ECU Pharmacology Final Study Guide

Bioavailability
The ability of a drug to reach the systemic circulation from its site of administration.
Absorption
The movement of a drug from its site of administration into the blood.
*Rate-determines how soon effects will begin
*Amount-Determine how intense effects will be
Factors that affect Drug Absorption
Rate, Surface area (the larger the faster), Blood flow, Lipid Solubility (Lipid-soluble are absorbed more rapidly because they can cross membranes that separate them from blood), pH partioning

The nurse understands that the dose-response relationship is graded and therefore would expect to observe what?

Once a drug is given, the response is predictably all-or-nothing.
B. The response is maintained at a specific level when the therapeutic objective is achieved.
C. As the dosage increases, the response becomes progressively greater.
D. A graded response is based on relative potency and maximal efficacy.

C. As the dosage increases, the response becomes progressively greater.

If drug responses were all-or-nothing instead of graded, drugs could produce only one intensity level of response. The response may be maintained at a specific level when the therapeutic objective is achieved, but that option does not pertain to a dose-response relationship that is graded.

Protein binding
Drugs can form reversible bonds w/various proteins in the body. Plasma Albumin is the most abundant protein in the body.
An important consequence of protein binding is restriction of drug distribution (because albumin is too large to leave the bloodstream, drug molecules that are bound to albumin can’t leave either)
*it can be a source of drug interactions
Metabolism of Medications
Defined as the enzymatic alteration of drug structureMost metabolism takes place in the liver.
Therapeutic consequences of drug metabolism
Accelerated renal excretion of drug
Drug inactivation
Increased therapeutic action
activation of “pro drugs”
Increased toxicity
Decreased toxicity
The most important consequence of drug metabolism
promotion of renal drug excretion
Special considerations in drug metabolism
Age
Induction of drug-metabolizing enzymes
First-pass effect
Nutritional status
Competition between drugs

The nurse is monitoring a group of patients for adverse drug reactions (ADRs). Which patient is most at risk for developing drug toxicity?

A. A 30-year-old man admitted for altered mental status
B. A 55-year-old woman with abnormal arterial blood gas values
C. A 70-year-old woman with an elevated creatinine level
D. A laboring 25-year-old woman with a positive Homans’ sign

C. A 70-year-old woman with an elevated creatinine level

The liver, kidneys, and bone marrow are important sites of drug toxicity. Creatinine is a measure of kidney function and would be the most helpful for monitoring for ADRs. In addition, patients over age 60 are at greater risk for ADRs. Mental status is a measure of central nervous system (CNS) function, which may be affected by drugs but is not one of the most important and common sites of drug toxicity. Arterial blood gas measurements reflect respiratory and acid-base function. Homans’ sign is used to detect deep vein thrombosis.

Peak and Trough
The highest level is PEAK
The lowest level is TROUGH
*To reduce fluctuations in drug levels
1. administer drugs by continuous infusion
2. Administer a depot preparation, which releases the drug slowly and steadily
3. reduce both the size of each dose and the dose interval
Side effect
Nearly unavoidable secondary drug effect produced at therapeutic doses
Adverse effect
any noxious, unintended, and undesired effect that occurs at normal drug doses
Patients who are at risk for adverse effect
*Very young
*Elderly
*Very ill
*taking multiple drugs
Synergistic effect
An effect arising between two or more agents, entities, factors, or substances that produces an effect greater than the sum of their individual effects
The nurse administers naloxone to a patient receiving morphine sulfate who has a respiratory rate of 8 breaths per minute. Why?

Naloxone prevents the activation of opioid receptors.

Naloxone is an antagonist, which prevents the activation of opioid receptors, reversing the respiratory depression effects of morphine. Continuous exposure of cells to antagonists can result in hypersensitivity. Continuous exposure of cells to agonists can lead to desensitization, refractoriness, or down-regulation.

Agonist
MIMIC
Molecules that activate receptors
*When drugs act as agonists, they simply bind to receptors and mimic the actions of the body’s own regulatory molecules
Antagonists
BLOCK
Produce their effects by preventing receptor activation by endogenous regulatory molecules and drugs and by preventing the activation of receptors by agonists.
Grapefruit Juice Effects
Can inhibit the metabolism of certain drugs, thereby raising their blood levels. Inhibits CYP3A4 (isozyme of cytochrome P450) found in the liver and intestinal wall.
Metabolism can still be inhibited even if a patient drinks grapefruit juice in the morning, but waits later to take medicine. It can lasts up to 3 days if the patient drinks it on a regular basis.
Addiction
A chronic, relapsing brain disease that is characterized by compulsive drug seeking and use, despite harmful consequences.
*NOTE- Addiction is NOT physical dependence
A nurse is teaching a class on addiction. Which statement by one of the class participants indicates a need for further teaching?

Addictive drugs lead to dopamine release in amounts similar to those released by normal reward circuits

Drugs of addiction use the same reward circuits that are used to reward biologically critical behaviors such as eating and sexual intercourse. However, addictive drugs lead to dopamine release that can be 2 to 10 times higher than that released naturally. Eventually, neural remodeling occurs, causing the brain to produce less dopamine and to reduce the number of dopamine receptors, leaving addicts feeling depressed and lifeless. This process of down-regulation reduces the response to the drug. All of this is part of the synaptic remodeling that occurs when the brain is exposed to a drug over a period of time.

