivity is maximal, and selectivity declines as the dose increases. Dopamine is the only drug in this class that acts on dopamine receptors, but it also has effects on alpha and beta receptors. Epinephrine is the least selective of this class.

A patient brought to the emergency department requires sutures. The prescriber orders a local anesthetic with epinephrine. The nurse understands that epinephrine is ordered to:
a. prevent hypertension induced by the anesthetic.
b. allow a reduced dose of the anesthetic.
c. reduce anesthetic-induced nausea.
d. reduce the pain of an injection.

B
Epinephrine prolongs absorption of the anesthetic, because it is an alpha1 agonist. It is frequently combined with a local anesthetic for this purpose, so that the amount of anesthetic required may be reduced. Local anesthetics do not induce hypertension; therefore, epinephrine would not be needed to prevent it. Epinephrine does not act as an antiemetic and would not reduce anesthetic-induced nausea. Epinephrine is not used to reduce the pain of an injection.

A nurse is administering intravenous dopamine [Intropin] to a patient in the intensive care unit. Which assessment finding would cause the most concern?
a. Blood pressure of 100/70 mm Hg
b. Increased urine output
c. Edema at the IV insertion site
d. Headache

C
The nurse would be concerned if the patient's peripheral IV were edematous, because this could signal infiltration of the solution into the tissues. Dopamine can cause necrosis if it extravasates. Dopamine is indicated to increase the patient's blood pressure; this blood pressure reading is acceptable. When dopamine is effective at increasing cardiac output, it also causes an increase in urine output. Headache is not a contraindication to the use of dopamine.

A patient with asthma uses albuterol [Ventolin] for wheezing. The nurse assesses the patient and notes vital signs of HR, 96 beats per minute; RR, 18 breaths per minute; and BP, 116/78 mm Hg. The patient has clear breath sounds and hand tremors. What will the nurse do?
a. Ask the patient how often the inhaler is used.
b. Check the patient's blood glucose level.
c. Request an order for isoproterenol [Isuprel] to reduce side effects.
d. Stop the medication and report the tremors to the provider.

A
Tachycardia is a response to activation of beta1 receptors. It can occur when large doses of albuterol are used and selectivity decreases. The nurse should question the patient about the number of inhalations used. Isoproterenol can cause hyperglycemia in diabetic patients. Isoproterenol has more side effects than albuterol. Tremors are an expected side effect and are not an indication for stopping the drug.

A nurse is teaching parents how to use an Epi-Pen for their child, who has a peanut allergy. Which statement by the parents indicates understanding of the teaching?
a. "After using the Epi-Pen, we must go to the emergency department."
b. "The Epi-Pen should be stored in the refrigerator, because epinephrine is sensitive to heat."
c. "The teacher should call us when symptoms start so that we can bring the Epi-Pen to school."
d. "We should jab the device into the thigh until it is empty of solution."

A
After using the Epi-Pen, it is important that the individual get medical attention as quickly as possible. The effects of epinephrine fade in 10 to 20 minutes, and the anaphylactic reaction can be biphasic and prolonged. Epinephrine is sensitive to heat, but storing the device in the refrigerator can compromise the injection mechanism; the device should be stored at room temperature in a dark place. Individuals who need an Epi-Pen must have the device with them at all times; any delay in treatment can be fatal, because anaphylaxis can occur within minutes after exposure. The Epi-Pen contains 2 mL of epinephrine, but only 0.3 mL is injected; the device will not be empty with a successful injection.

Because they cause vasoconstriction, alpha1-adrenergic agonists are especially useful for:
a. causing hemostasis in skin and mucous membranes.
b. producing mydriasis to facilitate ophthalmic examinations.
c. slowing the heart rate in tachycardic patients.
d. treating hypotension.

A
The vasoconstrictive effects of alpha1-adrenergic agonists, such as epinephrine, help produce hemostasis in skin and mucous membranes. These agents can increase blood pressure but are not the primary drugs used except in emergency situations. Alpha1 receptors in the radial muscles of the iris, not vasoconstriction, cause mydriasis. Reflex bradycardia is a side effect and not a clinical use of these agents.

A patient is admitted to the intensive care unit for treatment of shock. The prescriber orders isoproterenol [Isuprel]. The nurse expects this drug to increase tissue perfusion in this patient by activating:
a. alpha1 receptors to cause vasoconstriction.
b. alpha1 receptors to increase blood pressure.
c. beta1 receptors to cause a positive inotropic effect.
d. beta2 receptors to cause bronchodilation.

C
Isoproterenol is used for shock because of its actions on beta1 receptors in the heart. It has a positive inotropic effect, which improves cardiac output and thus increases tissue perfusion. Isoproterenol does not affect alpha1 receptors. Although it activates beta2 receptors to cause bronchodilation, this is not indicated for the treatment of shock.

A nursing student asks the nurse why epinephrine, and not other adrenergic agonists, is used to treat anaphylactic shock. What will the nurse tell the student?
a. "Epinephrine is the only adrenergic agonist that may be given parenterally."
b. "Epinephrine has the ability to activate multiple types of adrenergic receptors."
c. "Other adrenergic agonists have more severe adverse effects and are not safe in the doses needed to treat anaphylaxis."
d. "Other adrenergic agonists have little or no effects on beta2-adrenergic receptors."

B
Epinephrine is used to treat anaphylactic shock because of its ability to activate multiple adrenergic receptor types. Activation of beta1 receptors helps to increase cardiac output and improve blood pressure as well as suppress glottal edema. Activation of beta2 receptors helps to counteract bronchoconstriction. Activation of alpha1 receptors also causes vasoconstriction, which improves blood pressure. Isoproterenol may also be given parenterally but does not activate multiple receptor types. Other adrenergic agonists, such as albuterol, are more specific to beta2 receptors and have fewer side effects.

A nursing student asks why albuterol, which is selective for beta2 receptors, causes an increased heart rate in some patients. How should the nurse respond?
a. "Adrenergic agonists can lose their selectivity when given at higher doses."
b. "Bronchodilation lowers blood pressure, which causes a reflex tachycardia."
c. "Some patients metabolize the drug differently and have unusual side effects."
d. "Systemic effects are intensified with inhaled doses."

A
Although albuterol affects the beta2 receptors, at higher doses it may also activate beta1 receptors, causing an increase in the heart rate. Bronchodilation does not lower the blood pressure, and activation of beta1 receptors actually may increase it. Tachycardia is a common side effect. The inhaled route reduces the likelihood of systemic side effects.

A patient is receiving dobutamine [Dobutrex] as a continuous infusion in the immediate postoperative period. The patient also is receiving a diuretic. What adverse drug reactions are possible in this patient? (Select all that apply.)
a. Angina
b. Dysrhythmias
c. Hypotension
d. Oliguria
e. Tachycardia

A, B, E
Angina, dysrhythmias, and tachycardia are the most common adverse effects of dopamine; general anesthetics can increase the likelihood of dysrhythmias. Dopamine elevates blood pressure by increasing cardiac output. Diuretics complement the beneficial effects of dopamine on the kidney, so urine output would be increased, not decreased.

A nurse is teaching nursing students about the use of alpha-adrenergic antagonists. Which statement by a student indicates the need for further teaching?
a. "Alpha-adrenergic antagonists block alpha1 receptors on arterioles and veins."
b. "Dilation of arterioles has a direct effect on arterial pressure."
c. "Dilation of veins by alpha-adrenergic antagonists improves cardiac output."
d. "Venous dilation by alpha-adrenergic antagonists indirectly lowers arterial pressure."

C
Cardiac output is decreased as a result of the venous dilation caused by alpha-adrenergic antagonists. Alpha-adrenergic antagonists block alpha1 receptors on arterioles and veins. When alpha1 receptors on arterioles are blocked by alpha-adrenergic antagonists, a direct effect on arterial pressure occurs. When alpha1 receptors on veins are blocked by alpha-adrenergic antagonists, an indirect effect on arterial pressure occurs.

A patient with pheochromocytoma is admitted for surgery. The surgeon has ordered an alpha-blocking agent to be given preoperatively. What does the nurse understand about this agent?
a. It is ordered to prevent perioperative hypertensive crisis.
b. It prevents secretion of catecholamines by the adrenal tumor.
c. It reduces contraction of smooth muscles in the adrenal medulla.
d. It is given chronically after the surgery to prevent hypertension.

A
Manipulation of the adrenal tumor in patients with pheochromocytoma can cause a massive catecholamine release. Alpha-adrenergic antagonists are given to reduce the risk of acute hypertension during surgery. These agents do not prevent secretion of catecholamines; they block catecholamine receptor sites. They do not act on the tissue of the adrenal medulla. They are given chronically in patients who have inoperable tumors.

A patient with type 1 diabetes is taking NPH insulin, 30 units every day. A nurse notes that the patient is also taking metoprolol [Lopressor]. What education should the nurse provide to the patient?
a. "Metoprolol has no effect on diabetes mellitus or on your insulin requirements."
b. "Metoprolol interferes with the effects of insulin, so you may need to increase your insulin dose."
c. "Metoprolol may mask signs of hypoglycemia, so you need to monitor your blood glucose closely."
d. "Metoprolol may potentiate the effects of the insulin, so the dose should be reduced."

C
Because metoprolol may mask the signs of hypoglycemia, the patient should monitor the blood glucose closely and report changes to the prescriber. Metoprolol does have an indirect effect on diabetes mellitus and/or insulin requirements in that it may mask the signs of hypoglycemia, causing the patient to make a healthcare decision based on the drug-to-drug interaction rather than actual physiologic factors. The patient should not increase the insulin, because metoprolol will cause a decrease in blood glucose, increasing the risk of a hypoglycemic reaction. The patient should not reduce the dose of insulin when taking metoprolol, because this might alter serum glucose levels.

The nurse is discussing home management with a patient who will begin taking an alpha-adrenergic antagonist for hypertension. Which statement by the patient indicates understanding of the teaching?
a. "I need to stop the medication if my heart rate increases."
b. "I should not drive while taking this medication."
c. "I should take the first dose at bedtime."
d. "I will stop taking the medication if I feel dizzy."

C
Orthostatic hypotension is a common side effect of this class of drugs and is most severe with the first dose. Administering the first dose at bedtime eliminates the risk associated with this first-dose effect. Tachycardia is an expected side effect; if severe, it can be treated with other medications. Patients should not drive during the first 12 to 24 hours after taking these agents, because fainting and dizziness may occur, but they may drive after that. Dizziness is not an indication for stopping the drug; patients who experience dizziness are instructed to sit or lie down until symptoms pass.

A nurse prepares to administer propranolol [Inderal] to a patient recovering from acute myocardial infarction. The patient's heart rate is 52 beats per minute, and the rhythm is regular. What action should the nurse take next?
a. Administer the drug as prescribed.
b. Request an order for atropine.
c. Withhold the dose and document the pulse rate.
d. Withhold the dose and notify the prescriber.

D
A beta blocker, such as propranolol, should not be given if the pulse is lower than 60 beats per minute; therefore, the nurse should withhold the dose and notify the prescriber. Administering the dose as prescribed would not be appropriate, because the patient's pulse rate is too slow at this time. The dose should be withheld and the prescriber notified. The patient's heart rate is slow, and atropine may be necessary if the bradycardia persists, but the first step is to withhold the dose of propranolol. Withholding the dose and documenting the pulse rate is an appropriate but incomplete nursing intervention. The nurse must notify the prescriber to obtain further orders related to the medication.

The nurse assesses a patient who has been given phentolamine [OraVerse] to treat pheochromocytoma. The nurse notes a blood pressure of 76/52 mm Hg and a heart rate of 90 beats per minute. Which action by the nurse is correct?
a. Contact the provider to request an order for epinephrine.
b. Continue to monitor the patient's vital signs and notify the provider if the heart rate increases.
c. Notify the provider and request an order for a beta blocker.
d. Notify the provider and request an order for norepinephrine.

D
Phentolamine can cause orthostatic hypotension, reflex tachycardia, nasal congestion, and inhibition of ejaculation. Overdose can produce profound hypotension. When this occurs, blood pressure can be elevated with norepinephrine. Epinephrine should not be used because, in the presence of alpha1 blockade, the ability of epinephrine to promote vasodilation by activation of beta2 receptors may outweigh its ability to cause vasoconstriction, causing further lowering of blood pressure. Norepinephrine does not activate beta2 receptors. Beta blockers may be used to treat severe reflex tachycardia. This patient has significant hypotension, so it is not correct to continue to monitor without notifying the provider.

A nurse is discussing phentolamine [OraVerse] with a nursing student. Which statement by the student indicates the need for further teaching?
a. "Phentolamine can be used to block both epinephrine- and norepinephrine-mediated vasoconstriction."
b. "Phentolamine can be used to prevent tissue necrosis after extravasation of drugs such as norepinephrine."
c. "Phentolamine is a competitive adrenergic agonist that acts selectively on alpha1 receptors."
d. "Side effects of phentolamine may include tachycardia and hypotension."

C
Phentolamine has actions on both alpha1 and alpha2 receptors; it is not selective for alpha1 receptors only. It blocks both epinephrine- and norepinephrine-mediated vasoconstriction. It is used to prevent tissue necrosis after extravasation of drugs such as norepinephrine and other drugs that produce alpha1-mediated vasoconstriction. Side effects include tachycardia and hypotension.

A patient taking a beta blocker complains of shortness of breath. The patient has respirations of 28 breaths per minute, a blood pressure of 162/90 mm Hg, and a pulse of 88 beats per minute. The nurse auscultates crackles in all lung fields. The nurse understands that these assessments are consistent with:
a. bronchoconstriction.
b. left-sided heart failure.
c. rebound cardiac excitation.
d. sinus bradycardia.

B
The signs and symptoms describe left-sided heart failure, in which the blood normally handled by the left ventricle and forced out through the aorta into the body backs up into the lungs, producing respiratory signs and symptoms. The patient's signs and symptoms are not indicative of bronchoconstriction, which would cause wheezing and diminished breath sounds. Rebound cardiac excitation occurs when the beta blocker is withdrawn, not during administration of the drug. The patient's heart rate is elevated, so sinus bradycardia is not present.

A male patient is being treated for benign prostatic hyperplasia and has stopped taking his alpha-adrenergic antagonist medication because of ejaculatory difficulties. Which medication does the nurse expect the provider to prescribe?
a. Alfuzosin [Uroxatral]
b. Prazosin [Minipress]
c. Silodosin [Rapaflo]
d. Tamsulosin [Flomax]

A
Alfuzosin is used for BPH and does not interfere with ejaculation. All of the other drugs have ejaculatory side effects. Prazosin may be useful for BPH, but it is not approved for this use.

A patient is taking a beta-adrenergic antagonist medication for angina pectoris and asks the nurse how the drug works to relieve the discomfort associated with this condition. Which statement by the patient after the nurse's teaching indicates understanding of the drug's effects?
a. "It causes bronchodilation, which increases oxygen flow."
b. "It helps reduce the heart's oxygen needs."
c. "It improves blood flow to the heart."
d. "It increases cardiac output."

B
Blockade of beta1 receptors in the heart reduces cardiac work by reducing the heart rate, the force of contraction, and the velocity of impulse conduction through the AV node. Beta blockers result in bronchoconstriction, not bronchodilation. They do not increase blood flow to the heart. Cardiac output is decreased, not increased.

A nurse is caring for a newborn 1 day after delivery. The infant's mother used betaxolol during pregnancy. The nurse will expect to monitor this infant for which condition?
a. Hyperglycemia
b. Hyperthyroidism
c. Respiratory distress
d. Tachycardia

C
Use of beta blockers during pregnancy can affect a newborn for several days after birth. Newborns are at risk for bradycardia, respiratory distress, and hypoglycemia. Hyperglycemia, hyperthyroidism, and tachycardia are not expected residual effects.

A patient will begin taking propranolol [Inderal] for hypertension. Which statement by the nurse is important when teaching this patient about the medication?
a. "Check your hands and feet for swelling and report that to your provider."
b. "It is safe to take this medication with a calcium channel blocker."
c. "Stop taking the drug if you become short of breath."
d. "Take your pulse and do not take the medication if your heart rate is fast."

A
Patients taking propranolol can develop heart failure because of the suppression in myocardial contractility. Patients should be taught to watch for signs, which include shortness of breath, night coughs, and swelling of the extremities. Use of these agents with calcium channel blockers is contraindicated, because the effects are identical and excessive cardiosuppression can occur. Shortness of breath should be reported to the provider, but abrupt cessation of the drug can cause rebound cardiac excitability. Propranolol reduces the heart rate and should not be given if the pulse is less than 60 beats per minute.

A patient with migraines is started on a beta blocker. The nurse explains the benefits of taking the medication for migraines. Which statement by the patient indicates an understanding of the medication's effects?
a. "I need to take it every day to reduce the frequency of migraines."
b. "I will take it as needed to get relief from migraines."
c. "I will take it to shorten the duration of my migraines."
d. "I will take this drug when a migraine starts."

A
When taken prophylactically, beta blockers can reduce the frequency of migraine attacks. Beta blockers do not provide complete relief from migraines. They do not reduce the duration of migraines. They are not effective for treating a migraine once the migraine has begun.

Which are adverse effects of alpha blockade? (Select all that apply.)
a. Hypertension
b. Reflex tachycardia
c. Nasal congestion
d. Ejaculation
e. Hypernatremia

B, C, E
Adverse effects of alpha blockade include reflex tachycardia, nasal congestion, and hypernatremia. Other adverse effects include orthostatic hypotension and inhibition of ejaculation. Hypertension and ejaculation are not adverse effects of alpha blockade.

Which are conditions that may be treated using beta blockers? (Select all that apply.)
a. Cardiac dysrhythmias
b. Heart failure
c. Hypotension
d. Hypothyroidism
e. Stage fright

A, B, E
Beta blockers are used to treat cardiac dysrhythmias, heart failure, and stage fright. They are used to treat hypertension and hyperthyroidism.

A prescriber has ordered clonidine [Catapres] for a patient who has hypertension. The nurse teaches the patient about side effects of this drug. Which statement by the patient indicates understanding of the teaching?
a. "I should chew sugar-free gum or drink water to reduce dry mouth."
b. "I should not drive as long as I am taking this drug."
c. "I should stand up slowly when taking this medication."
d. "I should stop taking this drug if I feel anxious or depressed."

A
Xerostomia is a common side effect of clonidine and is often uncomfortable enough that patients stop using the drug. Counseling patients to chew sugar-free gum and take frequent sips of liquid can help alleviate this discomfort. Drowsiness is common, but this side effect becomes less intense over time. Patients should be counseled to avoid hazardous activities in the first weeks of therapy if they feel this effect. The hypertensive effects of clonidine are not posture dependent, as they are with the peripheral alpha-adrenergic blockers, so orthostatic hypotension is minimal with this drug. Clonidine causes euphoria, hallucinations, and sedation in high doses and can cause anxiety or depression, although the last two effects are less common. The drug should not be stopped abruptly because of the risk of rebound hypertension, so patients experiencing unpleasant central nervous system (CNS) effects should consult their provider about withdrawing the medication slowly.