Tolerance
Results from regular drug use and can be defined as a state in which a particular dose elicits a smaller response that it did with the first initial dose. As tolerance increases the dose needs to be increased as well.
Dependence
Psychologic- Intense subjective need for a particular psychoactive drug.
Physical dependence- State in which an abstinence syndrome will occur if drug use is discontinued. (result of neuroadaptive processes that take place in response to prolonged drug exposure)
Cross-dependence- Ability of one drug to support physical dependence of another drug. Taking Drug A, will help prevent withdrawals of Drug B.
The ideal goal of treatment is:
Complete abstinence
Drug Abuse
Drug use that is inconsistent with medical or social norms.
A college student admits frequent use of LSD to a nurse and reports plans to stop using it. What will the nurse tell this student?

Tolerance to the effects of LSD will fade quickly once use of the drug has stopped.

Tolerance to the effects of LSD develops rapidly but fades quickly when the drug is stopped. Flashback episodes may occur but are not common. Haloperidol may actually intensify symptoms associated with an acute panic reaction; it is not indicated for LSD withdrawal. Abstinence syndrome does not occur when LSD is stopped.

A college student is brought unresponsive to the emergency department by friends, who say that their friend drank more than half of a large bottle of whiskey 3 hours ago. Assessment reveals a blood alcohol level of 0.32%. The vital signs are BP, 88/32 mm Hg; R, 6/min; T, 96.8° F; and P,76/min and weak and thready. The nurse should prepare the patient for which intervention?

Gastric lavage and dialysis

The average rate at which a person can metabolize alcohol is about 15 mL (0.5 ounce) per hour. The patient in this scenario has consumed more than half of a large bottle of whiskey within 3 hours. Alcohol can be removed from the body by gastric lavage and dialysis. Gastric lavage “washes out” most of the alcohol if any is left in the gut, and dialysis is implemented to reduce the chance of renal failure and cardiovascular shock. Although intravenous fluids may be appropriate, stimulants are contraindicated for this patient. Charcoal is not indicated in this situation. Naloxone is indicated in opiate overdoses, not alcohol overdoses.

A client verbalizes an intense need for psychoactive drugs. The nurse recognizes this behavior as what

A. Physical dependence
B. Drug tolerance
C. Psychologic dependence
D. Addiction

C. Psychologic dependence

Psychologic dependence is defined as an intense subjective need for a drug. Physical dependence is a state in which withdrawal symptoms occur when use of the drug is discontinued. Tolerance is the state in which higher and higher doses are needed to produce the same effect. Addiction is a disease process characterized by continued use of a substance despite the risk for physical, psychologic, or social harm.

The nurse is working on a unit in which patients regularly receive controlled substances. Which principles guide the appropriate care of patients receiving these drugs? (Select all that apply.)

A. Drugs that are categorized in Schedule V have the highest potential for abuse.
B. Drugs are categorized into schedules based on their potential for abuse and dependence.
C. When federal and state laws differ, federal laws always take precedence.
D. Prescriptions for Schedule I drugs must be written for no more than a 90-day supply.
E. A transfer must be documented every time a controlled substance is purchased or dispensed.

B Drugs are categorized into schedules based on their potential for abuse and dependence.

E. A transfer must be documented every time a controlled substance is purchased or dispensed.

Drugs considered controlled substances are categorized according to their potential for abuse and dependence. Each time a controlled substance is purchased or dispensed, that transfer must be recorded. Drugs in Schedule I have the highest potential for abuse. The more stringent law, whether state or federal, always takes precedence. Schedule I drugs have no approved medical uses in the United States and therefore cannot be prescribed legally.

Drug Accumulation/Toxicity Why & How this occurs
Adverse drug reaction caused by excessive dosing

The nurse is caring for a patient who has jaundice, dark urine, malaise, light-colored stools, nausea, and vomiting. This patient is most likely experiencing what?

An idiosyncratic drug effect on the bone marrow
B. Iatrogenic disease of the kidneys
C. Drug toxicity of the liver
D. An allergic reaction

C. Drug toxicity of the liver

Drug toxicity is an adverse drug reaction in which certain drugs are toxic to specific organs. Signs and symptoms of liver toxicity include jaundice, dark urine, light-colored stools, nausea, vomiting, malaise, abdominal discomfort, and loss of appetite.

The nurse is caring for a patient who is experiencing a respiratory rate of 6 breaths per minute as a result of a large dose of pain medication. Which term most accurately describes this reaction?

A. Side effect
B.Toxicity
C. Allergic reaction
D. Idiosyncratic reaction

B. Toxicity

Toxicity is an adverse drug reaction caused by excessive dosing. A side effect is a nearly unavoidable secondary drug effect produced at a therapeutic dose. An allergic reaction is an immune response. An idiosyncratic effect is an uncommon drug response resulting from a genetic predisposition.

The nurse is reviewing the laboratory work for a patient who is taking atorvastatin (Lipitor). Which laboratory value is most useful for monitoring this drug?

A. Aspartate aminotransferase (AST)
B. Blood urea nitrogen (BUN)
C. International normalized ratio (INR)
D. C-reactive protein (CRP)

A. Aspartate aminotransferase (AST)

AST is a liver enzyme that is helpful for monitoring liver function (hepatotoxicity). Lipitor, a lipid-lowering drug, is a commonly prescribed example of a hepatotoxic drug. The BUN is a measure of kidney function. The INR is a comparative rating of prothrombin time ratios that is used to monitor patients taking the anticoagulant agent warfarin. The CRP is elevated in inflammatory and neoplastic disease, myocardial infarction, and the third trimester of pregnancy. It is used as a cardiac risk marker.

The three most common types of fatal medication errors
are giving an overdose, giving the wrong drug, and using the wrong route.
Insulin
Regular- Humilin R & Novolin R (short duration, slower acting)
U 500 should never be given IV
subQ, IV, IM
ClearNPH (Intermediate) Humilin N, Novolin N
Cloudy
SUB Q

Which instruction should the nurse provide when teaching a patient to mix regular insulin and NPH insulin in the same syringe?

A. “Draw up the clear regular insulin first, followed by the cloudy NPH insulin.”
B. “It is not necessary to rotate the NPH insulin vial when it is mixed with regular insulin.”
C. “The order of drawing up insulin does not matter as long as the insulin is refrigerated.”
D. “Rotate subcutaneous injection sites each day among the arm, thigh, and abdomen.”

A. “Draw up the clear regular insulin first, followed by the cloudy NPH insulin.”

To ensure a consistent response, only NPH insulin is appropriate for mixing with a short-acting insulin. Unopened vials of insulin should be refrigerated; current vials can be kept at room temperature for up to 1 month. Drawing up the regular insulin into the syringe first prevents accidental mixture of NPH insulin into the vial of regular insulin, which could alter the pharmacokinetics of subsequent doses taken out of the regular insulin vial. NPH insulin is a cloudy solution, and it should always be rotated gently to disperse the particles evenly before loading the syringe. Subcutaneous injections should be made using one region of the body (e.g., the abdomen or thigh) and rotated within that region for 1 month.

A patient who took NPH insulin at 0800 reports feeling weak and tremulous at 1700. Which action should the nurse take?

A. Take the patient’s blood pressure.
B. Give the patient’s PRN dose of insulin.
C. Check the patient’s capillary blood sugar.
D. Advise the patient to lie down with the legs elevated.

C. Check the patient’s capillary blood sugar.

The patient is showing symptoms of hypoglycemia at 5 PM. NPH has a peak action of 8 to 10 hours after administration. Based on the duration of action of NPH insulin, the patient’s hypoglycemic symptoms are from the 8 AM injection of NPH insulin. An injection of NPH insulin at 2 AM, 1 PM, or 3 PM would not cause hypoglycemic symptoms based on the average duration of action of NPH insulin.

A nurse caring for a patient who has diabetic ketoacidosis recognizes which characteristics in the patient? (Select all that apply.)

A. Type 2 diabetes
B. Altered fat metabolism leading to ketones
C. Arterial blood pH of 7.35 to 7.45
D. Sudden onset, triggered by acute illness
E. Plasma osmolality of 300 to 320 mOsm/L

B. Altered fat metabolism leading to ketones
D. Sudden onset, triggered by acute illness
E. Plasma osmolality of 300 to 320 mOsm/LDiabetic ketoacidosis is the most severe manifestation of insulin deficiency in patients with type 1 diabetes. It develops and worsens acutely over several hours to days. Alterations in fat metabolism lead to the production of ketones and ketoacids. Increased ketoacid levels lead to a fall in arterial blood pH below 7.35. Altered glucose metabolism leads to hyperglycemia, water loss, and an elevated plasma osmolality (285 to 295 mOsm/L).

Routes of Administration- PO
PO- By mouth
Absorbed: stomach, intestines, or both
Two barriers to cross: Layer of epithelial cells that line GI & capillary wall
Major barrier- GI epithelium
Factors that can influence absorption: solubility & stability, gastric & intestinal pH, gastric emptying time, food in the gut, coadministration of other drugs, special coating on the drug preparation.
Advantage- easy, convenient, inexpensive, SAFER than injection
Disadvantage- Variability, absorption can be highly variable, inactivation, patients who can’t take them orally (comatose, psychosis), local irritation
Routes of Administration- IM
IM- Intramuscular
Barrier to absorption- capillary wall
Can be absorbed rapidly or slowly
Rate determines by two factors: water solubility and blood flow
Advantage- Used for parenteral administration of poorly soluble drugs, use it to administer depot preparations
Disadvantage- Painful, bleeding risk, less convenient than oral administration
Route of Administration- IV

IV- Intravenous

No barriers to absorption
Absorption is instanteous and complete
Rapid onset, ideal for emergencies
Irreversible

Z-tracking
The Z-track is a better injection technique. It’s been shown to
reduce leakage of medication through subcutaneous tissue and
decrease skin lesions at the injection site. Plus, it doesn’t hurt
patients quite as much as a regular I.M. injection.
When using the Z-track method, you displace the tissue before
you insert the needle. Once the needle’s withdrawn, the tissue’s
restored to its normal position. this traps the drug inside the
muscle and prevents any leakage. The benefit: The patient gets
the full dose of medication.

The nurse is preparing to administer a dose of penicillin. Before administering the medication, the nurse assesses the patient’s allergy history. Which aspect of drug therapy does this represent?

A. Making PRN (as needed) decisions
B. Evaluating therapeutic effects
C. Ensuring proper dosage
D. Identifying high-risk patients

D. Identifying high-risk patients

Patients receiving penicillin are at high risk for dangerous allergic reactions. This intervention represents the nurse’s role in identifying situations with high risk. This situation does not represent the remaining responses.

The nurse is preparing to administer a medication with the following order: “Aldomet 250 mg daily.” What should the nurse do?

A. Administer the medication as it was given last time.
B. Administer the medication by mouth.
C. Verify the order with the prescriber.
D. Ask the patient how this medication is usually given.

C. Verify the order with the prescriber

This order does not include a drug route. The nurse should clarify any questionable orders with the prescriber. The other responses are incorrect.

Which aspect of drug therapy indicates to the nurse whether a drug is having a beneficial effect?

A. Performing a preadministration assessment
B. Evaluating therapeutic responses
C. Minimizing adverse effects
D. Managing toxicity

B. Evaluating therapeutic responses

Evaluation is one of the most important aspects of drug therapy, because it tells the nurse whether a drug is having its intended effect. The other aspects of drug administration are important but do not give information about a drug’s effectiveness.