A prescriber has ordered methyldopa for a patient with hypertension. The nurse teaches the patient about drug actions, adverse effects, and the ongoing blood tests necessary with this drug. The nurse is correct to tell the patient what?
a. "If you have a positive Coombs' test result, you will need to discontinue the medication, because this means you have hemolytic anemia."
b. "Methyldopa can be used for its analgesic effects and for its hypertensive effects."
c. "Xerostomia and orthostatic hypotension are serious side effects and indications for withdrawing the medication."
d. "You will need to contact the provider and stop taking the medication if your eyes look yellow."

D
Hepatotoxicity is a serious adverse effect of methyldopa and is an indication for withdrawal of the drug to prevent fatal hepatic necrosis. Jaundice is a sign of liver toxicity. Patients should undergo periodic liver function tests while taking the drug. Liver function usually improves when the drug is withdrawn. A positive Coombs' test result is not an indication for withdrawal of the drug in itself. About 5% of patients with a positive Coombs' test result develop hemolytic anemia; withdrawal of the drug is indicated for those patients. Methyldopa does not have analgesic effects. Xerostomia and orthostatic hypotension are known side effects of methyldopa but usually are not serious.

A patient complains to the nurse that the clonidine [Catapres] recently prescribed for hypertension is causing drowsiness. Which response by the nurse to this concern is appropriate?
a. "Drowsiness is a common side effect initially, but it will lessen with time."
b. "You may also experience orthostatic hypotension along with the drowsiness."
c. "You may be at risk for addiction if you have central nervous system side effects."
d. "You should discontinue the medication and contact your prescriber."

A
CNS depression, evidenced in this patient by drowsiness, is common in about 35% of the population. These responses become less intense with continued drug use. Orthostatic hypotension is less likely with clonidine, because its antihypertensive effects are not posture dependent. The experience of drowsiness does not indicate abuse potential. The patient should not discontinue the medication abruptly because of the potential for rebound hypertension; the patient should contact the prescriber before stopping the medication.

A nurse is teaching nursing students about the pharmacology of methyldopa. Which statement by a student indicates the need for further teaching?
a. "Methyldopa results in alpha2 agonist activation, but it is not itself an alpha2 agonist."
b. "Methyldopa is not effective until it is converted to an active compound."
c. "Methyldopa reduces blood pressure by reducing cardiac output."
d. "Methyldopa's principal mechanism is vasodilation, not cardiosuppression."

C
Methyldopa does not reduce the heart rate or cardiac output, so its hypotensive actions are not the result of cardiac depression. The drug is not, in itself, an alpha2 agonist. When taken up into brainstem neurons, it is converted into methylnorepinephrine, which is an alpha2 agonist; it is not effective until converted to this active compound. Its hypotensive effects are the result of vasodilation, not cardiosuppression.

A nurse is teaching a patient about a new prescription for reserpine [Serpasil] for hypertension. Which statement by the patient indicates the need for further teaching?
a. "Depressive side effects are common and will improve over time."
b. "I should report gastrointestinal side effects to the provider."
c. "I should stand up slowly when getting up and lie down if I feel dizzy."
d. "Therapeutic effects may not be optimal for a couple of weeks."

A
Reserpine can produce severe depression, which may persist for months during drug therapy and after the drug is withdrawn. Reserpine can stimulate the secretion of gastric acid, which can cause ulcers; it also can increase the tone and motility of intestinal smooth muscle, which can cause cramps and diarrhea. Reserpine can cause orthostatic hypotension, so patients should be counseled to rise slowly when standing up and to sit or lie down if they feel dizzy. Reserpine works by depleting norepinephrine, and the processes necessary for this may take 1 to 2 weeks.

A patient who has been taking clonidine [Catapres] for several weeks complains of drowsiness and constipation. What will the nurse do?
a. Recommend that the patient take most of the daily dose at bedtime.
b. Suggest asking the provider for a transdermal preparation of the drug.
c. Suspect that the patient is overusing the medication.
d. Tell the patient to stop taking the drug and call the provider.

A
CNS depression is common with clonidine, but this effect lessens over time. Constipation is also a common side effect. Patients who take most of the daily amount at bedtime can minimize daytime sedation. Transdermal forms of clonidine do not alter adverse effects. Patients who are abusing clonidine often experience euphoria and hallucinations along with sedation, but they generally find these effects desirable and would not complain about them to a healthcare provider. Clonidine should not be withdrawn abruptly, because serious rebound hypertension can occur.

A patient with hypertension has a previous history of opioid dependence. Which medication would the nurse question?
a. Clonidine [Catapres]
b. Guanabenz [Wytensin]
c. Methyldopa
d. Reserpine [Serpasil]

A
Patients who abuse cocaine, opioids, and other such drugs also frequently abuse clonidine, so this agent would not be the best choice for this patient. The other drugs do not share this abuse potential.

A prescriber orders transdermal clonidine [Catapres TTS] for a patient with hypertension. What will the nurse teach this patient?
a. That medication given by transdermal patch has fewer systemic side effects
b. That localized skin reactions are uncommon
c. To apply the patch to intact skin on the forearm or leg
d. To change the patch every week

D
Transdermal patches are to be changed every 7 days. Medication administered by patch has the same therapeutic effect and adverse effects as that given by other routes, except that localized skin reactions may occur and are common with clonidine patches. The patch should be applied to intact, hairless skin on the upper arm or torso.

A prescriber orders clonidine [Kapvay] ER tablets for a 12-year-old child. The nurse understands that this drug is being given to treat which condition?
a. ADHD
b. Hypertension
c. Severe pain
d. Tourette's syndrome

A
Kapvay ER is used to treat ADHD and is given as a single dose at bedtime. This form of clonidine is not used for hypertension, severe pain, or treatment of Tourette's syndrome.

A prescriber has ordered methyldopa for a female patient with hypertension. The nurse understands that which laboratory tests are important before beginning therapy with this drug? (Select all that apply.)
a. Coombs' test
b. Hemoglobin and hematocrit (H&H)
c. Liver function tests
d. Pregnancy test
e. Urinalysis

A, B, C
A positive Coombs' test result occurs in 10% to 20% of patients who take methyldopa chronically. A few of these patients (5%) develop hemolytic anemia. Blood should be drawn for a Coombs' test and an H&H before treatment is started and at intervals during treatment. Because methyldopa is associated with liver disorders, liver function tests should be performed before therapy is started and periodically during treatment. Clonidine, not methyldopa, is contraindicated during pregnancy. A urinalysis is not indicated.

Clonidine is approved for the treatment of which conditions? (Select all that apply.)
a. ADHD
b. Hypertension
c. Opioid withdrawal
d. Severe pain
e. Smoking cessation

A, B, D
Clonidine has three approved uses: treatment of ADHD, hypertension, and severe pain. It has investigational uses for management of opioid withdrawal and for smoking cessation

A psychiatric nurse is teaching a patient about an antidepressant medication. The nurse tells the patient that therapeutic effects may not occur for several weeks. The nurse understands that this is likely the result of:
a. changes in the brain as a result of prolonged drug exposure.
b. direct actions of the drug on specific synaptic functions in the brain.
c. slowed drug absorption across the blood-brain barrier.
d. tolerance to exposure to the drug over time.

A
It is thought that beneficial responses to central nervous system (CNS) drugs are delayed because they result from adaptive changes as the CNS modifies itself in response to prolonged drug exposure, and that the responses are not the result of the direct effects of the drugs on synaptic functions. The blood-brain barrier prevents protein-bound and highly ionized drugs from crossing into the CNS, but it does not slow the effects of drugs that can cross the barrier. Tolerance is a decreased response to a drug after prolonged use.

A nurse is teaching a group of nursing students how the CNS adapts to psychotherapeutic medications. Which statement by a nursing student indicates a need for further teaching?
a. "Adaptation can lead to tolerance of these drugs with prolonged use."
b. "Adaptation helps explain how physical dependence occurs."
c. "Adaptation often must occur before therapeutic effects develop."
d. "Adaptation results in an increased sensitivity to side effects over time."

D
With adaptation of the central nervous system to prolonged exposure to CNS drugs, many adverse effects diminish and therapeutic effects remain. Adaptation helps explain how tolerance and physical dependence occur, as the brain adapts to the presence of the drug. Therapeutic effects can take several weeks to manifest, because they appear to work by initiating adaptive changes in the brain.

A group of nursing students asks a nurse to explain the blood-brain barrier. The nurse would be correct to say that the blood-brain barrier:
a. prevents some potentially toxic substances from crossing into the central nervous system.
b. causes infants to be less sensitive to CNS drugs and thus require larger doses.
c. allows only ionized or protein-bound drugs to cross into the central nervous system.
d. prevents lipid-soluble drugs from entering the central nervous system.

A
The blood-brain barrier can prevent some drugs and some toxic substances from entering the CNS. The blood-brain barrier in infants is not fully developed, so infants are more sensitive to CNS drugs and often require lower doses. The blood-brain barrier prevents highly ionized and protein-bound drugs from crossing into the CNS and allows lipid-soluble drugs and those that can cross via specific transport systems to enter.

A nurse is teaching a group of students about how CNS drugs are developed. Which statement by a student indicates a need for further teaching?
a. "Central nervous system drug development relies on observations of their effects on human behavior."
b. "Studies of new central nervous system drugs in healthy subjects can produce paradoxical effects."
c. "Our knowledge of the neurochemical and physiologic changes that underlie mental illness is incomplete."
d. "These drugs are developed based on scientific knowledge of CNS transmitters and receptors."

D
The deficiencies in knowledge about how CNS transmitters and receptors work make systematic development of CNS drugs difficult. Testing in healthy subjects often leads either to no effect or to paradoxical effects. Medical knowledge of the neurochemical and physiologic changes underlying mental illness is incomplete. The development of CNS drugs depends less on knowledge of how the CNS functions and how these drugs affect that process and more on how administering one of these agents leads to changes in behavior.

A patient asks a nurse to explain what drug tolerance means. The nurse responds by telling the patient that when tolerance occurs, it means the patient:
a. has developed a psychologic dependence on the drug.
b. may need increased amounts of the drug over time.
c. will cause an abstinence syndrome if the drug is discontinued abruptly.
d. will have increased sensitivity to drug side effects.

B
When tolerance develops, a dose increase may be needed, because a decreased response may occur with prolonged use. Psychologic dependence involves cravings for drug effects and does not define tolerance. Physical dependence occurs when the drug becomes necessary for the brain to function "normally," meaning the patient should be weaned from the drug slowly to prevent an abstinence syndrome. Patients may have a decreased sensitivity to drug side effects over time as the brain adapts to the medication.

An infant who receives a drug that does not produce CNS side effects in adults exhibits drowsiness and sedation. The nurse understands that this is because of differences in which physiologic system in infants and adults?
a. Blood-brain barrier
b. First-pass effect
c. Gastrointestinal absorption
d. Renal filtration

A
The blood-brain barrier is not fully developed at birth, making infants much more sensitive to CNS drugs than older children and adults. CNS symptoms may include sedation and drowsiness. The first-past effect and GI absorption affect metabolism and absorption of drugs, and renal filtration affects elimination of drugs, all of which may alter drug levels.

Which monoamines act as neurotransmitters in the central nervous system? (Select all that apply.)
a. Acetylcholine
b. Norepinephrine
c. Serotonin
d. Dopamine
e. Epinephrine
f. Histamine

B, C, D, E
Acetylcholine and histamines are not monoamines.

Which are medical applications of central nervous system drugs? (Select all that apply.)
a. Analgesia
b. Anesthesia
c. Depression
d. Euphoria
e. Seizure control

A, B, E
CNS drugs have medical uses for pain management, anesthesia, and seizure control. Depression and euphoria are side effects that can contribute to abuse of these drugs.

A patient has taken levodopa [Dopar] for Parkinson's disease for 2 weeks but reports no improvement in the symptoms. Which response by the nurse is correct?
a. "Another agent will be needed to manage your symptoms."
b. "Double the dose to see whether an effect occurs."
c. "It may take several months for a response to occur."
d. "The prescriber may need to change your drug regimen."

C
A full therapeutic response with levodopa may take several months to develop. Until the true effect of the dose is seen, it is not necessary to change to another drug, increase the dose, or change the drug regimen.

A nurse provides teaching for a patient who is newly diagnosed with Parkinson's disease. Which statement by the patient indicates understanding of the drug therapy for this disease?
a. "A levodopa/carbidopa combination is used to improve motor function."
b. "There are several drugs available to treat dyskinesias."
c. "When 'off' times occur, I may need to increase my dose of levodopa."
d. "With adequate drug therapy, the disease progression may be slowed."

A
Levodopa combined with carbidopa is the initial drug of choice to treat motor symptoms. Amantadine is the only drug recommended to treat dyskinesias. Entacapone and rasagiline are used to treat abrupt loss of effect, or "off" times. Drug therapy does not slow the progression of the disease.

A patient has been diagnosed with Parkinson's disease (PD) and begins treatment with levodopa/carbidopa [Sinemet]. After several months of therapy, the patient reports no change in symptoms. The nurse will expect the provider to:
a. add a dopamine agonist.
b. discuss the "on-off" phenomenon.
c. increase the dose of Sinemet.
d. re-evaluate the diagnosis.

D
Patients beginning therapy with levodopa/carbidopa should expect therapeutic effects to occur after several months of treatment. Levodopa is so effective that a diagnosis of PD should be questioned if the patient fails to respond in this time frame. Adding a dopamine agonist is not indicated. The "on-off" phenomenon occurs when therapeutic effects are present. Increasing the dose of levodopa/carbidopa is not indicated.

A patient with Parkinson's disease is taking levodopa/carbidopa [Sinemet] and reports occasional periods of loss of drug effect lasting from minutes to several hours. The nurse questions the patient further and discovers that these episodes occur at different times related to the medication administration. The nurse will contact the provider to discuss:
a. administering a catechol-O-methyltransferase (COMT) inhibitor, such as entacapone.
b. adding the DA-releasing agent amantadine to the regimen.
c. giving a direct-acting dopamine agonist.
d. shortening the dosing interval of levodopa/carbidopa.

A
This patient is describing abrupt loss of effect, or the "off" phenomenon, which is treated with entacapone or another COMT inhibitor. Amantadine is used to treat dyskinesias. A direct-acting dopamine agonist is useful for gradual loss of effect, which occurs at the end of the dosing interval as the dose is wearing off. Shortening the dosing interval does not help with abrupt loss of effect.

A patient newly diagnosed with Parkinson's disease has been taking levodopa/carbidopa [Sinemet] for several weeks and complains of nausea and vomiting. The nurse tells the patient to discuss what with the provider?
a. Taking a lower dose on an empty stomach
b. Taking an increased dose along with a high-protein snack
c. Taking a lower dose with a low-protein snack
d. Taking dopamine in addition to levodopa/carbidopa

C
Because levodopa activates the chemoreceptive trigger zone (CTZ) of the medulla, causing nausea and vomiting (N/V), the patient may need to take a lower dose temporarily until tolerance develops. A meal helps slow absorption to minimize this side effect. A high protein intake contributes to abrupt loss of effect, so meals should be low in protein. Taking a dose on an empty stomach increases absorption and also N/V. An increased dose with a high-protein snack increases N/V and also abrupt loss of effect. Dopamine increases N/V, because it activates the CTZ of the medulla.

A nurse is discussing motor symptoms with a patient with Parkinson's disease who has been taking levodopa/carbidopa [Sinemet] for 9 months and who is now having regular tics. Which statement by the patient indicates understanding of this symptom?
a. "I may need to try a lower dose of Sinemet to reduce my tics."
b. "My provider may order clozapine to treat these tics."
c. "These tics are an indication that my dose of Sinemet is too low."
d. "This means I will have to have surgery to stop the symptoms."

A
Levodopa can cause movement disorders, generally within the first year of therapy. If they occur, a lower dose of levodopa may be required to alleviate them. Clozapine is an antipsychotic used to treat levodopa-induced psychoses. Movement disorders generally occur as the dose of levodopa increases. Surgery is a last option for treating movement disorders, after amantadine fails.

A patient who has begun taking levodopa/carbidopa [Sinemet] reports feeling lightheaded and dizzy, especially when standing up from a sitting position. What will the nurse recommend?
a. An alpha-adrenergic antagonist medication
b. Discussing amantadine with the prescriber
c. Increasing salt and water intake
d. Taking a drug holiday

C
Postural hypotension is common early in treatment and can be reduced by increasing the intake of salt and water. An alpha-adrenergic agonist, not an antagonist, can help. Amantadine is used to treat levodopa-induced dyskinesias. Drug holidays are used when adverse effects increase with long-term use of levodopa; the drug holiday allows beneficial effects to be achieved with lower doses, which reduces the incidence of side effects.

A nursing student wants to know why a patient who has been taking levodopa [Dopar] for years will now receive levodopa/carbidopa [Sinemet]. The nurse explains the reasons that levodopa as a single agent is no longer available. Which statement by the student indicates a need for further education?
a. "Carbidopa increases the availability of levodopa in the central nervous system."
b. "Carbidopa reduces the incidence of nausea and vomiting."
c. "Combination products reduce peripheral cardiovascular side effects."
d. "Combination products cause fewer dyskinesias and decreased psychosis."

D
Adding carbidopa to levodopa does not reduce the incidence of dyskinesias or psychosis. In fact, carbidopa can increase the intensity and the speed of onset of these effects. Carbidopa inhibits decarboxylation of levodopa in the intestine and peripheral tissues, leading to more levodopa in the CNS. Carbidopa cannot cross the blood-brain barrier, so it does not have this action in the CNS. Peripheral side effects are reduced, including nausea, vomiting, and cardiovascular effects.

A nurse is teaching a group of nurses about Parkinson's medications. The nurse is correct to state that one side effect associated with pramipexole [Mirapex] that is less likely to occur with other dopamine agonists is:
a. sleep attacks.
b. dizziness.
c. hallucinations.
d. dyskinesias.

A
A few patients taking pramipexole have experienced sleep attacks, or an overwhelming and irresistible sleepiness that comes on without warning. Dizziness, hallucinations, and dyskinesias are listed as side effects of pramipexole and other dopamine agonists.

A nursing student wants to know how carbidopa can be effective for treating Parkinson's disease if it prevents the conversion of levodopa to dopamine. The nurse explains that carbidopa:
a. can be taken with high-protein meals.
b. does not cross the blood-brain barrier.
c. has dopamine-like effects of its own.
d. reduces abrupt loss of effect.

B
Carbidopa inhibits decarboxylation of levodopa in the intestine and peripheral tissues, leading to more levodopa in the CNS. Carbidopa cannot cross the blood-brain barrier, so it does not have this action in the CNS. Carbidopa is not given with high-protein meals. Carbidopa does not have dopamine-like effects. Carbidopa does not affect abrupt loss of effect.

A 25-year-old patient has been newly diagnosed with Parkinson's disease, and the prescriber is considering using pramipexole [Mirapex]. Before beginning therapy with this drug, the nurse will ask the patient about:
a. any history of alcohol abuse or compulsive behaviors.
b. any previous history of hypertension.
c. difficulty falling asleep or staying asleep.
d. whether any family members have experienced psychoses.

A
Pramipexole has been associated with impulse control disorders, and this risk increases in patients with a history of alcohol abuse or compulsive behaviors. Pramipexole increases the risk of hypotension and sleep attacks, so a history of hypertension or insomnia would not be cautionary. Unlike with levodopa, the risk of psychoses is not increased.