The nurse is managing the care of a group of patients with cancer who will be receiving chemotherapy. The nurse defines goals, sets priorities, identifies interventions, and establishes criteria for evaluating success. Which phase of the nursing process does this represent?

A. Assessment
B. Planning
C. Implementation
D. Evaluation

B. Planning

These activities are all carried out in the planning phase of the nursing process. Assessment is a time of data gathering, implementation begins with carrying out the interventions, and evaluation is performed to determine the degree to which treatment has succeeded

The nurse is obtaining a drug history for a patient admitted to the unit. The nurse obtains information about past and present health histories, currently used prescription drugs, behavioral factors, and use of over-the-counter (OTC) drugs. What other information does the nurse need to obtain? (Select all that apply.)

A. Correct Use of recreational drugs and substances
B. Usual sleep patterns and disturbances
C. Highest level of education completed
D. Use of home remedies
E. Self-treatment with complementary and alternative drugs

D. Use of home remedies
E. Self-treatment with complementary and alternative drugsWhen answering a multiple-response question, consider each option independently. In this case, three answers are correct. The nurse must take a holistic approach when assessing the drug history. Recreational drugs and substances, home remedies, and self-treatment with complementary and alternative drugs are vital components of a patient’s drug history. Sleep patterns and level of education are not considered vital information in the drug history.

Which statements about medication administration would the nurse identify as true? (Select all that apply.)

A. All drugs have the potential to produce undesired effects.
B.Drug therapy often can be enhanced by nonpharmacologic measures.
C. Patients taking two drugs are not likely to have a drug interaction.
D. Nurses’ knowledge of pharmacology is more important for standing orders than for PRN medications.
E. Patient adherence is essential in achieving the therapeutic objective of medications.

A. All drugs have the potential to produce undesired effects.
B. Drug therapy often can be enhanced by nonpharmacologic measures.
E. Patient adherence is essential in achieving the therapeutic objective of medications.All drugs have the potential to produce undesired effects. Drug therapy often can be enhanced by nonpharmacologic measures, such as physical therapy or dietary changes. Patient adherence is the extent to which a patient’s behavior coincides with medical advice. This is especially important for patients taking medications at home. Patients taking two drugs are at risk for drug interactions. PRN medications require a high level of nursing discretion, judgment, and knowledge and are not less important than standing orders.

When educating patients about their medications, the nurse includes information about which topics? (Select all that apply.)

A. What to do if a dose is missed
B. The duration of treatment
C. Prescription drug coverage
D. The method of drug storage
E. Symptoms of adverse effects

A. What to do if a dose is missed
B. The duration of treatment
D. The method of drug storage
E. Symptoms of adverse effectsPrescription drug coverage is not considered part of essential patient drug information. The remaining options are topics the nurse would include in patient education.

Medication assessment prior to any med

Preadministration assessment has four basic goals:

collection of baseline data needed to evaluate therapeutic responses
collection of baseline data needed to evaluate adverse effects
identification of high risk patients
assessment of the patient’s capacity for self-care

CHAPTER 104 EYES
EYES
Anticholinergic effects
Produces Mydriasis(dilation) and cyclopegia (paralysis)
Mydriasis results from blocking muscarinic receptors that promote contraction of the iris sphincter
Cyclopegia results from blocking muscarinic receptors that promote contraction of the ciliary muscle
*Relaxation of the iris can lead to elevation of IOP
Timoptic affects (think she meant Timolol) lol= beta blocker
Lower IOP by decreasing aqueous humor production
Latanoprost affects
Lower IOP by facilitating aqueous humor production
Most significant side effect is a harmless heightened brown pigmentation of the iris. Heightened pigmentation stops when medicine is discontinued but, the darker pigmentation will remain.
Emergency glaucoma medications
Combo of osmotic agents, short-acting miotics, carbonic anhydrase inhibitors, topical beta-adrenergic blocking agents is employed to suppress symptoms. Once IOP has been reduced, definitive treatment is surgery
Glaucoma treatment Medications
First- Line
Beta Blockers
Beta 1, selective
Alpha 2-adrenergic agonists
Prostaglandin analogsSecond Line Agents
Cholinergic drugs
Carbonic-anyhydrase inhibitors

Topical beta blockers
Can be absorbed in amounts sufficient enough to cause bronchospasm, bradycardia, and AV heart block.
Beta Blockers used in Glaucoma
Betaxolol
Carteolol
Levobunolol
Mitpranolol
Timolol
Adverse effects from beta blockers
Occular stinging, occasionally cause conjunctivitis, blurred vision, photophobia, and dry eyes
When using beta blockers to treat Glaucoma always monitor
Pulse rate
Prostaglandin Analogs used in Glaucoma
Latanoprost (Xalatan)
Travoprost (Travatan)
Bimatroprost (Lumigan)
Adverse effects from prostaglandin
blurred vision, burning, stinging, conjunctiva hyperemia, migraine (rarely)
Alpha 2-Adrenergic Agonist

Brimonindine- first and only topical agonist approved for long term reduction of elevated IOP

Common side effect- dry mouth, ocular hyperemia, local burning and stinging, HA, ocular itching

NOTE: can cross the BBB, and cause drowsiness, fatigue and hypotension

NOTE: can also be absorbed in soft contact lenses, at least 15 minutes should elapse between administration and installation

A nurse caring for a patient who is taking the prostaglandin analog latanoprost (Xalatan) documents which finding as an adverse effect?

Tachycardia and hypertension
B. Heightened brown pigment of the iris
C. Headache, dry mouth, and altered taste
D. Ocular stinging and conjunctivitis

B. Heightened brown pigment of the iris

Latanoprost is used to increase aqueous outflow in the treatment of open-angle glaucoma. Heightened brown pigmentation of the iris occurs as an adverse effect. Tachycardia and hypertension are associated with nonselective adrenergic agonists. Headache, dry mouth, and altered taste are associated with alpha-adrenergic agonists. Ocular stinging and conjunctivitis are seen with carbonic anhydrase inhibitors.

A nurse administers pilocarpine (Pilocar) eye drops to a patient who has glaucoma. The nurse would expect an increase in which outcome if the medication is having the desired effect?

A. Aqueous inflow
B. Pupillary constriction
C. Aqueous production
D. Pupillary dilation

B. Pupillary constriction

Pilocarpine is a direct-acting cholinergic agonist that is used as a miotic in the treatment of open-angle glaucoma. In addition, contraction of the ciliary muscle lowers the IOP. Miosis causes pupillary constriction, increasing the outflow of aqueous humor. Aqueous inflow and production and pupillary dilation are not expected therapeutic responses to pilocarpine.

A nurse prepares to apply timolol (Timoptic) eye drops to a patient who has asthma. Which action should the nurse take when applying the eye drops?

A. Give the patient a bronchodilator inhaler before administering the eye drops.
B. Keep the patient in an upright sitting position for 3 hours after administration.
C. Administer the drops to one eye; wait 30 minutes, and then apply them to the other eye.
D. Apply pressure to the inner aspects of the eye during and after administration.

D. Apply pressure to the inner aspects of the eye during and after administration.

Timolol is a beta-adrenergic blocking agent. Systemic absorption should be minimized to reduce the risk of bronchospasm. Applying pressure to the inner aspects of the eye during and after administration reduces systemic absorption. This action is particularly important for a patient with a history of asthma. Giving a bronchodilator inhaler, keeping the patient upright, and waiting 30 minutes between administrations to each eye are incorrect actions to take with a patient who has asthma and is receiving timolol.

A nurse prepares a patient for an intraocular examination by administering a topical anticholinergic agent intended to achieve which outcome?

A. Dilation of the pupil
B. Constriction of the iris
C. Relaxation of the ciliary muscle
D. Incorrect Drainage of aqueous humor

A. Dilation of the pupil

Anticholinergic medications produce mydriasis and cycloplegia, dilation of the pupil, and paralysis of the ciliary muscle. These actions facilitate diagnosis of and surgery for ophthalmic problems. Dilation of the pupil, constriction of the iris, and drainage of aqueous humor are not therapeutic effects of anticholinergic agents.

A nurse teaches a patient who is to start taking brinzolamide (Azopt) about which adverse effect?

A. Malaise
B. Bitter aftertaste
C. Dry mouth
D. Photophobia

B. Bitter aftertaste

Brinzolamide, a carbonic anhydrase inhibitor, is a topical treatment for elevated IOP in patients with POAG. It reduces the IOP by slowing the production of aqueous humor. Brinzolamide has mild adverse effects of transient blurred vision and a bitter aftertaste. Malaise is common with systemic carbonic anhydrase inhibitors. Dry mouth occurs with alpha2-adrenergic agonists. Photophobia is not associated with brinzolamide.

Which ophthalmic solution would be most appropriate for a patient with open-angle glaucoma and a history of chronic obstructive pulmonary disease (COPD)?

A. Timolol
B. Carteolol
C. Betaxolol
D. Levobunolol

C. Betaxolol

Betaxolol is a beta1-selective blocker and the preferred drug for use in patients with asthma and COPD. Timolol, carteolol, and levobunolol are nonselective beta-adrenergic blockers; that is, they block both beta1 and beta2 receptors. Blockade of beta2 receptors can lead to bronchospasm.

For which underlying condition would treatment with betaxolol ophthalmic drops for open-angle glaucoma be contraindicated?

A. History of asthma
B. History of type 2 diabetes mellitus
C. Asymptomatic first-degree heart block
D. Newly diagnosed COPD

C. Asymptomatic first-degree heart block

Betaxolol, a beta1-selective blocker, is contraindicated in patients with an AV block, as well as those with bradycardias and cardiogenic shock. Type 2 diabetes mellitus, asthma, and COPD are not contraindications for the administration of betaxolol.

Which instruction should the nurse include in the teaching plan for a patient who is to be started on brimonidine (Alphagan) ophthalmic drops?

A. “A common side effect is an increase in salivation.”
B. “The drug may cause an increase in brown pigmentation of your iris.”
C. “You may notice an increase in the length and thickness of your eyelashes.”
D. “Wait 15 minutes after instilling the eye drops before putting in your contact lenses.”

D. “Wait 15 minutes after instilling the eye drops before putting in your contact lenses.”

Brimonidine can be absorbed into contact lenses. Patients should wait at least 15 minutes between applying the eye drops and putting in their contact lenses. The drug can lead to dry mouth, not increased salivation. Changes in iris pigmentation and eyelash length and thickness are associated with the prostaglandin analogs.

A nurse at a screening clinic for primary open-angle glaucoma (POAG) assesses patients for which major risk factors? (Select all that apply.)

A. Hypertension
B. Correct Black race
C. Correct Familial history
D. Correct Advancing age
E. Correct Elevated intraocular pressure (IOP)

B. Black race
C. Familial history
D. Advancing age
E. Elevated intraocular pressure (IOP)The risk factors for POAG include elevation of the IOP, black race, family history of POAG, and advancing age. Hypertension is not associated with the development of POAG.