A hospitalized patient with Parkinson's disease who is receiving apomorphine to treat "off" episodes develops nausea and vomiting. The nurse will discuss the use of which medication with the patient's provider?
a. Levodopa [Dopar]
b. Ondansetron [Zofran]
c. Prochlorperazine [Compazine]
d. Trimethobenzamide [Tigan]

D
Trimethobenzamide can be used as an antiemetic in patients treated with apomorphine. Serotonin receptor agonists (eg, ondansetron) and dopamine receptor antagonists (eg, prochlorperazine) cannot be used, because they increase the risk of serious postural hypotension. Levodopa only increases nausea and vomiting.

A patient with Parkinson's disease is taking levodopa/carbidopa [Sinemet]. The prescriber orders bromocriptine [Parlodel] to treat dyskinesias. The nurse notes that the patient is agitated, and the patient reports having frequent nightmares. The nurse will contact the provider to discuss:
a. adding an antipsychotic medication.
b. changing from bromocriptine to cabergoline [Dostinex].
c. reducing the dose of bromocriptine.
d. reducing the dose of levodopa/carbidopa.

C
Bromocriptine is used to treat levodopa-induced dyskinesias and has dose-dependent psychologic side effects. The nurse should suggest reducing the dose of this drug to minimize these side effects. Adding an antipsychotic medication is not indicated. Cabergoline is not approved for this use. Reducing the dose of levodopa/carbidopa is not indicated.

A patient who is newly diagnosed with Parkinson's disease is prescribed levodopa [Dopar]. The patient asks the nurse about drugs to prevent disease progression. What will the nurse tell this patient?
a. "Levodopa may prevent disease progression in higher doses and is safe to use for this purpose."
b. "MAO-B inhibitors and dopamine agonists have both shown neuroprotective effects in human studies."
c. "Vitamin E has been shown to delay neuron degeneration and may be used as adjunctive therapy."
d. "While some drugs show promise, there are no studies that have proven a neuroprotective effect."

D
To date, there is no definitive proof that any drug can protect dopaminergic neurons from progressive degeneration. Levodopa has shown neuroprotective effects, but studies have demonstrated toxic effects in the doses required for this purpose. MAO-B inhibitors have shown benefits, but only in animal studies. Vitamin E was once theorized to offer this protection, but recent studies have provided good evidence that this is not the case.

The nurse provides teaching for a patient who will begin taking rotigotine [Neupro] to treat Parkinson's disease. What will the nurse include in teaching?
a. "If you develop nausea and vomiting, you should stop taking the medication."
b. "If you need to stop this drug, your provider will order a gradual withdrawal."
c. "You will start this drug regimen with a higher than usual loading dose."
d. "You will take this medication by mouth with food."

B
Rotigotine is a nonergot dopamine agonist, which is given by starting with a 2-mg dose that is increased by 2 mg each week until the lowest effective dose is reached. It should not be stopped abruptly but should be decreased by 2 mg per week until tapered off. It undergoes extensive first-pass metabolism, so it is not given orally and is currently available as a transdermal patch.

A patient with Parkinson's disease is taking levodopa/carbidopa [Sinemet] along with amantadine [Symmetrel] 400 mg/day to treat dyskinesias. The patient reports having increased dyskinesias several months after beginning the amantadine. The nurse will contact the provider to discuss which action?
a. Increasing the dose of amantadine [Symmetrel]
b. Interrupting treatment with amantadine for several weeks
c. Ordering renal function tests
d. Ordering another anticholinergic medication

B
When amantadine is added to therapy to treat dyskinesias associated with levodopa, it often loses effectiveness after several months. If the effects diminish, they can be restored by either increasing the dosage or by interrupting treatment for several weeks. The maximum dosage of amantadine is 400 mg/day, so it is incorrect to increase the dose. Altered renal function would result in drug toxicity, not ineffectiveness of the drug. It is not necessary to order another drug until determining whether the effectiveness can be restored.

A patient asks the nurse what can be given to alleviate severe, chronic pain of several months' duration. The patient has been taking oxycodone [OxyContin] and states that it is no longer effective. The nurse will suggest discussing which medication with the provider?
a. Fentanyl [Duragesic] transdermal patch
b. Hydrocodone [Vicodin] PO
c. Meperidine [Demerol] PO
d. Pentazocine [Talwin] PO

A
Transdermal fentanyl is indicated only for persistent, severe pain in patients already opioid tolerant. Hydrocodone, a combination product, has actions similar to codeine and is not used for severe, chronic pain. Meperidine is not recommended for continued use because of the risk of harm caused by the accumulation of a toxic metabolite. Pentazocine is an agonist-antagonist opioid and is less effective for pain; moreover, when given to a patient who is already opioid tolerant, it can precipitate an acute withdrawal syndrome.

A patient who has had abdominal surgery has been receiving morphine sulfate via a patient-controlled analgesia (PCA) pump. The nurse assesses the patient and notes that the patient's pupils are dilated and that the patient is drowsy and lethargic. The patient's heart rate is 84 beats per minute, the respiratory rate is 10 breaths per minute, and the blood pressure is 90/50 mm Hg. What will the nurse do?
a. Discuss possible opiate dependence with the patient's provider.
b. Encourage the patient to turn over and cough and take deep breaths.
c. Note the effectiveness of the analgesia in the patient's chart.
d. Prepare to administer naloxone and possibly ventilatory support.

D
Opioid toxicity is characterized by coma, respiratory depression, and pinpoint pupils. Although pupils are constricted initially, they may dilate as hypoxia progresses, which also causes blood pressure to drop. This patient has a respiratory rate of fewer than 12 breaths per minute, dilated pupils, and low blood pressure; the patient also is showing signs of central nervous system (CNS) depression. The nurse should prepare to give naloxone and should watch the patient closely for respiratory collapse. Patients with opioid dependence show withdrawal symptoms when the drug is discontinued. When postoperative patients have adequate analgesia without serious side effects, encouraging patients to turn, cough, and breathe deeply is appropriate. This patient is probably relatively pain free, but providing emergency treatment is the priority.

A patient with moderate to severe chronic pain has been taking oxycodone [OxyContin] 60 mg every 6 hours PRN for several months and tells the nurse that the medication is not as effective as before. The patient asks if something stronger can be taken. The nurse will contact the provider to discuss:
a. administering a combination opioid analgesic/acetaminophen preparation.
b. changing the medication to a continued-release preparation.
c. confronting the patient about drug-seeking behaviors.
d. withdrawing the medication, because physical dependence has occurred.

B
Oxycodone is useful for moderate to severe pain, and a continued-release preparation may give more continuous relief. Dosing is every 12 hours, not PRN. A combination product is not recommended with increasing pain, because the nonopioid portion of the medication cannot be increased indefinitely. This patient does not demonstrate drug-seeking behaviors. Physical dependence is not an indication for withdrawing an opioid, as long as it is still needed; it indicates a need for withdrawing the drug slowly when the drug is discontinued.

A patient with cancer has been taking an opioid analgesic four times daily for several months and reports needing increased doses for pain. What will the nurse tell the patient?
a. PRN dosing of the drug may be more effective.
b. The risk of respiratory depression increases over time.
c. The patient should discuss increasing the dose with the provider.
d. The patient should request the addition of a benzodiazepine to augment pain relief.

C
This patient is developing tolerance, which occurs over time and is evidenced by the need for a larger dose to produce the effect formerly produced by a smaller dose. This patient should be encouraged to request an increased dose. PRN dosing is less effective than scheduled, around-the-clock dosing. The risk of respiratory depression decreases over time as patients develop tolerance to this effect. Benzodiazepines are CNS depressants and should not be given with opioids, because they increase the risk of oversedation.

A woman in labor receives meperidine [Demerol] for pain. The nurse caring for the infant will observe the infant closely for:
a. congenital anomalies.
b. excessive crying and sneezing.
c. respiratory depression.
d. tremors and hyperreflexia.

C
Use of morphine or other opioids during delivery can cause respiratory depression in the neonate, because the drug crosses the placenta. Infants should be monitored for respiratory depression and receive naloxone if needed. Opioids given during delivery do not contribute to birth defects in the newborn. Excessive crying and sneezing and tremors and hyperreflexia are signs of neonatal opioid dependence, which occurs with long-term opioid use by the mother during pregnancy and not with short-term use of these drugs during labor.

A patient who has biliary colic reports a pain level of 8 on a 1 to 10 pain scale with 10 being the most severe pain. The patient has an order for ibuprofen as needed for pain. Which action by the nurse is correct?
a. Administer the ibuprofen as ordered.
b. Contact the provider to discuss nonpharmacologic pain measures.
c. Request an order for meperidine [Demerol].
d. Request an order for morphine sulfate.

C
Opioids can induce spasm of the common bile duct and can cause biliary colic. For patients with existing biliary colic, morphine may intensify the pain. It is important to treat pain, however, and certain opioids, such as meperidine, which cause less smooth muscle spasm, may be given. Ibuprofen is used for mild to moderate pain and is not appropriate for this patient. Nonpharmacologic methods are appropriate when used as adjunctive therapy with an opioid.

A patient is brought to the emergency department by friends, who report finding the patient difficult to awaken. The friends report removing two fentanyl transdermal patches from the patient's arm. On admission to the emergency department, the patient has pinpoint pupils and a respiratory rate of 6 breaths per minute. A few minutes after administration of naloxone, the respiratory rate is 8 breaths per minute and the patient's pupils are dilated. The nurse recognizes these symptoms as signs of:
a. a mild opioid overdose.
b. decreased opioid drug levels.
c. improved ventilation.
d. worsening hypoxia.

D
The classic triad of symptoms of opioid overdose are coma, respiratory depression, and pinpoint pupils. The pupils may dilate as hypoxia worsens, and this symptom, along with continued respiratory depression (fewer than 12 breaths per minute), indicates worsening hypoxia. Fentanyl is a strong opioid, so this is not likely to be a mild overdose, because the patient was wearing two patches. Fentanyl continues to be absorbed even after the patches are removed because of residual drug in the skin, so the drug levels are not likely to be decreasing. The patient does not have improved ventilation, because the respiratory rate is still fewer than 12 breaths per minute.

A patient with chronic pain has been receiving morphine sulfate but now has decreased pain. The prescriber changes the medication to pentazocine [Talwin]. The nurse will monitor the patient for:
a. euphoria.
b. hypotension.
c. respiratory depression.
d. yawning and sweating.

D
Pentazocine is an agonist-antagonist opioid, and when given to a patient who is physically dependent on morphine, it can precipitate withdrawal. Yawning and sweating are early signs of opioid withdrawal. Pentazocine does not produce euphoria, hypotension, or respiratory depression.

A patient will receive buprenorphine [Butrans] as a transdermal patch for pain. What is important to teach this patient about the use of this drug?
a. Avoid prolonged exposure to the sun.
b. Cleanse the site with soap or alcohol.
c. Remove the patch daily at bedtime.
d. Remove hair by shaving before applying the patch.

A
Patients using the buprenorphine transdermal patch should be cautioned against heat, heating pads, hot baths, saunas, and prolonged sun exposure. The skin should be cleaned with water only. The patch should stay on for 7 days before a new patch is applied. Patients should remove hair by clipping, not shaving.

A nurse is preparing a pediatric patient for surgery and is teaching the patient and the child's parents about the use of the patient-controlled analgesia pump. The parents voice concern about their child receiving an overdose of morphine. What will the nurse do?
a. Instruct the parents not to activate the device when their child is sleeping.
b. Reassure the parents that drug overdose is not possible with PCA.
c. Suggest that the child use the PCA sparingly.
d. Tell the patient that the pump can be programmed for PRN dosing only.

A
The nurse should instruct parents not to activate the PCA when their child is sleeping because that can lead to drug overdose. Postoperative pain should be treated appropriately with medications that are effective. Nonopioid medications are not sufficient to treat postoperative pain. Patients should be encouraged to use the PCA as needed so that pain can be controlled in a timely fashion. PRN dosing is not as effective as dosing that is continuous, so a basal dose should be given as well as a PRN dose.

A patient has been taking methadone [Dolophine] for 5 months to overcome an opioid addiction. The nurse should monitor the patient for which of the following electrocardiographic changes?
a. Prolonged QT interval
b. Prolonged P-R interval
c. AV block
d. An elevated QRS complex

A
Methadone prolongs the QT interval. It does not prolong the P-R interval, cause AV block, or produce an elevated QRS complex.

A patient who has developed opioid tolerance will experience which effect?
a. Decreased analgesic effect
b. Decreased constipation
c. Increased euphoria
d. Increased respiratory depression

A
Patients who develop tolerance to opioids will develop tolerance to its analgesic, euphoric, and sedative effects and will also develop tolerance to respiratory depression. Very little tolerance develops to constipation.

A nurse is administering morphine sulfate to a postoperative patient. Which are appropriate routine nursing actions when giving this drug? (Select all that apply.)
a. Counting respirations before and after giving the medication
b. Encouraging physical activity and offering increased fluids
c. Monitoring the patient's blood pressure closely for hypertension
d. Palpating the patient's lower abdomen every 4 to 6 hours
e. Requesting an order for methylnaltrexone [Relistor] to prevent constipation

A, B, D
Respiratory depression, constipation, and urinary retention are common adverse effects of opioid analgesics. It is important to count respirations before giving the drug and periodically thereafter to make sure that respiratory depression has not occurred. Increased physical activity, increased fluid intake, and increased fiber help alleviate constipation. It is important to assess the patient's abdomen and palpate the bladder to make sure that urinary retention has not occurred. Patients taking morphine often experience hypotension, not hypertension. Methylnaltrexone is given as a last resort to treat constipation, because it blocks mu receptors in the intestine.

Which side effects of opioid analgesics can have therapeutic benefits? (Select all that apply.)
a. Biliary colic
b. Cough suppression
c. Suppression of bowel motility
d. Urinary retention
e. Vasodilation

B, C, E
Individual effects of morphine may be beneficial, detrimental, or both. Cough suppression is usually beneficial; suppression of bowel motility and vasodilation can be either beneficial or detrimental. Biliary colic and urinary retention are always detrimental side effects.

A patient taking fluoxetine [Prozac] complains of decreased sexual interest. A prescriber orders a "drug holiday." What teaching by the nurse would best describe a drug holiday?
a. "Cut the tablet in half anytime to reduce the dosage."
b. "Discontinue the drug for 1 week."
c. "Don't take the medication on Friday and Saturday."
d. "Take the drug every other day."

C
Sexual dysfunction may be managed by having the patient take a drug holiday, which involves discontinuing medication on Fridays and Saturdays. Cutting the tablet in half anytime to reduce the dosage is an inappropriate way to manage drug administration effectively. In addition, it does not describe a drug holiday. The patient should not take the drug every other day, nor should it be discontinued for a week at a time, because this would diminish the therapeutic levels of the drug, thereby minimizing the therapeutic effects. In addition, neither of those options describe a drug holiday.

A patient whose spouse has died recently reports feeling down most of each day for the past 2 months. On further questioning, the nurse learns that the patient has quit participating in church and social activities, has difficulty falling asleep, and has lost 5 pounds. The patient reports feeling tired and confused all the time but does not have suicidal thoughts. What does the nurse suspect?
a. Grief and sadness
b. Hypomania
c. Major depression
d. Situational depression

C
This patient has symptoms of major depression, which include depressed mood, loss of pleasure in usual activities, insomnia, weight loss, and feelings of fatigue. For a diagnosis of major depression, these symptoms must be present most of the day, nearly every day, for at least 2 weeks. Grief and sadness and situational depression are common responses to the death of a loved one, but this patient's symptoms go beyond this normal response. This patient does not show signs of hypomania.

A patient is diagnosed with major depression with severe symptoms and begins taking an antidepressant medication. Three weeks after beginning therapy, the patient tells the nurse that the drug is not working. The nurse will counsel this patient to ask the provider about:
a. adding a second medication to complement this drug.
b. changing the medication to one in a different drug class.
c. increasing the dose of this medication.
d. using nondrug therapies to augment the medication.

D
Patients with severe depression benefit more from a combination of drug therapy and psychotherapy than from either component alone, so this patient should ask the provider about nondrug therapies. Once a drug has been selected for treatment, it must be used for 4 to 8 weeks before its efficacy can be assessed. Until a drug has been used at least 1 month without success, it should not be considered a failure. Adding a second medication, changing to a different medication, and increasing the dose of this medication should all be reserved until the current drug is deemed to have failed after at least 4 weeks.

A young adult patient has been taking an antidepressant medication for several weeks and reports having increased thoughts of suicide. The nurse questions further and learns that the patient has attempted suicide more than once in the past. The patient identifies a concrete plan for committing suicide. The nurse will contact the provider to discuss:
a. changing the medication to another drug class.
b. discontinuing the medication immediately.
c. hospitalizing the patient for closer monitoring.
d. requiring more frequent clinic visits for this patient.

C
Patients with depression often think of suicide, and during treatment with antidepressants, these thoughts often increase for a time. Patients whose risk of suicide is especially high should be hospitalized. All antidepressants carry this risk, so changing medication is not recommended. Discontinuing the medication is not recommended. More frequent clinic visits are recommended for patients with a low to moderate risk of suicide.

A patient has been taking fluoxetine [Prozac] for 2 years and reports feeling cured of depression. The nurse learns that the patient is sleeping well, participates in usual activities, and feels upbeat and energetic most of the time. The patient's weight has returned to normal. The patient reports last having symptoms of depression at least 9 months ago. What will the nurse tell this patient?
a. Indefinite drug therapy is necessary to maintain remission.
b. Discuss gradual withdrawal of the medication with the provider.
c. Stop the drug while remaining alert for the return of symptoms.
d. Take a drug holiday to see whether symptoms recur.

B
Abrupt discontinuation of selective serotonin reuptake inhibitors (SSRIs) can cause a withdrawal syndrome, so these drugs should be withdrawn gradually. After symptoms are in remission, treatment should continue for 4 to 9 months to prevent relapse; these drugs are not taken indefinitely. It is incorrect to counsel the patient to stop taking the drug without tapering it. Drug holidays are used to minimize sexual dysfunction side effects, not to monitor symptoms.

A patient has been taking an SSRI antidepressant for major depression and reports having headaches and jaw pain. What will the nurse tell the patient?
a. This represents an irreversible extrapyramidal side effect.
b. Discuss discontinuing the antidepressant with the provider.
c. Discuss these symptoms with a dentist.
d. Try stress-relieving methods and relaxation techniques.

C
Bruxism is a side effect of SSRIs and can result in headache and jaw pain. Patients who experience these signs should be evaluated for bruxism by a dentist, who can determine whether the patient may benefit from use of a mouth guard. Headache and jaw pain are not signs of extrapyramidal side effects. Discontinuing the antidepressant is not indicated, because depression may return. Stress-relieving methods and relaxation techniques are not recommended, because these symptoms occur during sleep.

A patient who has been taking a monoamine oxidase inhibitor (MAOI) for depression for several months tells the provider that the medication has not helped with symptoms. The provider plans to switch the patient to an SSRI. The nurse will teach this patient to:
a. start taking the SSRI and stop the MAOI when symptoms improve.
b. start taking the SSRI and then gradually withdraw the MAOI.
c. stop taking the MAOI and wait 5 weeks before starting the SSRI.
d. stop taking the MAOI 2 weeks before starting the SSRI.