EARS
CHAPTER 106 EARS
Otitis Media
Inflammation and fluid in the middle ear
Otalgia is characteristic
Other sx include: fever, vomiting, irritability, impaired hearing, sleeplessness, and otorrhea
Can be viral or bacterial, or BOTH
To diagnose three elements must be present
1. acute onset of s/sx
2. middle-ear effusion
3. middle-ear inflammation
Otitis Media Treatment
All children with AOM should receive required pain medication and some should receive antibiotics
Major risk factors for developing resistant AOM
Attending day care
Age less than 2 years
Exposure to antibiotics in the prior 1 to 3 months
Winter and spring seasons
How should resistant AOM be treated?
High-dose amoxicillin/clavulanate
Prevention-
Breast feeding, eliminating exposure to tobacco smoke, reducing pacifier use in the second 6 months of life, and avoiding supine bottle feeding, vaccinations
OME tx
1. Short-term antibacterial therapy
2. Prophylactic Antibacterial therapy
3.Prevention and tx of influenza
4. placement of tympanostomy tube

A nurse assesses a patient who has bacterial acute otitis media (AOM). The nurse should recognize which manifestation if identified in the patient?

A. Bulging tympanic membrane with otorrhea and otalgia
B. Excessive inner ear moisture and loss of protective cerumen
C. Rapid onset of ear pain with pruritus and hearing loss
D. Pronounced tenderness of the auricle on manipulation

A. Bulging tympanic membrane with otorrhea and otalgia

Bacterial AOM is characterized by the acute onset of symptoms that include otalgia (ear pain) and inflammation. An inner ear that is filled with purulent fluid causes the tympanic membrane to bulge outward. If the membrane is perforated, otorrhea can result. Excessive inner ear moisture and the loss of protective cerumen are not effects associated with AOM. Rapid-onset of ear pain with pruritus and hearing loss and pronounced tenderness of the auricle on manipulation are associated with acute otitis externa.

A nurse is preparing teaching materials about high-dose amoxicillin for a parent whose child has AOM. The child must meet which treatment guideline?

A. Age 2 years or older with mild otalgia
B. Age younger than 6 months with a certain diagnosis
C. Weight of 10 pounds with a certain diagnosis
D. Age 2 years or older with bacterial AOM only

B. Age younger than 6 months with a certain diagnosis

New guidelines for treating AOM in children stress the need for basing treatment on three factors: age, the severity of the illness, and the degree of diagnostic certainty. All children younger than 6 months of age should receive antibiotics, regardless of the diagnostic certainty or symptom severity. Observation is the preferred strategy in children age 2 years or older when the illness is not severe (mild otalgia and fever under 39°C). Weight is not a treatment guideline, nor is bacterial AOM alone.

The nursing instructor asks a student nurse which bacterial pathogen is most commonly found in the middle ear of children with AOM. The nursing student demonstrates understanding by giving which answer?

A. Escherichia coli
B. Moraxella catarrhalis
C. Haemophilus influenzae
D. Streptococcus pneumoniae

D. Streptococcus pneumoniae

S. pneumoniae accounts for 40% to 50% of bacterial pathogens found in the middle ear during an episode of AOM. H. influenzae accounts for 20% to 24%, and M. catarrhalis accounts for 10% to 15%. E. coli typically is not found.

A 6-year-old is diagnosed with acute otitis externa (AOE). What would not be recommended as part of the treatment plan for this child?

A. Ear drops should be warmed before they are instilled.
B. A 2% solution of acetic acid should be instilled.
C. The external auditory canal (EAC) should be kept as dry as possible.
D. Tympanostomy tubes may need to be inserted if no response is seen to conventional treatment.

D. Tympanostomy tubes may need to be inserted if no response is seen to conventional treatment.

Tympanostomy tubes may be indicated for recurrent otitis media to permit aeration and drainage of the middle ear. They are not part of the treatment plan for AOE. Ear drops should be warmed before instillation to prevent dizziness. A topical 2% solution of acetic acid is a safe, effective treatment for AOE. The EAC should be kept as dry as possible to prevent bacterial growth.