D
MAOIs increase 5-HT availability, thus greatly increasing the risk of serotonin syndrome. MAOIs should be withdrawn at least 14 days before an SSRI is started. An SSRI should never be given at the same time as an MAOI. It is not necessary to wait 5 weeks before starting an SSRI.

A neonate is born to a patient who reports taking venlafaxine [Effexor XR]. The nurse caring for the infant will observe the infant for:
a. irritability, tremor, and respiratory distress.
b. poor appetite and disturbed sleeping patterns.
c. serotonin syndrome.
d. sustained mydriasis.

A
Use of venlafaxine late in pregnancy can result in a neonatal withdrawal syndrome characterized by irritability, abnormal crying, tremor, respiratory distress, and possibly seizures. Poor appetite and disturbed sleep are not part of this withdrawal syndrome. Serotonin syndrome is not likely. Sustained mydriasis occurs as an adverse effect in patients taking the drug.

A provider has indicated that a serotonin/norepinephrine reuptake inhibitor (SNRI) will be prescribed for a patient who is experiencing major depression. When conducting a pretreatment health history, the nurse learns that the patient has a recent history of alcohol abuse. Which SNRI would be contraindicated for this patient?
a. Desvenlafaxine [Pristiq]
b. Duloxetine [Cymbalta]
c. Escitalopram [Lexapro]
d. Venlafaxine [Effexor SR]

B
Duloxetine can cause elevation of serum transaminases, indicating liver disease. Patients with existing liver disease or alcohol abuse should not receive this drug. This side effect is not likely with desvenlafaxine or venlafaxine. Escitalopram is an SSRI.

A nurse is teaching a group of nursing students about tricyclic antidepressants (TCAs). Which statement by a student indicates a need for further teaching?
a. "TCAs block receptors for histamine, acetylcholine, and norepinephrine."
b. "TCAs block the uptake of norepinephrine and 5-HT."
c. "TCAs have many side effects, but none of them are serious."
d. "TCAs have other uses than for depression."

C
TCAs can adversely affect cardiac function, and these effects can be serious in patients with preexisting cardiac impairment. TCAs do block receptors for histamine, acetylcholine, and norepinephrine; they do block the uptake of norepinephrine and 5-HT; and they do have other uses besides depression.

An older adult patient who is to begin taking imipramine [Tofranil] asks the nurse when the drug should be taken. The nurse will instruct the patient to:
a. divide the daily dose into two equal doses 12 hours apart.
b. take the entire dose at bedtime to minimize sedative effects.
c. take the medication once daily in the late afternoon.
d. take the medication once daily in the morning.

A
For many patients, taking the entire dose of a TCA at bedtime is advantageous for facilitating adherence, minimizing daytime sedation, and promoting sleep. However, older adult patients are at greater risk for cardiotoxicity and may experience intolerable effects on the heart if the entire dose is taken at once; therefore, twice-daily dosing is recommended in the elderly.

A patient who has fibromyalgia is diagnosed with major depression. The provider orders a TCA. The nurse will teach this patient to:
a. avoid foods containing tyrosine.
b. consume alcohol in moderation.
c. sit or lie down when feeling lightheaded.
d. take the medication in the morning.

C
Orthostatic hypotension can occur with TCAs. Patients should be advised to sit or lie down if they feel lightheaded to prevent falls. Foods containing tyrosine cause adverse effects in patients taking MAOIs. Patients taking TCAs should be counseled to avoid all alcohol. Because TCAs cause sedation, the medication should be taken at bedtime.

A patient taking an MAOI is seen in the clinic with a blood pressure of 170/96 mm Hg. What will the nurse ask this patient?
a. Whether any antihypertensive medications are used
b. Whether the patient drinks grapefruit juice
c. To list all foods eaten that day
d. Whether SSRIs are taken in addition to the MAOI

C
Patients taking an MAOI should be counseled to follow strict dietary restrictions and to avoid all foods containing tyramine. Patients who consume such foods when taking an MAOI experience a hypertensive episode. Antihypertensive medications, given with an MAOI, will result in hypotension. Grapefruit juice does not alter the metabolism of an MAOI. SSRIs and MAOIs, when administered together, cause a serotonin syndrome

A patient who has been taking an SSRI tells the nurse that the drug has caused reduced sexual performance, weight gain, and sedation. The nurse will suggest that the patient ask the provider about using which drug?
a. Bupropion [Wellbutrin]
b. Imipramine [Tofranil]
c. Isocarboxazid [Marplan]
d. Trazodone [Oleptro]

A
Bupropion does not cause weight gain, sexual dysfunction, or sedation, so it may be a useful adjunct to or substitute for an SSRI when those side effects become intolerable. Imipramine causes sedation. Isocarboxazid is an MAOI and is not used unless other drugs are ineffective. Trazodone causes sedation.

A first-time parent of a 6-week-old infant tells the nurse that she feels anxious and sad, cries a lot, and has difficulty sleeping. What will the nurse do?
a. Ask her to complete the Edinburgh Postnatal Depression Scale.
b. Reassure her that the "baby blues" are normal after childbirth.
c. Suggest that she get more sleep and try to increase her activity.
d. Suggest that she talk to her provider about using an SSRI.

A
Women who experience depressive symptoms after childbirth can be screened using a quick test: the Edinburgh Postnatal Depression Scale, which may be administered 6 to 8 weeks after delivery. Reassuring her that her feelings are normal does not acknowledge her concerns; also, without objective screening, this reassurance may not be warranted. Increased sleep and activity may help, but screening is necessary to determine the severity of the depression. Until the patient is diagnosed as having postpartum depression, an SSRI is not indicated.

A woman who is nursing a newborn develops postpartum depression and her provider orders sertraline [Zoloft] to treat her symptoms. The patient is concerned about the safety of this medication for her infant. What will the nurse tell her about this medication?
a. To stop nursing while taking the medication
b. To expect symptoms of colic and poor weight gain in the baby
c. That sertraline is safer than other antidepressants for nursing mothers
d. To ask her provider about switching to fluoxetine [Prozac] instead

C
Sertraline is safer than other antidepressants for nursing women when used to treat postpartum depression. It is not necessary for her to stop nursing while taking the medication. Colic and poor weight gain occur with fluoxetine, which is not safe for nursing mothers.

A patient is brought to the emergency department after taking a handful of TCA pills. The nurse will expect to provide what when caring for this patient? (Select all that apply.)
a. Cardiac monitoring
b. Cholinesterase inhibitors
c. Gastric lavage and activated charcoal
d. Sedative medications
e. Procainamide

A, B, C
Patients who overdose with a TCA should have cardiac monitoring, because cardiac side effects can occur. Cholinesterase inhibitors are given to counteract anticholinergic side effects. Gastric lavage followed by activated charcoal can reduce absorption of the TCA. Sedative drugs would only increase the sedative effects of the TCA. Procainamide causes cardiac depression and is not recommended to treat TCA dysrhythmias.

Which patients are candidates for MAOIs? (Select all that apply.)
a. Patients who have not responded to SSRIs and TCAs
b. Patients with atypical depression
c. Patients with bulimia nervosa
d. Patients with hypotension
e. Patients with postpartum depression

A, B, C
Patients who have not responded to SSRIs or TCAs, patients with atypical depression, and patients with bulimia nervosa are candidates for MAOIs. MAOIs contribute to hypotension and therefore are contraindicated in patients with hypotension. MAOIs are not recommended for the treatment of postpartum depression.

A nurse is discussing the use of benzodiazepines as sedative-hypnotic agents with a group of nursing students. A student asks about the actions of these drugs in the central nervous system. The nurse makes which correct statement?
a. "Benzodiazepines affect the hippocampus and the cerebral cortex to cause anterograde amnesia."
b. "Benzodiazepines depress neuronal functions by acting at a single site in the brain."
c. "Benzodiazepines induce muscle relaxation by acting on sites outside the central nervous system."
d. "Benzodiazepines promote sleep through effects on the limbic system."

A
All beneficial and most adverse effects of benzodiazepines occur from depressant actions in the central nervous system (CNS); the various effects depend on the site of action. Anterograde amnesia is the result of effects in the hippocampus and the cerebral cortex. Benzodiazepines act at multiple sites in the CNS. Muscle relaxant effects are the result of actions on supraspinal motor areas in the CNS. Benzodiazepines promote sleep through effects on cortical areas and on the sleep-wakefulness "clock."

A patient who has been using secobarbital for several months to treat insomnia tells the nurse that the prescriber has said the prescription will be changed to temazepam [Restoril] because it is safer. The patient asks why this agent is safer. The nurse is correct in telling the patient that temazepam:
a. does not depress the central nervous system.
b. shows no respiratory depression, even in toxic doses.
c. mimics the actions of a central nervous system inhibitory neurotransmitter.
d. potentiates endogenous gamma-aminobutyric acid (GABA) producing a finite CNS depression.

D
Benzodiazepines potentiate the actions of GABA, and because the amount of GABA in the CNS is finite, these drugs' depressive effect on the CNS is limited. Benzodiazepines depress the CNS but not to the extent that barbiturates do. Benzodiazepines are weak respiratory depressants at therapeutic doses and moderate respiratory depressants at toxic doses. Barbiturates mimic GABA; therefore, because they produce CNS depression, this effect is limited only by the amount of barbiturate administered.

A hospitalized patient who is given one dose of flurazepam continues to show drowsiness the next day. A nursing student asks the nurse the reason for this, because the drug's half-life is only 2 to 3 hours. Which response by the nurse is correct?
a. "Benzodiazepines commonly cause residual effects lasting into the day after the dose is given."
b. "The patient is having a paradoxical reaction to this medication."
c. "This patient must have developed a previous tolerance to benzodiazepines."
d. "When this drug is metabolized, the resulting compound has longer-lasting effects."

D
Flurazepam has a half-life of 2 to 3 hours; however, its metabolite has a long half-life, so giving the drug results in long-lasting effects. Barbiturates, not benzodiazepines, are commonly associated with residual, or hangover, effects. A paradoxical reaction to a sedative would manifest as insomnia, euphoria, and excitation, not drowsiness. Tolerance means that the patient would need increased amounts of a drug to get the desired effects and would not have prolonged effects of the medication.

A patient who is experiencing alcohol withdrawal is given a benzodiazepine. The nurse understands that this drug is effective because:
a. the alcohol does not interact with the benzodiazepine.
b. the benzodiazepine potentiates alcohol withdrawal symptoms.
c. the benzodiazepine relieves muscle spasms and spasticity.
d. the patient has a cross-dependence to the benzodiazepine.

D
Benzodiazepines are given to ease withdrawal from alcohol because of cross-dependence with these drugs and alcohol, enabling the benzodiazepine to suppress withdrawal symptoms. Alcohol and benzodiazepines can potentiate one another. The benzodiazepine does not potentiate withdrawal symptoms. Benzodiazepines relieve muscle spasms, but this is not why they are given for alcohol withdrawal.

A patient takes temazepam [Restoril] for insomnia. The patient tells the nurse that a recent telephone bill lists several calls to friends that the patient does not remember making. What will the nurse do?
a. Ask the patient about any alcohol consumption in conjunction with the benzodiazepine.
b. Contact the prescriber to request an order for a benzodiazepine with a shorter duration.
c. Reassure the patient that this is most likely caused by a paradoxical reaction to the benzodiazepine.
d. Tell the patient that this is an example of anterograde amnesia, which is an expected effect of the benzodiazepine.

A
This patient is describing complex sleep-related behavior, which occurs when patients carry out complex behaviors while taking benzodiazepines but have no memory of their actions. These actions can occur with normal doses but are more likely with excessive doses or when benzodiazepines are combined with alcohol or other CNS depressants, so the nurse is correct in evaluating this possibility. The duration of the benzodiazepine does not contribute to this phenomenon. Paradoxical effects of benzodiazepines include insomnia, excitation, euphoria, anxiety, and rage. Anterograde amnesia occurs when patients have impaired recall of events that occur after dosing.

A patient has been taking high doses of clorazepate [Tranxene] for several months for an anxiety disorder. The nurse assessing the patient observes that the patient is agitated, euphoric, and anxious. What will the nurse do?
a. Double-check the chart to make sure the last dose was given.
b. Request an order for a longer-acting benzodiazepine.
c. Suspect a possible paradoxical reaction to the clorazepate.
d. Withhold the next dose until a drug level can be drawn.

C
Patients taking benzodiazepines for anxiety sometimes develop paradoxical responses to the drug, which include insomnia, excitation, euphoria, heightened anxiety, and rage. A missed dose would trigger withdrawal symptoms, which would include anxiety, insomnia, sweating, tremors, and dizziness. Because this is a paradoxical reaction to the drug, a longer-acting drug would make the symptoms worse. This is not caused by overdose, which would manifest as drowsiness, lethargy, and confusion, so a drug level is not warranted.

A patient in the emergency department is given intravenous diazepam [Valium] for seizures. When the seizures stop, the nurse notes that the patient is lethargic and confused and has a respiratory rate of 10 breaths per minute. The nurse will expect to administer which of the following?
a. Flumazenil [Romazicon]
b. Gastric lavage
c. Respiratory support
d. Toxicology testing

C
When benzodiazepines are administered IV, severe effects, including profound hypotension, respiratory arrest, and cardiac arrest, can occur. Respiration should be monitored, and the airway must be managed if necessary. Flumazenil [Romazicon] is a competitive benzodiazepine receptor antagonist and is used to reverse the sedative effects but may not reverse respiratory depression. Gastric lavage would not be effective, because the benzodiazepine has been given IV. Without further indication of the ingestion of other drugs, toxicology testing is not a priority.

A patient is brought to the emergency department by friends, who say that they were at a party where alcohol and a mix of barbiturates and benzodiazepines were all available. They tell the nurse that the patient was among the first to arrive at the party, which started several hours ago. The patient is nonresponsive and has pinpoint pupils and respirations of 6 breaths per minute. After oxygen has been administered, the nurse should prepare the patient for which intervention?
a. A central nervous system stimulant and IV fluids
b. Activated charcoal and flumazenil [Romazicon]
c. Maintaining adequate oxygenation to the brain
d. Naloxone [Narcan] and a cathartic

C
Because time has elapsed, enough medication is present in the system to warrant treatment for systemic effects. A central nervous system stimulant is contraindicated, and intravenous fluids do not address the overdose. Although activated charcoal may assist in absorption of medication in the gut, flumazenil will be effective only for the benzodiazepines. Naloxone, a narcotic antagonist, is not effective for barbiturates and benzodiazepines.

A patient who travels frequently for business reports occasional instances of being unable to fall asleep. The patient tells the nurse that job demands require staying up late and then getting up early for meetings. The nurse expects that the provider will prescribe which medication for this patient?
a. Flurazepam
b. Trazodone [Desyrel]
c. Zaleplon [Sonata]
d. Zolpidem [Ambien

C
Zaleplon [Sonata] works well for people who have trouble falling asleep and, because of its short duration of action, can be taken late at night without causing a hangover or next-day sedation early in the morning. Zolpidem [Ambien] has a longer duration and is a good choice for patients who have difficulty maintaining sleep. Flurazepam has a long duration of action. Trazodone causes daytime grogginess.

A patient with a new-onset seizure disorder receives a prescription for phenobarbital. The patient reports being concerned about the sedative side effects of this drug. Which response by the nurse is correct?
a. "Phenobarbital doses for seizures are nonsedating."
b. "This is a short-acting barbiturate, so sedation wears off quickly."
c. "Tolerance to the sedative effects will develop in a few weeks."
d. "You may actually experience paradoxical effects of euphoria."

A
Phenobarbital and mephobarbital are used for seizure disorders and suppress seizures at doses that are nonsedative. Phenobarbital is a long-acting barbiturate. At therapeutic doses, sedative effects do not occur. Paradoxical drug effects are associated with benzodiazepines and in older adults and debilitated patients with barbiturates.

A patient with a history of depression and suicidal ideation is taking fluoxetine [Prozac]. The patient reports difficulty maintaining sleep and is prescribed secobarbital [Seconal] as a sedative-hypnotic. The nurse preparing this patient for discharge from the hospital will:
a. contact the provider to suggest an order for ramelteon [Rozerem].
b. instruct the patient to use alcohol in moderation.
c. request an order to change to trazodone [Desyrel] for sleep.
d. suggest that the patient try alternative remedies for sleep.

C
Trazodone is an atypical antidepressant with sedative actions and can be used to prolong sleep duration. It is useful for treating insomnia related to antidepressants such as Prozac. Ramelteon is not a drug of choice to treat patients who have difficulty maintaining sleep. Patients who are depressed or at increased risk for suicide should not take barbiturates, because overdose can readily cause death. Alcohol is contraindicated when taking barbiturates. Alternative remedies have not shown effectiveness in treating insomnia.

A nurse is obtaining a health history from an older adult patient in an outpatient clinic. The patient reports chronic difficulty falling asleep and staying asleep. The nurse knows that the best treatment for this patient will be:
a. alternative medications.
b. improved sleep hygiene.
c. short-term barbiturates.
d. triazolam [Halcion].

B
Research has shown that cognitive behavioral therapy is superior to drug therapy for short-term and long-term management of chronic insomnia in older adults. Alternative remedies have not been proven effective. Barbiturates may elicit paradoxical effects in elderly patients. Triazolam does not help to maintain sleep.

A patient complains of chronic insomnia and reports being tired of being tired all the time. The patient is reluctant to try pharmacologic remedies and asks the nurse what to do. What will the nurse suggest?
a. "Eat a large meal in the evening to induce drowsiness."
b. "Get out of bed for a while if you can't fall asleep."
c. "Have a glass of wine at bedtime to relax."
d. "Take a short nap early in the afternoon every day."

B
Rules for sleep fitness recommend getting out of bed if unable to fall asleep in 20 minutes and doing something relaxing and then returning to bed when drowsy. Eating a large meal will increase insomnia. Drinking alcohol helps some people to fall asleep but causes fragmented sleep. Taking a nap reduces feelings of drowsiness at bedtime.

A nurse recognizes that the actions of benzodiazepines include which findings? (Select all that apply.)
a. Sleep deprivation
b. Relief of general anxiety
c. Suppression of seizures and/or seizure activity
d. Development of tardive dyskinesia
e. Increase in muscle spasms

B, C
Benzodiazepines are indicated to relieve the symptoms of general anxiety and to suppress the central nervous system, thereby suppressing seizures and/or seizure activity. Benzodiazepines cause sleepiness, not sleep deprivation. Benzodiazepines do not cause tardive dyskinesia. Benzodiazepines relax muscles; they do not increase muscle spasms.

Which sedative-hypnotics are useful for both difficulty falling asleep and difficulty maintaining sleep? (Select all that apply.)
a. Eszopiclone [Lunesta]
b. Flurazepam [Dalmane]
c. Temazepam [Restoril]
d. Triazolam [Halcion]
e. Extended-release zolpidem [Ambien CR]

A, B, E
Eszopiclone [Lunesta], flurazepam, and extended-release zolpidem [Ambien CR] help with difficulty falling asleep and difficulty maintaining sleep. Temazepam is useful for maintaining sleep only. Triazolam helps with difficulty falling asleep but does not maintain sleep.

A patient is brought to the emergency department with shortness of breath, a respiratory rate of 30 breaths per minute, intercostal retractions, and frothy, pink sputum. The nurse caring for this patient will expect to administer which drug?
a. Furosemide [Lasix]
b. Hydrochlorothiazide [HydroDIURIL]
c. Mannitol [Osmitrol]
d. Spironolactone [Aldactone]

A
Furosemide, a potent diuretic, is used when rapid or massive mobilization of fluids is needed. This patient shows severe signs of congestive heart failure with respiratory distress and pulmonary edema and needs immediate mobilization of fluid. Hydrochlorothiazide and spironolactone are not indicated for pulmonary edema, because their diuretic effects are less rapid. Mannitol is indicated for patients with increased intracranial pressure and must be discontinued immediately if signs of pulmonary congestion or heart failure occur.

A patient who is taking digoxin is admitted to the hospital for treatment of congestive heart failure. The prescriber has ordered furosemide [Lasix]. The nurse notes an irregular heart rate of 86 beats per minute, a respiratory rate of 22 breaths per minute, and a blood pressure of 130/82 mm Hg. The nurse auscultates crackles in both lungs. Which laboratory value causes the nurse the most concern?
a. Blood glucose level of 120 mg/dL
b. Oxygen saturation of 90%
c. Potassium level of 3.5 mEq/L
d. Sodium level of 140 mEq/L

C
This patient has an irregular, rapid heartbeat that might be caused by a dysrhythmia. This patient's serum potassium level is low, which can trigger fatal dysrhythmias, especially in patients taking digoxin. Furosemide contributes to loss of potassium through its effects on the distal nephron. Potassium-sparing diuretics often are used in conjunction with furosemide to prevent this complication. This patient's serum glucose and sodium levels are normal and of no concern at this point, although they can be affected by furosemide. The oxygen saturation is somewhat low and needs to be monitored, although it may improve with diuresis.

A patient has 2+ pitting edema of the lower extremities bilaterally. Auscultation of the lungs reveals crackles bilaterally, and the serum potassium level is 6 mEq/L. Which diuretic agent ordered by the prescriber should the nurse question?
a. Bumetanide [Bumex]
b. Furosemide [Lasix]
c. Spironolactone [Aldactone]
d. Hydrochlorothiazide [HydroDIURIL]

C
Spironolactone is a non-potassium-wasting diuretic; therefore, if the patient has a serum potassium level of 6 mEq/L, indicating hyperkalemia, an order for this drug should be questioned. Bumetanide, furosemide, and hydrochlorothiazide are potassium-wasting diuretics and would be appropriate to administer in a patient with hyperkalemia.

A nurse preparing to administer morning medications notes that a patient with a history of hypertension has been prescribed spironolactone [Aldactone]. The nurse assesses the patient and notes dyspnea, bilateral crackles, and pitting edema in both feet. Which intervention is appropriate?
a. Administer the medications as ordered.
b. Ask the patient about the use of salt substitutes.
c. Contact the provider to request an order for serum electrolytes.
d. Request an order for furosemide [Lasix].

D
Spironolactone takes up to 48 hours for its effects to develop, so it should not be used when the patient needs immediate diuresis. This patient has shortness of breath, crackles, and edema and needs a short-acting diuretic, such as furosemide. Asking the patient about the use of salt substitutes is not indicated. The patient does not need assessment of serum electrolytes.

A patient who was in a motor vehicle accident sustained a severe head injury and is brought into the emergency department. The provider orders intravenous mannitol [Osmitrol]. The nurse knows that this is given to:
a. reduce intracranial pressure.
b. reduce renal perfusion.
c. reduce peripheral edema.
d. restore extracellular fluid.

A
Mannitol is an osmotic diuretic that is used to reduce intracranial pressure by relieving cerebral edema. The presence of mannitol in blood vessels in the brain creates an osmotic force that draws edematous fluid from the brain into the blood. Mannitol can also be used to increase renal perfusion. It can cause peripheral edema and is not used to restore extracellular fluid.

A patient is taking gentamicin [Garamycin] and furosemide [Lasix]. The nurse should counsel this patient to report which symptom?
a. Frequent nocturia
b. Headaches
c. Ringing in the ears
d. Urinary retention

C
Patients taking furosemide should be advised that the risk of furosemide-induced hearing loss can be increased when other ototoxic drugs, such as gentamicin, are also taken. Patients should be told to report tinnitus, dizziness, or hearing loss. Nocturia may be an expected effect of furosemide. Headaches are not likely to occur with concomitant use of gentamicin and furosemide. Urinary retention is not an expected side effect.

An older adult patient with congestive heart failure develops crackles in both lungs and pitting edema of all extremities. The physician orders hydrochlorothiazide [HydroDIURIL]. Before administering this medication, the nurse reviews the patient's chart. Which laboratory value causes the nurse the most concern?
a. Elevated creatinine clearance
b. Elevated serum potassium level
c. Normal blood glucose level
d. Low levels of low-density lipoprotein (LDL) cholesterol

A
Hydrochlorothiazide should not be given to patients with severe renal impairment; therefore, an elevated creatinine clearance would cause the most concern. Thiazide diuretics are potassium-wasting drugs and thus may actually improve the patient's potassium level. Thiazides may elevate the serum glucose level in diabetic patients. Thiazides increase LDL cholesterol; however, this patient's levels are low, so this is not a risk.

A patient with chronic congestive heart failure has repeated hospitalizations in spite of ongoing treatment with hydrochlorothiazide [HydroDIURIL] and digoxin. The prescriber has ordered spironolactone [Aldactone] to be added to this patient's drug regimen, and the nurse provides education about this medication. Which statement by the patient indicates understanding of the teaching?
a. "I can expect improvement within a few hours after taking this drug."
b. "I need to stop taking potassium supplements."
c. "I should use salt substitutes to prevent toxic side effects."
d. "I should watch closely for dehydration."

B
Spironolactone is a potassium-sparing diuretic used to counter the potassium-wasting effects of hydrochlorothiazides. Patients taking potassium supplements are at risk for hyperkalemia when taking this medication, so they should be advised to stop the supplements. Spironolactone takes up to 48 hours to have effects. Salt substitutes contain high levels of potassium and are contraindicated. Spironolactone is a weak diuretic, so the risk of dehydration is not increased.

Besides having diuretic effects for patients with congestive heart failure, thiazides are also used to treat what? (Select all that apply.)
a. Diabetes insipidus
b. Hepatic failure
c. Increased intracranial pressure
d. Intraocular pressure
e. Postmenopausal osteoporosis

A, B, E
Thiazide diuretics have the paradoxical effect of reducing urine output in patients with diabetes insipidus. They can also be used to mobilize edema associated with liver disease. They promote tubular reabsorption of calcium, which may reduce the risk of osteoporosis in postmenopausal women. Mannitol is used to treat edema that causes increased intracranial pressure and intraocular pressure.

A patient who is a chronic alcoholic is admitted to the hospital. Admission laboratory work reveals a magnesium level of 1.2 mEq/L. The prescriber orders intravenous magnesium sulfate in a 10% solution at a rate of 10 mL/min. What will the nurse do?
a. Administer the IV dose as ordered and have calcium gluconate on hand.
b. Administer the IV dose and make preparations for mechanical ventilation.
c. Hold the IV dose until the infusion rate has been clarified with the provider.
d. Request an order for renal function tests before administering the IV dose.

C
This patient has hypomagnesemia and should be given magnesium sulfate intravenously. The percent of magnesium in solution is correct; however, magnesium should not be infused faster than 1.5 mL/min, so the nurse is correct to question the rate of infusion. Calcium gluconate should be available when magnesium is given, but the nurse needs to clarify the rate of infusion first. Mechanical ventilation is necessary with excessive magnesium. Renal function tests are not indicated.

A patient who was injured at home is brought to the emergency department. The nurse caring for this patient notes a respiratory rate of 32 breaths per minute and a heart rate of 90 beats per minute. The injuries are minor, but the patient is inconsolable and hysterical. The nurse expects that initial management will include:
a. administering a gas mixture of 5% carbon dioxide (CO2).
b. providing 100% oxygen via nasal cannula.
c. giving sodium bicarbonate IV.
d. providing sedatives to calm the patient.

A
The patient is at risk for respiratory alkalosis as a result of hyperventilation, and giving the patient a gas mixture containing CO2 will help correct the alkalosis. Administering oxygen would worsen the problem. Sodium bicarbonate is given to correct metabolic acidosis. Sedatives may be necessary if initial measures fail.

A child who ingested a handful of aspirin tablets from a medicine cabinet at home is brought to the emergency department. The nurse caring for the child notes a respiratory rate of 48 breaths per minute. The nurse understands that this child's respiratory rate is the result of the body's attempt to compensate for:
a. metabolic acidosis.
b. metabolic alkalosis.
c. respiratory acidosis.
d. respiratory alkalosis.

A
Metabolic acidosis can result from the ingestion of aspirin. The body responds by hyperventilating to reduce CO2, which represents volatile carbonic acid, and raise pH. This child has a rapid respiratory rate in response to metabolic acidosis. In patients with metabolic alkalosis, the body responds with hypoventilation in an effort to increase the CO2 level. Patients with respiratory acidosis usually have retention of CO2 secondary to hypoventilation, and compensation is the result of retention of bicarbonate by the kidneys, which is a slow process. Respiratory alkalosis is caused by hyperventilation; treatment involves having the patient rebreathe CO2 or administering sedatives.

A patient with congestive heart failure is admitted to the hospital. During the admission assessment, the nurse learns that the patient is taking a thiazide diuretic. The nurse notes that the admission electrolyte levels include a sodium level of 142 mEq/L, a chloride level of 95 mEq/L, and a potassium level of 3 mEq/L. The prescriber has ordered digoxin to be given immediately. What will the nurse do initially?
a. Give the digoxin and maintain close cardiac monitoring.
b. Hold the digoxin and report the laboratory values to the provider.
c. Hold the thiazide diuretic and give the digoxin.
d. Request an order for an electrocardiogram (ECG).

B
Potassium depletion is common with thiazide diuretics, and hypokalemia is especially dangerous for patients receiving digoxin, because the drug can precipitate a fatal dysrhythmia and digoxin toxicity. The provider should be notified of the serum potassium level so that it can be corrected before the digoxin is administered. Giving the digoxin could produce a fatal adverse effect, so this is not an appropriate course of action. Holding the thiazide diuretic will not correct the potassium deficiency. An ECG is not the initial priority.

A patient collapses after running a marathon on a hot day and is brought to the emergency department to be treated for dehydration. The nurse will expect to provide which therapy?
a. Intravenous hypertonic fluids given slowly over several hours
b. Intravenous hypotonic fluids administered in stages
c. Intravenous isotonic fluids given as a rapid bolus
d. Oral electrolyte replacement fluids with potassium

A patient collapses after running a marathon on a hot day and is brought to the emergency department to be treated for dehydration. The nurse will expect to provide which therapy?
a. Intravenous hypertonic fluids given slowly over several hours
b. Intravenous hypotonic fluids administered in stages
c. Intravenous isotonic fluids given as a rapid bolus
d. Oral electrolyte replacement fluids with potassium

A nurse is caring for a child whose respirations are shallow and marked by a prolonged expiratory phase. The nurse auscultates wheezes and poor air movement bilaterally. The child's respiratory rate is 26 breaths per minute, and the oxygen saturation is 89%. What does the nurse suspect?
a. Metabolic acidosis
b. Metabolic alkalosis
c. Respiratory acidosis
d. Respiratory alkalosis

C
Respiratory acidosis results from retention of CO2 secondary to hypoventilation caused either by depression of the medullary respiratory center in the central nervous system (CNS) or by a pathologic lung condition, such as asthma. This child has shallow respirations with evidence of airway obstruction and poor ventilation. Metabolic acidosis occurs in chronic renal failure, loss of bicarbonate with severe diarrhea, metabolic disorders, and ingestion of acids such as salicylates; hyperventilation is a compensatory mechanism. Metabolic alkalosis is usually caused by excessive loss of gastric acid or by ingestion of alkalinizing salts; hypoventilation is a compensatory mechanism. Respiratory alkalosis is produced by hyperventilation and can occur in any condition that increases the respiratory rate and depth.

A nurse is caring for a postoperative patient who has a nasogastric tube with continuous suction. The nurse notes that the patient has shallow respirations and suspects that this patient has developed:
a. metabolic acidosis.
b. metabolic alkalosis.
c. respiratory acidosis.
d. respiratory alkalosis.

B
Metabolic alkalosis occurs with excessive loss of acid, such as gastric acid, or an excessive increase in alkalinizing salts. The body compensates for metabolic alkalosis by hypoventilating in an attempt to retain CO2. Metabolic acidosis is usually caused by ingestion of acids or excessive loss of bicarbonate and is compensated by hyperventilation. Respiratory acidosis results from hypoventilation. Respiratory alkalosis is the result of hyperventilation.

While performing an admission assessment on a patient, the nurse learns that the patient is taking furosemide [Lasix], digoxin, and spironolactone [Aldactone]. A diet history reveals the use of salt substitutes. The patient is confused and dyspneic and complains of hand and foot tingling. Which is an appropriate nursing action for this patient?
a. Contact the provider to request orders for an electrocardiogram and serum electrolyte levels.
b. Evaluate the patient's urine output and request an order for intravenous potassium.
c. Hold the next dose of furosemide and request an order for intravenous magnesium sulfate.
d. Request an order for intravenous insulin to help this patient regulate extracellular potassium.

A
This patient is taking a potassium-sparing diuretic and is ingesting dietary potassium in salt substitutes. The patient shows signs of hyperkalemia: confusion, shortness of breath, and tingling of the hands and feet. The cardiac effects can be fatal, especially if a patient also is taking digoxin. The most appropriate first action would be to obtain an ECG and serum electrolyte levels to evaluate the extent of the patient's hyperkalemia. The patient does not need increased potassium. Furosemide is a potassium-wasting diuretic and would be helpful. Magnesium sulfate is not indicated. Until the patient's status has been assessed further, intravenous insulin is not indicated.

A patient arrives in the emergency department complaining of muscle weakness and drowsiness. The nurse notes a heart rate of 80 beats per minute, a respiratory rate of 18 breaths per minute, and a blood pressure of 90/50 mm Hg. The electrocardiogram reveals an abnormal rhythm. The nurse will question the patient about which over-the-counter medication?
a. Antacids
b. Aspirin
c. Laxatives
d. Potassium supplements

A
Hypermagnesemia can occur when patients are taking magnesium-containing antacids. Symptoms include muscle weakness, sedation, hypotension, and ECG changes. Aspirin would cause metabolic acidosis. Laxatives can contribute to hypokalemia. Potassium supplements would cause hyperkalemia.

A patient arrives in the emergency department after becoming dehydrated. Based on the patient's history, the provider determines that isotonic dehydration has occurred. Which solution will the nurse expect to infuse to treat this patient?
a. 0.45% sodium chloride in sterile water
b. 0.9% sodium chloride in sterile water
c. 3% sodium chloride in sterile water
d. 5% dextrose solution

B
Isotonic dehydration should be treated with an isotonic solution of 0.9% NaCl in sterile water. A 0.45% solution or 5% dextrose is used to treat hypertonic dehydration. A 3% NaCl solution is used to treat hypotonic dehydration.

A patient is admitted to the hospital after several days of vomiting and diarrhea. After an initial bolus of isotonic (0.9%) sodium chloride solution, the prescriber orders dextrose 5% in normal saline (D5NS) with 20 mEq potassium chloride to infuse at a maintenance rate. What should the nurse review before implementing this order? (Select all that apply.)
a. Electrocardiogram
b. Arterial blood gas levels
c. Serum electrolyte levels
d. Serum glucose level
e. Urine output

A, C, E
Patients receiving potassium should be monitored for cardiovascular toxicity; an ECG before and during administration can help monitor for this adverse effect. Serum electrolyte levels should be reviewed to make sure the patient is not already hyperkalemic. Because potassium is excreted via the kidneys, it is important to determine that renal function is intact. Intravenous potassium should never be given if the patient has not voided. Patients who are hyperkalemic can be treated with sodium bicarbonate to increase pH and insulin to promote uptake of potassium by cells, but it is not necessary to evaluate the blood gas or glucose levels before administering potassium.

Which order for potassium (KCl) would the nurse question? (Select all that apply.)
a. NS with 20 mEq KCl to start after patient voids
b. NS with 60 mEq KCl for a patient with a serum potassium of 3.2 mEq/L
c. K-Dur, 1 tablet daily for a patient in diabetic ketoacidosis
d. K-Dur, 1 tablet with a full glass of water
e. Potassium chloride, 10 mEq rapid IV push

B, C, E
Patients receiving potassium should not receive potassium in solution diluted at more than 40 mEq/L. Diabetic ketoacidosis causes decreased cellular uptake of potassium, and patients in whom acidosis is present should also receive sodium bicarbonate if they need potassium. IV potassium should not be infused faster than 10 mEq/hr. NS with 20 mEq KCl is an appropriate solution for a patient with intact renal function. Oral potassium should be given with a full glass of water to minimize gastrointestinal (GI) effects.

1. A nurse is reviewing the immune system with a group of nursing students. One student asks about the difference between cell-mediated immunity and humoral immunity. What should the nurse reply?

a. "Humoral immunity does not involve helper T cells in the immune response."
b. "Humoral immunity does not have a role in hypersensitivity reactions."
c. "Humoral immunity requires cytolytic T cells that attack antigens directly."
d. "Humoral immunity uses cells produced by B lymphocytes in the immune response."

ANS: D
Humoral immunity refers to immunity mediated by antibodies, which are produced by B lymphocytes. Helper T cells have an essential role in antibody production by B cells. The antibody immunoglobulin E plays a role in hypersensitivity reactions. Cytolytic T cells do not produce antibodies; they are key players in cellular immunity

2. A nurse is teaching a nursing student about a specific acquired immunity system. Which statement by the student indicates a need for further teaching?

a. "Cell-mediated immunity and humoral immunity are both types of specific acquired immune responses."
b. "Each exposure to an antigen causes a faster, more intense response."
c. "Immune responses occur only after exposure to a foreign substance."
d. "The skin is a factor in specific acquired immunity."

NS: D
The skin is a physical barrier that confers natural immunity. It is not a factor in specific acquired immunity. Cell-mediated and humoral immunity are both types of specific acquired immunity. In specific acquired immunity, each exposure to an antigen evokes a more intense response more quickly. Specific acquired immunity occurs only after initial exposure to an antigen.

3. A nurse is caring for a patient infected with the human immunodeficiency virus (HIV). Which finding would most concern the nurse?

a. High level of macrophages
b. Low neutrophil count
c. Low red blood cell (RBC) count
d. Very low helper T lymphocyte count

ANS: D
The nurse understands that this patient may be vulnerable to opportunistic infections, especially if there were an indication of the HIV conversion to acquired immunodeficiency syndrome (AIDS). A very low helper T lymphocyte count would most concern the nurse, because the helper T cells are essential to the immune system, and people with AIDS have a low or deficient count. A high level of macrophages could indicate an inflammatory response. A low RBC count may indicate anemia. A low neutrophil count can be caused by multiple conditions, but a high count most likely indicates an infection.