SKIN 7 Questions!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
SKIN!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
Accutane (Isotretinoin)
Highly effective against severe acne
Contraindicated for use while pregnant, Each patient (female) must use two effective forms of birth control, even if one of them had a tubal ligation, and do an iPledge management system.
Initial Acne treatment
Benzoyl Peroxide (first-line drug for mild to moderate acne
Antibiotics- for moderate to severe
Retinoids- derivatives of vitamin A (retinol)
NOTICE IT SPELLS BAR (like bar of soap, which would be the first non drug therapy..
Gentle cleansing 2-3xs a day.
Oil-based products should NOT be used
Avoid vigorous scrubbing… DUH
Tetracycline Treatment
Used topically to treat acne. Suppresses growth and metabolic activity of Propionibacterium acnes.
Salicylic Acid treatment affects
Promotes desquamation by dissolving the intracellular cement that binds scales to the stratum corneum.
3%-6% use for Keratolytic effects like dandruff, seborrheic dermatitis, acne, psoriasis
40% concentration to remove warts and corns
Salicylic Acid toxicity
Salicylism sx are tinnitus, hyperpnea, and psychologic disturbances.
Skin lesion types (Be able to describe)
Pustule
Pustule
turbid fluid (pus) in cavity; circumscribed and elevated; ex – impetigo, acne
Macule
Macule
solely a color change, flat and circumscribed, ofless than 1 cm; ex – freckles, flat nevi, hypopigmentation, peteciae, measles, scarlet fever
Patch
macules that are larger than 1 cm; ex – mongolian spot, vitiligo, cafe au lait spot, cholasma, measles rash
Papule
Papule
something you can feel (solid, elevated, circumscribed, less than 1 cm) caused by superficial thickening in epidermis; ex – elevated nevus (mole), lichen planus, molluscum, wart (verruca)
Plaque
papules coalesce to form surface elevation wider than 1 cm; a plateau-like, disk-shaped lesion; ex – psoriasis, lichen planus
Vesicle
Vesicle
elevated cavity containing free fluid, up to 1 cm; a “blister”; clear serum flows if wall is ruptured; ex – herpes simplex, early varicella (chickenpox), herpes zoster (shingles), contact dermatitis
Cyst
Cyst
encapsulated fluid-filled cavity in dermis or subcutaneous layer, tensely elevating skin; ex – sebaceous cyst, wen
Nodule
Nodule
solid, elevade, hard or soft, larger than 1 cm; may dextend deeper into dermis than papule; ex – xanthoma, fibroma, intradermal nevi
Tumor
larger than a few cm, firm or soft, deeper into dermis; may be benign or malignant, although “tumor” implies “cancer” to most people; ex – lipoma, hemangioma
Wheal
Wheal
superficial, rasied, transient, and erythematous; slightly irregular shape due to edema (fluid held diffusely in tissues); ex – mosquite bite, allergic reaction, dermographism
Uticaria
Hives; wheals coalesce to form extensive reaction, intesely pruritic
Bulla
larger than 1 cm; usually single chambered (unilocular); superficial in epidermis; it is thin walled, so it ruptures easily; ex – friction blister, pemphigus, burns, contact dermatitis
Dovonex- Psoriasis
Vitamin D analog (mild to moderate psoriasis) These do not cause thinning of the skin as do glucorticoids.
Anthralin- Psoriasis
Has only one indication of treatment: topical tx of psoriasis
May cause local irriation
Severe conjunctivitis can occur following contact with the eyes
Applied as a 0.5%-1% cream
Applied at bedtime
will stain so wear old clothing
tar and tazorac topical treatment Psoriasis
Unpleasant odor and can cause irritation. may stain the skin and hair
Systemic toxicity does not occur
HYPo Kalemia

Normal K lemia (Potassium) RANGE IS 3.5-5 meq/L

Hypokalmia- Below 3.5 meq/L
Most common cause: Trmt w/Thiazide or loop diuretic
Affects: Skeletal muscle, smooth muscle, blood pressure and heart
Weakness or paralysis of skeletal muscle, risk of fatal dysrhythmias, and intestinal dilation and ileus.

HYPer Kalemia
Anything above 5 meq/L
Most common cause: severe tissue trauma, untreated Addison’s disease, acute acidosis, misuse of potassium sparing diuretics, and overdose of IV potassiumAffects: disruption of electrical activity of the heart
Sx: confusion, anxiety, dyspnea, weakness or heaviness in legs, numb or tingling of hands, feet and lips

hypokalemia interventions
potassium never given as IV push or intramuscular or subcutaneous route.
1mEq/ per 10mL of solution is recommended
after adding to IV bag, invert bag to distributed evenly throughout IV solution/hr. never to exceed 20 mEq/hr.
label IV bag properly
maxium infusion rate is 5 to 10 mEq
client receiving more than 10 mEq/hr should be placed on cardiac monitor and monitored during the entire infusion and controlled by an infusion pump
A pt prescribed spironolactone is demonstrating ECG changes & complaining of muscle weakness. The nurse realizes this pt is exhibiting signs of which of the following?
1. hyperkalemia
2. hypokalemia
3. hypercalcemia
4. hypocalcemia
Answer: 1
Rationale 1: Hyperkalemia is serum potassium level greater than 5.0 mEq/L. Decreased potassium excretion is seen in potassium-sparing diuretics such as spironolactone. Common manifestations of hyperkalemia are muscle weakness & ECG changes.
Rationale 2: Hypokalemia is seen in non-potassium diuretics such as furosemide.
Rationale 3: Hypercalcemia has been associated with thiazide diuretics.
Rationale 4: Hypocalcemia is seen in pts who have received many units of citrated blood & is not associated with diuretic use.
A pt is diagnosed with hypokalemia. After reviewing the pt’s current medications, which of the following might have contributed to the pt’s health problem?
1. corticosteroid
2. thiazide diuretic
3. narcotic
4. muscle relaxer

Answer: 1 corticosteroid

Rationale 1: Excess potassium loss through the kidneys is often caused by such meds as corticosteroids, potassium-wasting diuretics, amphotericin B, & large doses of some antibiotics.
Rationale 2: Excessive sodium is lost with the use of thiazide diuretics.
Rationale 3: Narcotics do not typically affect electrolyte balance.
Rationale 4: Muscle relaxants do not typically affect electrolyte balance.