4. Which statement is true about helper T cells?

a. They are useful but are not essential to immune responses.
b. They do not play a role in antibody production.
c. They have highly specific receptors to antigens on their surface.
d. They prevent CD4 molecules from attaching to antigens.

ANS: C
Helper T cells have highly specific cell surface receptors that recognize individual antigens. Helper T cells play an essential role in several functions of the immune response. They have an essential role in the production of antibodies by B cells. They carry CD4 molecules on their surface and are also referred to as CD4 cells.

5. A nurse is caring for a patient who has undergone organ transplantation. Because the sequence of amino acids in the major histocompatibility complex (MHC) molecules of the donor is different from that of the patient, the nurse will expect to administer which class of drugs?

a. Antibiotics
b. Antihistamines
c. Immune globulins
d. Immunosuppressants

ANS: D
The MHC molecules from one individual are recognized as foreign by the immune system of another individual; therefore, when an attempt is made to transplant organs between individuals who are not identical twins, immune rejection of the transplant is likely. Immunosuppressants are given to counter this response. Antibiotics are used to destroy bacteria. Antihistamines block hypersensitivity reactions. Immune globulins are given to confer passive immunity when specific acquired immunity has not yet developed a response.

6. A nurse is teaching a group of nursing students about antibodies. The nurse correctly explains that which type of response is triggered when antigens bind to antibodies on mast cells or basophils?

a. Acquired immune response
b. Autoimmune response
c. Hypersensitivity reaction
d. Transplant rejection

ANS: C
When antigens bind to antibodies on mast cells and basophils, chemical mediators of hypersensitivity reactions are released. Although hypersensitivity is an acquired response, mast cells and basophils do not play a role in other acquired responses. An autoimmune response occurs when the immune system fails to discriminate between self and nonself. Transplant rejection occurs when the MHC molecules of the donor are different from those of the patient.

7. A nurse is teaching a group of nursing students about immunoglobulins. Which statement by a student indicates a need for further teaching?

a. "IgD provides a first line of defense against microbes entering the body through the lungs."
b. "IgE plays a role in hypersensitivity reactions and responses to parasites."
c. "IgG and IgM participate in the complement response to promote target cell lysis."
d. "Neonatal immunity is the result of IgG crossing the placenta."

ANS: A
IgD serves as a receptor for antigen recognition on B cells, which is the only place it is found. IgE is involved in hypersensitivity responses and responses to parasites. IgG and IgM are involved in complement responses. IgG crosses the placenta and confers passive immunity on the fetus.

8. A patient who breast-feeds her infant asks the nurse about the immunity the infant receives from breast milk. What does the nurse tell the patient about immunity through breast-feeding?

a. "The immunity protects the infant from hypersensitivity reactions."
b. "The immunity provides phagocytes to help the infant fight infections."
c. "The immunity results from the transfer of IgA through the breast milk."
d. "The immunity protects the infant from respiratory and gastrointestinal (GI) microbes."

ANS: C
IgA crosses breast milk and, in the GI tract, where it is not absorbed, provides passive immunity to microbes. Infants do not receive protection from hypersensitivity reactions through breast milk. Phagocytes are not transmitted through breast milk. Infants are not protected from respiratory microbes via breast milk.

9. A nurse is discussing the role of antibodies in the complement system with a group of nursing students. Which statement by a student is correct?

a. "Antibodies activate the complement cascade by turning on the alternative pathway."
b. "Antibodies that are free in solution can activate the complement system."
c. "Antibodies flag target cells to be lysed by membrane attack complexes."
d. "Antibody receptors are nonspecific to antigenic determinants."

ANS: C
Lysis of target cells that have been tagged with antibodies is the most dramatic effect of the complement system. Antibodies activate the complement cascade by turning on the classical pathway. C1 cannot bind with free antibodies. Antibody receptors are specific to antigen determinants.

10. A patient has a Type IV hypersensitivity (delayed-type hypersensitivity) response to an infection. The nurse understands that which two types of cells are necessary for this response?

a. Antigen-presenting cells and mast cells
b. Cytolytic T lymphocytes and target cells
c. Immunoglobulin cells and dendritic cells
d. Infected macrophages and CD4 helper T cells

ANS: D
The object of Type IV hypersensitivity (delayed-type hypersensitivity) is to rid the body of bacteria that replicate within macrophages. The macrophage activates the CD4 cell, which in turn activates the macrophage. The other cells listed are not a part of this response.

1. Which immune responses can result in harm to the body? (Select all that apply.)

a. Activation of the complement system
b. Autoimmune response
c. IgE binding to mast cells and basophils
d. Opsonization
e. Recognition of MHC molecules as nonself

ANS: B, C, E
The autoimmune response causes the immune system to attack the body's own cells. The hypersensitivity response, mediated by IgE, causes the release of harmful chemical mediators. Recognition of MHC molecules as nonself in a transplanted organ can cause organ rejection. Activation of the complement system causes a cascade of reactions that assist in the immune response. Opsonization is a process that assists with phagocytosis.

1. A nurse at an immunization clinic is providing vaccines to children. The parent of a child waiting to receive vaccines tells the nurse that the child has an immune deficiency disorder. The nurse understands that which vaccine should not be administered to this child?

a. Diphtheria and tetanus toxoids and acellular pertussis (DTaP) vaccine
b. Haemophilus influenzae type b (Hib) vaccine
c. Polio injection
d. Varicella virus vaccine

ANS: D
The varicella vaccine should be avoided by individuals who are immunocompromised, which includes those infected with the human immunodeficiency virus (HIV) and those who have a congenital immunodeficiency. The DTaP vaccine, Hib vaccine, and polio injection may be administered to immunocompromised individuals, because these are not live vaccines.

2. A nurse is preparing to administer vaccines to a 1-year-old child. The parents ask the nurse to give the child acetaminophen before administering the vaccine to reduce the pain. Which response by the nurse is correct?

a. "Children don't remember pain, so it isn't necessary to give acetaminophen."
b. "The small needles used to inject the vaccines cause hardly any discomfort."
c. "You can apply a topical anesthetic when you get home to reduce pain from the injection."
d. "Your child's immune response may not be as effective if I give acetaminophen before the vaccine."

ANS: D
Giving analgesic/antipyretic medications before or shortly after vaccines can reduce the immune response, so giving them to prevent pain or fever is not recommended. Children do remember pain, and it is important to provide other comfort measures and to give the injections rapidly. Small needles cause less discomfort, and it is important to reassure the parents about this; however, it is more important to explain why acetaminophen is not recommended. Topical anesthetics are useful before giving the injections, not afterwards.

The parents of an infant who will be attending day care tell the nurse that they do not want their child vaccinated against rotavirus because an older cousin developed intussusception after receiving this vaccine. Which response by the nurse is correct?

a. "Intussusception is much less serious than getting the disease."
b. "It was probably just a coincidental reaction to the vaccine."
c. "The newer vaccines for rotavirus are not associated with intussusception."
d. "Your child will have herd immunity and won't need the vaccine."

ANS: C
The rotavirus vaccine product RotaShield was withdrawn because of the high rate of intussusception associated with it. The two products currently on the market—RotaTeq and Rotarix—do not carry a risk for intussusception. Intussusception can be life threatening, so telling parents it is less serious than the disease is incorrect. Intussusception was not merely a coincidental reaction. Herd immunity is not guaranteed.

A -year-old child who has been receiving high-dose systemic glucocorticoids for several months comes to a clinic for school immunizations, which usually include the DTaP vaccine; varicella virus vaccine [Varivax]; the measles, mumps, and rubella virus (MMR) vaccine; and the inactivated poliovirus vaccine (IPV). The clinic nurse will expect to administer which vaccines to this child?

a. All four school immunizations
b. DTaP and IPV only
c. DTaP, OPV, and Varivax only
d. DTaP and IPV, along with immunoglobulins

ANS: B
Children who are immunocompromised should not receive live virus vaccines, including the MMR vaccine and Varivax. Children taking high-dose systemic glucocorticoids are immunocompromised and should not receive the vaccine until therapy is stopped and normal glucocorticoid production returns. The oral polio vaccine (OPV) contains live virus and is contraindicated. Immunoglobulins are not indicated unless children are exposed to the diseases themselves.

A 1-year-old child is scheduled to receive the MMR vaccine, pneumococcal vaccine (PCV), Varivax, and hepatitis A vaccine. The child's parents request that the MMR vaccine not be given, saying that, even though there is no demonstrated link with autism, they are still concerned about toxic levels of mercury in the vaccine. Which response by the nurse is correct?

a. "Most U.S.-made vaccines have zero to low amounts of mercury."
b. "Other vaccine preparations contain mercury as well."
c. "Thimerosal is a nontoxic form of mercury."
d. "You can get more mercury from breast milk and many foods on the market."

ANS: A
Because of concerns about mercury levels, most U.S.-made vaccines contain either zero or very low amounts of mercury. Some multidose vials of flu vaccine still contain thimerosal, but even that is a very low amount. Telling parents that other vaccines contain mercury will increase their suspicion about vaccines and further reduce their trust. Thimerosal is a mercury-based preservative and thus has the same toxicity as mercury. Although it is true that mercury is found in breast milk and other foods, telling parents this belittles their concerns about the vaccines.

The parent of a 2-month-old infant who has just received the first dose of DTaP asks the nurse about expected reactions to the vaccine. The nurse will respond by saying that:

a. "Mild reactions, including a low-grade fever, are common."
b. "Most children do not experience any reaction."
c. "Seizures are common and may require anticonvulsant medication."
d. "The most common reaction is a rash that develops into itchy vesicles."

ANS: A
Mild reactions to the first dose of the DTaP vaccine are common and most often are manifested by a low-grade fever, fretfulness, drowsiness, and local reactions of swelling and redness. At least 50% of children experience reactions. Seizures are not common. Itchy vesicles do not appear with the DTaP vaccine.

A 1-year-old child receives the MMR vaccine. The next day the child's parent calls the nurse to report that the child has a temperature of 103°F. What will the nurse do?

a. File an adverse event report with the Vaccine Adverse Event Reporting System (VAERS).
b. Notify the child's provider that thrombocytopenia is likely to occur.
c. Reassure the parent that fever can occur with the MMR vaccine.
d. Tell the parent to take the child to the emergency department.

ANS: C
The MMR vaccine can have several adverse effects, including fever up to 103°F; this is not considered a serious effect and does not warrant filing an adverse event report with VAERS. Thrombocytopenia is a rare but serious side effect of the MMR vaccine but is not associated with fever. There is no need to have the parent take the child to the emergency department.

The parent of a child who attends day care questions the need for Varivax. What will the nurse tell the parent?

a. "Chickenpox is not as contagious as other communicable diseases."
b. "The child will be protected by herd immunity and does not need the vaccine."
c. "Varicella is an uncomfortable disease, but it is not that serious."
d. "Varicella in adults can have serious consequences."

ANS: D
Varicella tends to cause more severe symptoms in adults than in children; adults have a 10-fold greater likelihood of hospitalization and a 20-fold increase in deaths. Chickenpox is highly contagious. Even with herd immunity, because of the degree of contagiousness, spread is likely. Varicella can be serious, even in children.

A clinic nurse receives a phone call from a parent who states that a 2-month-old infant has a severe cough, a low-grade fever, and a runny nose that have lasted over a week. What will the nurse ask the parent?

a. Whether the infant has had the first set of vaccines
b. Whether the infant received a hepatitis B vaccine as a newborn
c. Whether the infant attends day care
d. Whether there is a family history of respiratory disorders

ANS: A
This infant may have pertussis, for which the primary symptoms are low-grade fever, persistent cough, and runny nose. Infants who have not received the first set of immunizations, including the DTaP vaccine, are especially vulnerable to this disease. The hepatitis B vaccine does not protect against these symptoms. Asking about day care may be important for evaluating exposure, but differentiating between the cough of pertussis and other coughs is best done by determining immunization status. A family history of respiratory disorders may indicate whether the symptoms are related to a chronic lung disease, but these do not usually manifest at 2 months of age.

The nurse at a public health infant immunization clinic is acting as a preceptor for a nursing student. To assess the student's understanding of vaccinations, the nurse asks the student where the hepatitis B vaccine (HepB) should be administered. The student would be correct to respond that the hepatitis B vaccine should be administered in the:

a. dorsogluteal muscle in an adult.
b. anterolateral thigh in infants.
c. ventrogluteal muscle in adolescents.
d. deltoid of toddlers.

ANS: B
The HepB vaccine should be administered in the anterolateral thigh in infants and children. The vaccine should be administered in the deltoid of adults and adolescents. The vaccine should not be administered in the deltoid of toddlers, because they have little muscle in that location.

An 11-year-old boy received all childhood immunizations before attending school as a kindergartner. Which vaccines are recommended for this child at his current age?

a. DTaP, MCV4, Varivax
b. PCV-23, Td, MMR
c. Tdap, MCV4, HPV
d. Tdap, Varivax, hepatitis B

ANS: C
At age 11, both males and females should receive a booster of diphtheria, tetanus, and pertussis (Tdap); the Menactra vaccine against meningitis (MCV4); and the human papilloma virus (HPV) vaccine. A Varivax booster is not recommended at this age. The PCV-23 vaccine is indicated only in high-risk patients. The Td can be given, but a vaccine with a pertussis component is preferred. The MMR is not given at this age. The hepatitis B vaccine is not given at this age.

An immigrant child is in the clinic for MMR vaccination. The nurse learns that the child has recently received an immune globulin injection for a viral infection, currently has an upper respiratory infection with a temperature of 100°F, and has a recent history of thrombocytopenia, which has resolved. What does the nurse tell the child's parents?

a. "The vaccine is contraindicated in this child because of the history of thrombocytopenia."
b. "The child should be brought back for the vaccine when the temperature is back to normal."
c. "The child is at increased risk of developing autism from this vaccine."
d. "The vaccine must be postponed for 3 months after administration of the immune globulin."

ANS: D
The MMR vaccine should be postponed in children who have received immunoglobulins, because the immunoglobulin contains antibodies against the viruses in the vaccine. Thrombocytopenia is not a contraindication to the MMR vaccine. A low-grade temperature is not a contraindication. There is no link between receiving the MMR vaccine and the development of autism.

An otherwise healthy child receives a varicella virus vaccine. Three weeks later the parent calls to report that the child has a mild case of chickenpox and wonders how this could happen after the vaccination. What will the nurse tell the parent?

a. "A varicella-like rash can occur after the vaccine is given."
b. "The vaccine was probably ineffective."
c. "This represents a serious vaccine side effect."
d. "Give the child aspirin to treat any fever that may occur."

ANS: A
Children who receive the varicella vaccine may sometimes develop a mild, local varicella-like rash within a month of receiving the vaccine. This rash does not indicate that the vaccine was ineffective, and it is not a serious side effect. Because of the association with Reye's syndrome, children should not take aspirin or other salicylates for 6 weeks after receiving the vaccine.

A 3-year-old child who has asthma is in the clinic for a well-child checkup. The nurse notes that the child is up-to-date for the DTaP, Hepatitis A, Hepatitis B, and the MMR vaccines but has only had one each of the Hib, the Rotavirus, and the PCV13 vaccines. Which vaccine(s) will the nurse anticipate administering to this child?

a. Hib and Rotavirus vaccines
b. PCV13
c. PCV13 and Hib
d. Rotavirus

ANS: B
The PCV13 should be given to all children under the age of 2 years and to all healthy children between ages 2 and 5 years, especially those who have conditions such as chronic lung disease that put them at high risk of serious pneumococcal disease. The Hib vaccine is only given up to age 15 months. The Rotavirus vaccine is not given after 32 weeks of age.

The public health nurse is teaching a group of parents about immunizations. The nurse tells the parents that after receiving the varicella virus vaccine, children should temporarily avoid close contact with whom? (Select all that apply.)
a. Neonates
b. Siblings
c. Relatives older than 65 years
d. Pregnant women
e. Individuals infected with HIV

ANS: A, D, E
To reduce the risk of transmission, vaccine recipients should temporarily avoid close contact with susceptible high-risk individuals (e.g., neonates, pregnant women, and immunocompromised people).

Which are recommended measures to help minimize pain associated with vaccine administration? (Select all that apply.)

a. Administer acetaminophen or ibuprofen before the vaccine is given.
b. Apply a topical anesthetic to the injection site before the vaccine is given.
c. Give intramuscular vaccines rapidly without aspiration.
d. Have the child lie down while the vaccine is given.
e. Provide tactile stimulation as a diversion.

ANS: B, C, E
Topical anesthetics and tactile stimulation are helpful for minimizing pain associated with vaccine administration, as is giving IM injections rapidly without aspirating. Acetaminophen and ibuprofen are not recommended, because they can inhibit the immune response to the vaccine. Allowing the child to sit up helps minimize pain.

A patient has undergone liver transplantation. The provider orders cyclosporine [Sandimmune], prednisone, and sirolimus [Rapamune]. What will the nurse do?

a. Question the order for sirolimus.
b. Request an order for a serum glucose level.
c. Request an order for a macrolide antibiotic.
d. Suggest changing the cyclosporine to tacrolimus.

A
Sirolimus is given to prevent rejection in renal transplantation; it has no proof of efficacy in patients with heart, lung, or liver transplants. A serum glucose level is not indicated; patients taking repaglinide for diabetes should be monitored closely while taking cyclosporine. Although antibiotic prophylaxis may be necessary, macrolide antibiotics increase the level of cyclosporine. Tacrolimus is more toxic than cyclosporine.

A patient with a liver transplant has been receiving cyclosporine [Sandimmune] for 6 months. The nurse reviews this patient's laboratory results and notes a sharp increase in the blood urea nitrogen (BUN) and serum creatinine. Vital signs are normal, and the patient reports no discomfort. What does the nurse suspect?

a. Hepatotoxicity
b. Infection
c. Organ rejection
d. Nephrotoxicity

D
An elevation of BUN and serum creatinine is an indication of nephrotoxicity, which occurs in 75% of patients taking cyclosporine. Hepatotoxicity would cause elevations in liver enzymes, not the BUN and creatinine. Infection would be associated with fever. Organ rejection of a renal transplant would cause elevation in the BUN and creatinine but also would cause tenderness at the graft site and fever.

A nurse provides teaching to a patient who has undergone kidney transplantation and will begin taking cyclosporine [Sandimmune], a glucocorticoid, and sirolimus [Rapamune]. Which statement by the patient indicates understanding of the teaching?

a. "I should take sirolimus at the same time as the cyclosporine."
b. "I will need to have my blood sugar checked regularly."
c. "I will need to take an antibiotic to prevent lung infections."
d. "Taking this combination of drugs lowers my risk of kidney damage."

C
Immunosuppressant drugs increase the risk of infections, especially the BK virus, which can cause renal damage, and other organisms that cause lung infections. Patients taking these drugs must take antibiotics for the first 12 months to help prevent infection. Sirolimus and cyclosporine should be taken 4 hours apart. Patients with diabetes may have trouble with glucose tolerance and require monitoring. Taking cyclosporine and sirolimus increases the risk of renal damage.

A patient with a history of lung transplantation is admitted for treatment for a respiratory infection. The patient has been taking cyclosporine [Sandimmune], prednisone, and azathioprine [Imuran] for 8 months. The provider has ordered azithromycin [Zithromax] to treat the infection and acetaminophen [Tylenol] as needed for fever. The nurse will contact the provider to:

a. ask whether a different antibiotic can be used.
b. ask that the prednisone be discontinued until the infection clears.
c. suggest increasing the dose of cyclosporine.
d. suggest using ibuprofen instead of acetaminophen.

A
Macrolide antibiotics, such as azithromycin, can inhibit cyclosporine metabolism, leading to increased levels of the drug. This patient needs either a reduced dose of cyclosporine or a different antibiotic. There is no indication for discontinuing the prednisone during treatment. The dose of cyclosporine would need to be reduced, because azithromycin leads to increased drug levels. There is no contraindication to using acetaminophen.

A patient is taking cyclosporine [Sandimmune] and prednisone to prevent organ rejection after right renal transplantation. The patient is febrile and complains of right-sided flank pain. The nurse reviews the patient's chart and finds that the patient's BUN and serum creatinine are elevated. The cyclosporine trough is 150 ng/mL. What will the nurse do?

a. Be concerned that the left kidney is failing.
b. Expect the provider to order intravenous methylprednisolone.
c. Request an order for a urine culture.
d. Suspect nephrotoxicity secondary to an elevated cyclosporine level.

B
The patient is showing signs of acute organ rejection, which include pain at the graft site, fever, and elevated BUN and creatinine; therefore, intravenous methylprednisolone is indicated. Because the patient is having pain on the right side, along with fever and elevated renal function test results, there is no reason to suspect that the left kidney is failing or that an infection is present. The cyclosporine level is within normal limits.

A patient is started on immunosuppressant drugs after kidney transplantation and will be taking azathioprine [Imuran] as part of the drug regimen. The patient asks the nurse why it is necessary to have a specimen for a complete blood count drawn at the beginning of therapy and then periodically thereafter. The nurse explains that azathioprine can alter blood cells and tells the patient to report:

a. alopecia.
b. easy bruising.
c. fatigue.
d. gastrointestinal (GI) upset.

B
Azathioprine can cause bone marrow suppression, resulting in neutropenia and thrombocytopenia; therefore, a CBC must be evaluated at baseline and periodically thereafter. Patients who have low platelet counts bruise easily, so this symptom should be reported. Alopecia occurs with azathioprine but is not a life-threatening side effect. Fatigue is not a common adverse effect. GI side effects occur but are not life threatening.

A nurse is teaching a patient who is about to undergo allograft transplantation of the liver. Which statement by the patient indicates understanding of the post-transplant medications?

a. "Immunosuppressants help reduce the risk of postoperative infection."
b. "I will need to have periodic laboratory work to assess for toxicity."
c. "I will need to take immunosuppressants until all signs of organ rejection are gone."
d. "These drugs will prevent organ rejection."

B
To prevent toxicity from high drug levels or organ rejection from low levels, blood levels of immunosuppressants should be checked periodically. Immunosuppressants do not prevent infection; they increase the risk of infection. Patients must take immunosuppressants for life. Immunosuppressants do not prevent organ rejection; they help minimize the risk.

The nurse knows that which immunosuppressants are among the most effective?

a. Azathioprine [Imuran] and everolimus [Zortress]
b. Cyclosporine [Sandimmune] and tacrolimus [Prograf]
c. Methotrexate [Rheumatrex] and muromonab-CD3 [Orthoclone OKT3]
d. Sirolimus [Rapamune] and methylprednisolone

B
Cyclosporine and tacrolimus are the most effective immunosuppressants available.

A nursing student asks the nurse how antibodies provide immune suppression. The nurse responds by telling the student that antibodies:

a. block T-cell function.
b. boost immune responses.
c. reduce proliferation of B cells.
d. suppress interferon production.

A
Antibodies can be directed against components of the immune system to suppress the immune response and block T-cell function. They inhibit rather than boost immune responses. They do not reduce the proliferation of B cells or suppress interferon production.

10. The nurse is preparing to administer basiliximab [Simulect] to a patient to prevent acute rejection. By which route will the nurse administer the drug?

a. Oral
b. Intramuscular
c. Intravenous
d. Transdermal

C
Basiliximab is used to prevent acute rejection and is administered intravenously.

The nurse is caring for a patient after recent renal transplantation. The patient is taking sirolimus [Rapamune] to prevent transplant rejection. What other medications would the nurse expect the patient to be taking?

a. Rifampin and ketoconazole
b. Carbamazepine and phenobarbital
c. Cyclosporine and glucocorticoids
d. Amphotericin B and erythromycin

C
Sirolimus should be used in conjunction with cyclosporine and glucocorticoids to reduce the risk of transplant rejection. Rifampin can reduce and ketoconazole can increase therapeutic levels of sirolimus and cyclosporine; therefore, they are not indicated for transplant patients. Carbamazepine and phenobarbital are not indicated, because they can reduce the therapeutic levels of sirolimus and cyclosporine. Amphotericin B and erythromycin are not indicated, because they can increase the therapeutic levels of sirolimus and cyclosporine.

The nurse is administering medications to a patient who is receiving cyclosporine [Sandimmune]. Which medication, when administered concurrently with cyclosporine, would warrant a reduction in the dosage of cyclosporine?

a. Phenytoin [Dilantin]
b. Prednisone
c. Ketoconazole [Nizoral]
d. Trimethoprim/sulfamethoxazole [Bactrim]

C
Concurrent use of ketoconazole would warrant a reduction in the dosage of cyclosporine. Ketoconazole often is given concurrently with cyclosporine so that the patient's dosage of cyclosporine, which is costly, can be reduced. Phenytoin would cause a decrease in cyclosporine levels. Prednisone often is given concurrently with cyclosporine to suppress the immune response. Trimethoprim/sulfamethoxazole reduces levels of cyclosporine in the body.

The nurse is caring for a 15-year-old patient who has undergone a liver transplant. Which provider order will the nurse question?

a. Cyclosporine [Sandimmune] and ketoconazole [Nizoral]
b. Everolimus [Zortress] 1 mg twice daily
c. Prednisone 60 mg daily
d. Tacrolimus [Prograf] 50 mcg/kg twice daily the day after surgery

B
Everolimus is not approved in patients younger than 18 years of age. Ketoconazole can decrease the metabolism of cyclosporine and is often given concurrently to allow lower dosing and lower cost. Prednisone and tacrolimus are commonly used, and these doses are correct.

A patient who is taking azathioprine [Imuran] to prevent rejection of a renal transplant develops gout and the provider orders allopurinol. The nurse will contact the provider to discuss:

a. decreasing the allopurinol dose.
b. decreasing the azathioprine dose.
c. increasing the allopurinol dose.
d. increasing the azathioprine dose.

B
Allopurinol delays conversion of mercaptopurine to inactive products and increases the risk of azathioprine toxicity. Patients taking the two concurrently should have an approximate 70% reduction in the azathioprine dose. Altering the allopurinol dose is not indicated.

A pregnant patient asks the nurse if she can take antihistamines for seasonal allergies during her pregnancy. What will the nurse tell the patient?

a. Antihistamines should be avoided unless absolutely necessary.
b. Second-generation antihistamines are safer than first-generation antihistamines.
c. Antihistamines should not be taken during pregnancy but may be taken when breast-feeding.
d. The margin of safety for antihistamines is clearly understood for pregnant patients.

A
Antihistamines are pregnancy Category C, with debate currently occurring regarding degree of effects on the fetus. They should be avoided unless absolutely necessary. All antihistamines have adverse effects on the fetus. Antihistamines can be excreted in breast milk. The margin of safety of antihistamines in pregnancy is not clear, so these agents should be avoided unless a clear benefit of treatment outweighs any risks

A family is preparing for travel and the parents report that their 5-year-old child has frequent motion sickness. The nurse will tell the parents to ask the provider about which antihistamine to help prevent symptoms?

a. Desloratadine [Clarinex]
b. Dimenhydrinate [Dramamine]
c. Hydroxyzine [Vistaril]
d. Promethazine [Phenergan]

B
Some antihistamines, including dimenhydrinate and promethazine, are labeled for use in motion sickness. Promethazine, however, is contraindicated in children under age 2 years and should be used with caution in children older than 2 years because of the risks for severe respiratory depression. Desloratadine and hydroxyzine are not used for motion sickness.

A nurse is teaching a group of nursing students about antihistamines. Which statement by a student indicates an understanding of the mechanism of action of the antihistamines?

a. "Antihistamines block H1 receptors to prevent actions of histamine at these sites."
b. "Antihistamines block release of histamine from mast cells and basophils."
c. "H1 antagonists can bind to H1 receptors, H2 receptors, and muscarinic receptors."
d. "First-generation antihistamines are more selective than second-generation antihistamines."

A
Antihistamines block H1 receptors to prevent the actions of histamine. They do not block the release of histamine. H1 antagonists do not bind to H2 receptors; they do bind to muscarinic receptors. Second-generation antihistamines are more selective than first-generation antihistamines.

A patient who has chronic allergies takes loratadine [Claritin] and develops a severe reaction to bee stings. The patient asks the nurse why the antihistamine did not prevent the reaction. What will the nurse say?

a. "Allergy symptoms that are severe are caused by mediators other than histamine."
b. "H1 blockers do not prevent the release of histamine from mast cells and basophils."
c. "Second-generation H1 blockers contain less active drug and do not work in severe reactions."
d. "Severe allergic reactions occur through actions on muscarinic receptors."

A
Severe allergic reactions with symptoms of anaphylaxis are caused by mediators other than histamine, so the benefits of antihistamines are limited. H1 blockers do not block the release of histamine, but this is not why they are not effective in anaphylaxis. Second-generation agents are as effective as first-generation agents in allergic reactions mediated by histamine; neither is effective for treating anaphylaxis

A patient tells a nurse that antihistamines help relieve cold symptoms and wants to know why they are not recommended or prescribed for this purpose. The nurse tells the patient that antihistamines provide only mild relief from some cold symptoms by:

a. anticholinergic properties that decrease rhinorrhea.
b. blocking H1 receptors in nasal passages.
c. reducing secretions at H2 receptor sites.
d. having sedative effects, which help patients rest and sleep.

B
Histamine does not mediate cold symptoms, so antihistamines do not provide relief through H1 blockade. Their anticholinergic effects at muscarinic receptor sites can moderately reduce rhinorrhea, so some patients may experience some relief of this symptom. H1-receptor sites do not play a role in cold symptoms. H2-receptor sites do not play a role in cold symptoms. Sedative side effects do not alleviate cold symptoms.

A patient will begin taking fexofenadine [Allegra] for hay fever. The nurse teaching this patient will tell the patient that:

a. fexofenadine should be taken with food to prevent gastrointestinal (GI) symptoms.
b. the medication may be taken once or twice daily.
c. tolerance to sedation will occur in a few weeks.
d. with renal impairment, this drug should be taken every other day.

B
Fexofenadine may be given 60 mg twice daily or 180 mg once daily. Fexofenadine does not need to be given with food. Sedation is not a common side effect of fexofenadine. There is no caution to reduce the dosage or increase the dosing interval in patients with renal impairment who take fexofenadine.

An 18-month-old child develops an urticarial reaction after a transfusion. The prescriber orders intravenous promethazine [Phenergan]. What will the nurse do?

a. Give the medication as ordered.
b. Monitor the child for bronchoconstriction.
c. Question the order.
d. Request an order to give the drug orally.

C
Promethazine can cause severe respiratory depression, especially in very young patients; it is contraindicated in children younger than 2 years. The medication should not be given as ordered. It is not safe to give the drug and then monitor for bronchoconstriction. The drug is not safe in this age group when given orally.

A 5-year-old child is brought to the emergency department after ingesting diphenhydramine [Benadryl]. The child is uncoordinated and agitated. The nurse observes that the child's face is flushed, the temperature is 37.1oC, and the heart rate is 110 beats per minute. The nurse will expect to:

a. administer atropine to reverse the adverse effects.
b. apply ice packs to stop the flushing.
c. give activated charcoal to absorb the drug.
d. prepare to provide mechanical ventilation.

C
In acute toxicity, patients present with agitation, a flushed face, tachycardia, and uncoordinated movements. There is no specific antidote, so drug removal is the focus of treatment, starting with activated charcoal to absorb the drug, followed by a cathartic to enhance excretion. Atropine would cause an increase in the heart rate. Application of ice packs is recommended for hyperthermia and not for flushing. The child's temperature is normal. Mechanical ventilation is not indicated with this presentation of symptoms, although cardiovascular collapse may eventually develop.

A provider has ordered intravenous promethazine [Phenergan] for an adult patient postoperatively to prevent nausea and vomiting (N/V). What will the nurse do?

a. Administer the drug at a rate of 25 mg/min or more to achieve maximum effects.
b. Contact the provider to suggest using dimenhydrinate [Dramamine] instead.
c. Ensure that the IV is infusing freely through a large-bore needle.
d. Monitor the patient closely for cardiac dysrhythmias.

C
Promethazine can cause severe local tissue injury if it extravasates into tissues, so the medication should be administered in an IV that is flowing freely through a large-bore needle. The drug should be administered at a rate of 25 mg/min or less. Dimenhydrinate is indicated for motion sickness, not postoperative N/V. Cardiac dysrhythmias were a concern with two antihistamines no longer on the market, astemizole and terfenadine.

A prescriber orders hydroxyzine [Vistaril] for a patient with acute urticaria. The nurse will include which information when teaching the patient about this drug?

a. The drug will reduce redness and itching but not edema.
b. This antihistamine is not likely to cause sedation.
c. The patient should avoid drinking alcohol while taking the drug.
d. The patient should report shortness of breath while taking the drug.

C
Hydroxyzine is a first-generation antihistamine and has sedative effects, so patients should be cautioned not to consume alcohol while taking the drug. In capillary beds, antihistamines reduce edema, itching, and redness. This antihistamine causes sedation. It is not associated with respiratory depression at therapeutic doses.

A patient has seasonal allergies and needs an antihistamine to control symptoms. The patient likes to have wine with dinner occasionally and wants to know which antihistamine will be the safest to take. The nurse will tell the patient to discuss which medication with the provider?

a. Cetirizine [Zyrtec]
b. Fexofenadine [Allegra]
c. Levocetirizine [Xyzal]
d. Loratadine [Claritin]

B
Fexofenadine is the least sedating of the second-generation antihistamines and so is the least likely to have synergistic effects with alcohol. Cetirizine, levocetirizine, and loratadine all have sedative side effects to some extent and thus would be less safe.

A 5-year-old child with seasonal allergies has been taking 2.5 mL of cetirizine [Zyrtec] syrup once daily. The parents tell the nurse that the child does not like the syrup, and they do not think that the drug is effective. The nurse will suggest they discuss which drug with their child's healthcare provider?

a. Cetirizine [Zyrtec] 5-mg chewable tablet once daily
b. Loratadine [Claritin] 10-mg chewable tablet once daily
c. Fexofenadine [Allegra] syrup 5 mL twice daily
d. Desloratadine [Clarinex] 5-mg rapid-disintegrating tablet once daily

A
The child is receiving a low dose of cetirizine and can receive up to 5 mg per day in either a single dose or two divided doses. Cetirizine is available in a chewable tablet, which this child may tolerate better, so the parents should be encouraged to explore this option with their provider. The loratadine 10-mg chewable tablet is approved for children 6 years and older. Fexofenadine would be safe for this child, but it is unlikely that the syrup would be any better than the cetirizine syrup. Desloratadine is not approved for children under the age of 12 years.

A patient is brought to the emergency department after ingesting a handful of diphenhydramine [Benadryl] tablets. The patient has dilated pupils, a flushed face, and tremors. The patient is agitated and has a heart rate of 110 beats per minute. The nurse may anticipate administering which agents? (Select all that apply.)

a. Activated charcoal
b. Atropine
c. Cathartics
d. Lorazepam
e. Second-generation H1 antagonists

A, B, D
The patient is showing signs of acute antihistamine toxicity. Activated charcoal and cathartics are given to absorb the drug and increase excretion. Atropine is not indicated. Lorazepam may be administered for seizures. Second-generation antihistamines are not indicated.

Which parenteral antihistamines have sedative effects that are classified as low to none? (Select all that apply.)

a. Cetirizine [Zyrtec]
b. Clemastine [Tavist Allergy]
c. Desloratadine [Clarinex]
d. Fexofenadine [Allegra]
e. Loratadine [Claritin]

C, D, E
Desloratadine, fexofenadine, and loratadine all have sedative effects classified as low to none. Cetirizine and clemastine have moderate sedative effects.

A nurse is teaching a group of nursing students about cyclooxygenase (COX) inhibitors. A student asks the nurse about characteristics of COX-1 inhibitors. Which statement by the nurse is true?

a. "COX-1 inhibitors protect against colorectal cancer."
b. "COX-1 inhibitors protect against myocardial infarction and stroke."
c. "COX-1 inhibitors reduce fever."
d. "COX-1 inhibitors suppress inflammation."

B
COX-1 inhibitors have beneficial effects of reducing platelet aggregation and thus reducing the risk of myocardial infarction and stroke. COX-2 inhibitors protect against colorectal cancer, reduce inflammation, and reduce fever.

A patient who takes daily doses of aspirin is scheduled for surgery next week. The nurse should advise the patient to:

a. continue to use aspirin as scheduled.
b. reduce the aspirin dosage by half until after surgery.
c. stop using aspirin immediately.
d. stop using aspirin 3 days before surgery.

C
Aspirin must be withdrawn at least 1 week before surgery. Aspirin cannot be continued as scheduled, because the risk for bleeding is too great. An interval of 3 days is not long enough for the bleeding effects of aspirin to be reversed. Cutting the dose in half would not reduce the effects of bleeding associated with aspirin use.

A patient who is taking acetaminophen for pain wants to know why it does not cause gastrointestinal upset, as do other over-the-counter pain medications. The nurse will explain that this is most likely because of which property of acetaminophen?

a. It does not inhibit cyclooxygenase.
b. It has minimal effects at peripheral sites.
c. It is more similar to opioids than to nonsteroidal anti-inflammatory drugs (NSAIDs).
d. It is selective for cyclooxygenase-2.

B
The differences between the effects of acetaminophen and aspirin are thought to result from selective inhibition of cyclooxygenase; acetaminophen has only minimal effects on cyclooxygenase at peripheral sites, which may explain why acetaminophen does not have adverse GI, renal, and antiplatelet effects. Acetaminophen is a selective COX inhibitor. It is not more similar to opioids than NSAIDs. It is not selective for COX-2.

A patient tells the nurse that she takes aspirin for menstrual cramps, but she does not feel that it works well. What will the nurse suggest?

a. The patient should avoid any type of COX inhibitor because of the risk of Reye's syndrome.
b. The patient should increase the dose to a level that suppresses inflammation.
c. The patient should use a first-generation nonsteroidal anti-inflammatory medication instead.
d. The patient should use acetaminophen because of its selective effects on uterine smooth muscle.

C
Aspirin (ASA) has analgesic effects for joint pain, muscle pain, and headache, but it is relatively ineffective against visceral pain, including uterine smooth muscle pain, for which NSAIDs are indicated. The risk of Reye's syndrome is associated with the use of ASA in children to treat fever. Increasing the ASA dose to anti-inflammatory levels is useful for rheumatic fever, tendonitis, and bursitis. Acetaminophen is not effective for dysmenorrhea.

A patient who takes aspirin for rheumatoid arthritis is admitted to the hospital complaining of headache and ringing in the ears. The plasma salicylate level is 300 mcg/mL, and the urine pH is 6.0. What will the nurse do?

a. Increase the aspirin dose to treat the patient's headache.
b. Notify the provider of possible renal toxicity.
c. Prepare to provide respiratory support, because the patient shows signs of overdose.
d. Withhold the aspirin until the patient's symptoms have subsided.

D
This patient shows signs of salicylism, which occurs when ASA levels climb just slightly above the therapeutic level. Salicylism is characterized by tinnitus, sweating, headache, and dizziness. Tinnitus is an indication that the maximum acceptable dose has been achieved. Toxicity occurs at a salicylate level of 400 mcg/mL or higher. ASA should be withheld until the symptoms subside and then should be resumed at a lower dose. Increasing the dose would only increase the risk of toxicity. Signs of renal impairment include oliguria and weight gain, which are not present in this patient. This patient has salicylism, not salicylate toxicity, so respiratory support measures are not indicated.

An adolescent is brought to the emergency department by a parent who reports that the patient took a whole bottle of extended-release acetaminophen tablets somewhere between 8 and 10 hours ago. The nurse will anticipate administering which of the following?

a. Acetylcysteine [Mucomyst]
b. Activated charcoal
c. Hemodialysis
d. Respiratory support

A
The nurse should anticipate giving acetylcysteine, because it is the specific antidote for acetaminophen overdose. It is 100% effective when given within 8 to 10 hours after ingestion and may still have some benefit after this interval. Activated charcoal is effective only if given before the medication is absorbed, so it must be given much sooner. Hemodialysis is not indicated. Respiratory support is used for ASA overdose.

An older male patient with an increased risk of MI is taking furosemide [Lasix] and low-dose aspirin. The patient is admitted to the hospital, and the nurse notes an initial blood pressure of 140/80 mm Hg. The patient has had a 10-pound weight gain since a previous admission 3 months earlier. The patient has voided only a small amount of concentrated urine. The serum creatinine and blood urea nitrogen (BUN) levels are elevated. The nurse will contact the provider to discuss:

a. adding an antihypertensive medication.
b. obtaining serum electrolytes.
c. ordering a potassium-sparing diuretic.
d. withdrawing the aspirin.

D
This patient shows signs of renal impairment, as evidenced by weight gain despite the use of diuretics, decreased urine output, hypertension, and elevated serum creatinine and BUN. ASA can cause acute, reversible renal impairment and should be withdrawn. Hypertensive medications do not treat the underlying cause. Serum electrolytes are not indicated. Addition of a potassium-sparing diuretic is not indicated.

A pregnant patient in her third trimester asks the nurse whether she can take aspirin for headaches. Which response by the nurse is correct?

a. "Aspirin is safe during the second and third trimesters of pregnancy."
b. "Aspirin may cause premature closure of the ductus arteriosus in your baby."
c. "Aspirin may induce premature labor and should be avoided in the third trimester."
d. "You should use a first-generation nonsteroidal anti-inflammatory medication."

B
Aspirin poses risks to the pregnant patient and her fetus, including premature closure of the ductus arteriosus. ASA is not safe, especially in the third trimester, because it can cause anemia and can contribute to postpartum hemorrhage. ASA does not induce labor but can prolong labor by inhibiting prostaglandin synthesis. NSAIDs have similar effects and also should be avoided.

A nurse is caring for a patient who has been taking low-dose aspirin for several days. The nurse notes that the patient has copious amounts of watery nasal secretions and an urticarial rash. The nurse will contact the provider to discuss:

a. administering epinephrine.
b. changing to a first-generation NSAID.
c. reducing the dose of aspirin.
d. giving an antihistamine.

A
Aspirin can cause a hypersensitivity reaction in some patients. This may start with profuse watery rhinorrhea and progress to generalized urticaria, bronchospasm, laryngeal edema, and shock. It is not a true anaphylactic reaction, because it is not mediated by the immune system. Epinephrine is the treatment of choice. Patients with sensitivity to ASA often also have sensitivity to NSAIDs; the first indication with this patient is to treat the potential life-threatening effect, not to change the medication. Reduction of the dose of ASA is not indicated, because this reaction is not dose dependent. Antihistamines are not effective, because this is not an allergic reaction.

A nurse is teaching a nursing student who wants to know how aspirin and nonaspirin first-generation NSAIDs differ. Which statement by the student indicates a need for further teaching?

a. "Unlike aspirin, first-generation NSAIDs cause reversible inhibition of cyclooxygenase."
b. "NSAIDs do not increase the risk of myocardial infarction and stroke; however, unlike ASA, they do not provide protective benefits against those conditions."
c. "Unlike aspirin, first-generation NSAIDs do not carry a risk of hypersensitivity reactions."
d. "Unlike aspirin, first-generation NSAIDs cause little or no suppression of platelet aggregation."

C
Nonaspirin first-generation NSAIDs carry a risk of hypersensitivity reactions similar to the risk posed by ASA. These agents cause reversible COX inhibition, whereas ASA causes irreversible COX inhibition. NSAIDs do not provide protective benefits for myocardial infarction or stroke, as does ASA. Nonaspirin first-generation NSAIDs do cause suppression of platelet aggregation, but the suppression is reversible.

A nurse is providing teaching for an adult patient with arthritis who has been instructed to take ibuprofen [Motrin] for discomfort. Which statement by the patient indicates a need for further teaching?

a. "I may experience tinnitus with higher doses of this medication."
b. "I may take up to 800 mg 4 times daily for pain."
c. "I should limit alcohol intake to fewer than three drinks a day."
d. "I will take this medication with meals to help prevent stomach upset."

A
NSAIDs do not cause salicylism and therefore do not cause tinnitus with higher doses. The maximum dose for adults is 3200 mg/day, or 800 mg 4 times/day. Patients taking NSAIDs should be cautioned to limit alcohol intake. Taking NSAIDs with meals helps prevent GI upset.

A woman who has arthritis is breast-feeding her infant and asks the nurse if it is safe to take NSAIDs while nursing. What will the nurse tell this patient?

a. NSAIDs are safe to take while breast-feeding.
b. NSAIDs are not safe, even in small amounts.
c. She should take only COX-2 inhibitors while breast-feeding.
d. She should request a prescription for narcotic analgesics.

A
NSAIDs are safe and may be taken while breast-feeding. It is not necessary to use a COX-2 inhibitor while breast-feeding. Narcotics cross breast milk and should be used cautiously while breast-feeding.

A nurse is providing medication teaching for a patient who will begin taking diclofenac [Voltaren] gel for osteoarthritis in both knees and elbows. Which statement by the patient indicates understanding of the teaching?

a. "Because this is a topical drug, liver toxicity will not occur."
b. "I should cover areas where the gel is applied to protect them from sunlight."
c. "I will apply equal amounts of gel to all affected areas."
d. "The topical formulation has the same toxicity as the oral formulation."

B
Diclofenac is available in topical and oral preparations. Patients should be warned to protect treated areas from sunlight. Side effects occur, such as liver toxicity, even with topical dosing. Patients should apply smaller amounts to the upper extremities. Systemic toxicity is lower with topical formulations.

A patient has been receiving intravenous ketorolac 30 mg every 6 hours for postoperative pain for 4 days. The patient will begin taking oral ketorolac 10 mg every 4 to 6 hours to prepare for discharge in 1 or 2 days. The patient asks the nurse whether this drug will be prescribed for management of pain after discharge. The nurse will respond by telling the patient that the provider will prescribe a(n):

a. different nonsteroidal anti-inflammatory drug for home management of pain.
b. fixed-dose opioid analgesic/nonsteroidal anti-inflammatory medication.
c. lower dose of the oral ketorolac for long-term pain management.
d. intranasal preparation of ketorolac for pain management at home.

A
Ketorolac is not indicated for chronic or minor pain and should not be used longer than 5 days. Patients discharged home will be instructed to use other NSAIDs for pain. A fixed-dose opioid/NSAID is not indicated. Low-dose ketorolac would not be used, because 5 days would have passed. The intranasal therapy would not be indicated after 5 days.

A patient who reports regular consumption of two or three alcoholic beverages per day asks about taking acetaminophen when needed for occasional recurrent pain. What will the nurse tell the patient?

a. "Do not take more than 2 gm of acetaminophen a day."
b. "Do not take more than 3 gm of acetaminophen a day."
c. "Do not take more than 4 gm of acetaminophen a day."
d. "Do not take a fixed-dose preparation with opioid analgesics."

A
Acetaminophen poses a risk of liver toxicity when taken chronically or in larger doses, especially when combined with alcohol. Patients who drink regularly should be advised to take acetaminophen in low doses and not to exceed 2 gm per day.

A nurse is discussing glucocorticoids with a group of nursing students. Which statement by a student indicates understanding of the teaching?
a. "Glucocorticoids have both endocrine and nonendocrine uses."
b. "Patients treated for adrenocortical insufficiency receive pharmacologic doses."
c. "Pharmacologic effects are achieved with low doses of glucocorticoids."
d. "Physiologic doses are used to treat inflammatory disorders."

A
Glucocorticoids have applications for both endocrine and nonendocrine disorders. Adrenocortical insufficiency requires physiologic, or low-dose, treatment. Pharmacologic doses are used when large doses are required, such as to suppress inflammation. Physiologic doses are used to treat endocrine disorders.

A nurse tells a nursing student that the glucocorticoids given for rheumatoid arthritis are nearly identical to substances produced naturally by the body. The student remarks that the drug must be very safe. Which response by the nurse is correct?

a. "As long as the drug is taken as prescribed, side effects usually do not occur."
b. "By interrupting the inflammatory process, these drugs inhibit side effects."
c. "Side effects can occur and are dependent on the dose and duration of treatment."
d. "The negative feedback loop prevents side effects."

C
When taken in pharmacologic doses, as for inflammatory disorders, glucocorticoids can cause an array of serious adverse effects. When glucocorticoids are given in pharmacologic doses, side effects can occur even when the drugs are taken as prescribed. Interruption of the inflammatory process causes some of the adverse effects. The negative feedback loop does not inhibit side effects.

A clinic patient who has been taking a glucocorticoid for arthritis for several months remarks to the nurse, "It's a good thing my symptoms are better, because my mother has been quite ill, and I have to take care of her." The patient's blood pressure is 100/60 mm Hg. The nurse will report this to the provider and ask about:

a. reducing the patient's dose.
b. using every other day dosing.
c. increasing the patient's dose.
d. tapering the dose.

C
Because of their adrenal suppression, patients taking glucocorticoids long term require increased doses at times of stress and even for a time after stopping the drug until adrenal function returns. This patient's lower blood pressure is an indication that glucocorticoid levels may be depleted. Reducing the dose would only exacerbate the patient's problems. Every other day dosing is used early in glucocorticoid therapy to reduce adrenal suppression, but it would not be useful now. Tapering of doses is used to allow adrenal function to recover as the drug is discontinued.

A nurse is teaching a group of nursing students why glucocorticoids are preferred over nonsteroidal anti-inflammatory drugs in the treatment of inflammation. Which statement by a student indicates a need for further teaching?

a. "Glucocorticoids act by multiple mechanisms and have more anti-inflammatory effects than NSAIDs."
b. "Glucocorticoids have fewer side effects than nonsteroidal anti-inflammatory drugs."
c. "Glucocorticoids help avert damage to tissues from lysosomal enzymes."
d. "Glucocorticoids reduce the immune component of inflammation."

B
Glucocorticoids have many side effects. They are used because of their multiple mechanisms of action, including their ability to limit tissue damage caused by the inflammatory process and suppression of the immune component of inflammation.

A patient who is a long-distance runner has been diagnosed with rheumatoid arthritis in both knees and will begin glucocorticoid therapy. When teaching the patient about the medication, the nurse will include what information?

a. "By reducing inflammation, this drug will slow the progression of your disease."
b. "Glucocorticoids are used as adjunctive therapy during acute flare-ups."
c. "Oral glucocorticoids cause less toxicity than intra-articular injections."
d. "You may resume running when the pain and swelling improve."

B
Glucocorticoids are used as adjunctive therapy to treat acute exacerbations of rheumatoid arthritis. Glucocorticoids reduce pain and inflammation but do not alter the course of the disease. Oral glucocorticoids produce side effects similar to those of all glucocorticoids, but they are absorbed more rapidly and completely than intra-articular injections. Patients should be warned against overactivity even though their pain has been reduced, because they can further injure their joints.

The prescriber orders 20 mg of hydrocortisone orally once each day. The nurse will make sure the drug is scheduled to be administered at what time?

a. 8:00 AM
b. 12:00 PM
c. 4:00 PM
d. 9:00 PM

A
To allow the adrenals to recover, the hydrocortisone dose should be administered before 9:00 AM. The other times are incorrect for oral administration of daily hydrocortisone.

A patient is about to receive prednisone for tendonitis. The nurse reviewing the chart would be concerned about which of the following in the patient's medical history?

a. Asthma and allergic rhinitis
b. Gouty arthritis
c. Seborrheic dermatitis
d. Systemic fungal infection

D
Glucocorticoids are contraindicated in patients with a history of systemic fungal infections. Glucocorticoids are used to treat asthma, allergic rhinitis, gout, and seborrheic dermatitis.

A 60-year-old female patient is about to begin long-term therapy with a glucocorticoid. Which of the following will be important for minimizing the risk of osteoporosis?

a. Baseline vitamin D level
b. Calcium and vitamin D supplements
c. Estrogen therapy
d. Skeletal x-rays before treatment

B
Calcium and vitamin D supplements can help minimize the patient's risk of developing osteoporosis. A baseline vitamin D level is not recommended. Estrogen therapy can help in postmenopausal women, but its risks outweigh its benefits. Patients should undergo evaluation of the bone mineral density of the lower spine, not skeletal x-rays.

A patient taking high doses of a glucocorticoid develops weakness in the muscles of the upper arms and in the legs. What will the nurse do?

a. Contact the provider to ask about reducing the dose.
b. Encourage the patient to restrict sodium intake.
c. Reassure the patient that this is an expected side effect.
d. Tell the patient to stop taking the drug.

A
High-dose glucocorticoid therapy can cause myopathy, manifesting as weakness. If muscle weakness occurs, the dose should be reduced. Reducing the sodium intake is recommended to minimize sodium and water retention. Muscle weakness is not an expected side effect, because it indicates myopathy. It is incorrect to tell the patient to stop taking the drug, because a glucocorticoid must be withdrawn slowly to allow time for recovery of adrenal function.

A patient taking a glucocorticoid for arthritis reports feeling bloated. The nurse notes edema of the patient's hands and feet. Which action by the nurse is correct?

a. Ask the patient about sodium intake.
b. Obtain a blood glucose level.
c. Suggest the patient limit potassium intake.
d. Tell the patient to stop taking the drug.

A
Because of their mineralocorticoid activity, glucocorticoids can cause sodium and water retention and potassium loss. Asking about the sodium intake can help the nurse evaluate this patient. Although glucocorticoids can affect glucose tolerance, this patient does not have signs of hyperglycemia. Patients with sodium and water retention should be encouraged to increase their potassium intake. Telling a patient to stop taking the drug is incorrect, because a glucocorticoid must be withdrawn slowly to allow time for recovery of adrenal function.

A child is to begin long-term glucocorticoid therapy. The parents ask the nurse about the effects of this drug on the child's growth. Which response by the nurse is correct?

a. "A smaller dose may be indicated for your child."
b. "Ask your provider about every other day dosing."
c. "Long-acting glucocorticoid preparations should prevent growth suppression."
d. "Oral glucocorticoids rarely cause growth suppression."

B
Growth retardation can be minimized with alternate day dosing of glucocorticoids. Giving smaller doses does not prevent this effect with long-term therapy. Long-acting glucocorticoids do not prevent this effect. Oral glucocorticoids have the same side effects.

A patient who has been taking a glucocorticoid for several months arrives in the clinic. The nurse notes that the patient's cheeks appear full and that a prominent hump of fat is present on the upper back. The nurse will ask the provider to order which test(s)?

a. Liver function tests
b. Serum electrolytes
c. Tuberculin skin test
d. Vitamin D levels

B
This patient shows signs of iatrogenic Cushing's syndrome, which may include serum electrolyte disturbances; therefore, the electrolyte levels should be monitored. Liver function tests, tuberculin skin testing, and vitamin D levels are not indicated.

A nurse is teaching a patient who has taken glucocorticoids for over a year about glucocorticoid withdrawal. Which statement by the patient indicates a need for further teaching?

a. "I should reduce the dose by half each day until I stop taking the drug."
b. "I will need to have cortisol levels monitored during the withdrawal process."
c. "The withdrawal schedule may take several months."
d. "If I have surgery, I may need to take the drug for a while, even after I have stopped."

A
Glucocorticoid therapy can suppress adrenal function, so withdrawal should be done slowly to allow recovery of adrenal function. Reducing the dose of a glucocorticoid by half each day is not recommended. Patients should have their cortisol levels monitored to determine when therapy can be stopped. The withdrawal schedule may take several months. Patients who have stopped the drug may still experience adrenal insufficiency in times of physiologic stress, such as surgery.

A patient who has arthritis has been taking ibuprofen [Motrin] and a glucocorticoid medication. The patient reports having tarry stools but denies gastric pain. Which action by the nurse is correct?

a. Contact the provider to discuss ordering an antiulcer medication.
b. Counsel the patient to use over-the-counter antacids.
c. Reassure the patient not to worry unless there is gastric pain.
d. Tell the patient to stop taking the glucocorticoid immediately.

A
Glucocorticoid therapy, especially when combined with NSAIDs, can increase the risk of gastric ulcer and possibly GI bleeding. Treatment with antiulcer medications is indicated, but not with OTC antacids, since the provider needs to be aware of this adverse effect. Gastric pain is usually decreased because of the glucocorticoids, so absence of gastric pain is not reassuring. The glucocorticoid should be withdrawn slowly, not immediately.

A woman who is breastfeeding is prescribed a low pharmacologic dose of a glucocorticoid and asks the nurse about potential effects on her infant. What will the nurse tell her about this medication?

a. "At this dose, the concentration in your breast milk is safe."
b. "Contact your provider to discuss lowering the dose."
c. "There will be reversible side effects for your baby."
d. "This drug is likely to cause growth retardation in your baby."

A
Women who are nursing may take physiologic or low pharmacologic doses of glucocorticoids without achieving concentrations in breast milk that affect the nursing infant. It is not necessary to lower the dose. Since there are negligible levels, there are no effects on the infant. Large pharmacologic doses can cause growth retardation and other adverse effects in the infant.

Which disorders may be treated with glucocorticoids? (Select all that apply.)

a. Allergic rhinitis
b. Anaphylaxis
c. Bronchiolitis
d. Gout
e. Ulcerative colitis

A, D, E
Glucocorticoids are used topically for allergic rhinitis and are given systemically for gout and ulcerative colitis. They are not useful in anaphylactic reactions, for which epinephrine is the drug of choice, or in bronchiolitis, which generally is induced by a virus, not by an immune response.