The nurse is admitting a pt who was diagnosed with acute renal failure. Which of the following electrolytes will be most affected with this disorder?
1. calcium
2. magnesium
3. phosphorous
4. potassium
Answer: 4
Rationale 1: This pt will be less likely to develop a calcium imbalance.
Rationale 2: This pt will be less likely to develop a magnesium imbalance.
Rationale 3: This pt will be less likely to develop a phosphorous imbalance.
Rationale 4: Because the kidneys are the principal organs involved in the elimination of potassium, renal failure
The pt is receiving intravenous potassium (KCL). Which nursing actions are required? Select all that apply.
1. Administer the dose IV push over 3 minutes.
2. Monitor the injection site for redness.
3. Add the ordered dose to the IV hanging.
4. Use an infusion controller for the IV.
5. Monitor fluid intake & output.
Answer: 2,4,5
A pt is prescribed 40 mEq potassium as a replacement. The nurse realizes that this replacement should be administered
1. directly into the venous access line.
2. mixed in the prescribed intravenous fluid.
3. via a rectal suppository.
4. via intramuscular injection.
Answer: 2
Rationale 1: Never administer undiluted potassium directly into a vein.
Rationale 2: The intravenous route is the recommended route for diluted potassium.
Rationale 3: The nurse should administer diluted potassium into the pt’s intravenous line.
Rationale 4: The nurse should administer diluted potassium into the pt’s intravenous line.
A pt is prescribed 20 mEq of potassium chloride. The nurse realizes that the reason the pt is receiving this replacement is
1. to sustain respiratory function.
2. to help regulate acid-base balance.
3. to keep a vein open.
4. to encourage urine output.
Answer: 2
Rationale 1: Potassium does not sustain respiratory function.
Rationale 2: Electrolytes have many functions. They assist in regulating water balance, help regulate & maintain acid-base balance, contribute to enzyme reactions, & are essential for neuromuscular activity.
Rationale 3: Intravenous fluids are used to keep venous access not potassium.
Rationale 4: Urinary output is impacted by fluid intake not potassium.
A pt who is taking digoxin (Lanoxin) is admitted with possible hypokalemia. Which of the following does the nurse realize might occur with this pt?
1. Digoxin toxicity may occur.
2. A higher dose of digoxin (Lanoxin) may be needed.
3. A diuretic may be needed.
4. Fluid volume deficit may occur.
Answer: 1
Rationale 1: Hypokalemia increases the risk of digitalis toxicity in pts who receive this drug for heart failure.
Rationale 2: More digoxin is not needed.
Rationale 3: A diuretic may cause further fluid loss.
Rationale 4: There is inadequate information to assess for concerns related to fluid volume deficits.
A pt is admitted for treatment of hypercalcemia. The nurse realizes that this pt’s intravenous fluids will most likely be which of the following?
1. dextrose 5% & water
2. dextrose 5% & ? normal saline
3. dextrose 5% & ? normal saline
4. normal saline
Answer: 4
Rationale 1: If isotonic saline is not used, the pt is at risk for hyponatremia in addition to the hypercalcemia.
Rationale 2: This solution is hypotonic. Isotonic saline is used because sodium excretion is accompanied by calcium excretion through the kidneys.
Rationale 3: This solution is hypotonic. Isotonic saline is used because sodium excretion is accompanied by calcium excretion through the kidneys.
Rationale 4: Isotonic saline is used because sodium excretion is accompanied by calcium excretion through the kidneys.
When caring for a pt diagnosed with hypocalcemia, which of the following should the nurse additionally assess in the pt?
1. other electrolyte disturbances
2. hypertension
3. visual disturbances
4. drug toxicity
Answer: 1
Rationale 1: The pt diagnosed with hypocalcemia may also have high phosphorus or decreased magnesium levels.
Rationale 2: The pt with hypocalcemia may exhibit hypotension, & not hypertension.
Rationale 3: Visual disturbances do not occur with hypocalcemia.
Rationale 4: Hypercalcemia is more commonly caused by drug toxicities.
The nurse is planning care for a pt with fluid volume overload & hyponatremia. Which of the following should be included in this pt’s plan of care?
1. Restrict fluids.
2. Administer intravenous fluids.
3. Provide Kayexalate.
4. Administer intravenous normal saline with furosemide.
Answer: 1
Rationale 1: The nursing care for a pt with hyponatremia is dependent on the cause. Restriction of fluids to 1,000 mL/day is usually implemented to assist sodium increase & to prevent the sodium level from dropping further due to dilution.
Rationale 2: The administration of intravenous fluids would be indicated in fluid volume deficit & hypernatremia.
Rationale 3: Kayexalate is used in pts with hyperkalemia.
Rationale 4: The administration of normal saline with furosemide is used to increase calcium secretion.
A pt with fluid retention related to renal problems is admitted to the hospital. The nurse realizes that this pt could possibly have which of the following electrolyte imbalances?
1. hypokalemia
2. hypernatremia
3. carbon dioxide
4. magnesium
Answer: 2
Rationale 1: The kidneys are the principal organs involved in the elimination of potassium. Renal failure is often associated with elevations potassium levels.
Rationale 2: The kidney is the primary regulator of sodium in the body. Fluid retention is associated with hypernatremia.
Rationale 3: Carbon dioxide abnormalities are not normally seen in this type of pt.
Rationale 4: Magnesium abnormalities are not normally seen in this type of pt.
An elderly pt comes into the clinic with the complaint of watery diarrhea for several days with abdominal & muscle cramping. The nurse realizes that this pt is demonstrating which of the following?
1. hypernatremia
2. hyponatremia
3. fluid volume excess
4. hyperkalemia
Answer: 2
Rationale 1: Hypernatremia is associated with fluid retention & overload. FVE is associated with hypernatremia.
Rationale 2: This elderly pt has watery diarrhea, which contributes to the loss of sodium. The abdominal & muscle cramps are manifestations of a low serum sodium level.
Rationale 3: This pt is more likely to develop clinical manifestations associated with fluid volume deficit.
Rationale 4: Hyperkalemia is associated with cardiac dysrhythmias.
A pt is admitted with hypernatremia caused by being str&ed on a boat in the Atlantic Ocean for five days without a fresh water source. Which of the following is this pt at risk for developing?
1. pulmonary edema
2. atrial dysrhythmias
3. cerebral bleeding
4. stress fractures
Answer: 3
Rationale 1: Pulmonary edema is not associated with dehydration.
Rationale 2: Atrial dysrhythmias are not a factor for this pt.
Rationale 3: The brain experiences the most serious effects of cellular dehydration. As brain cells contract, the brain shrinks, which puts mechanical traction on cerebral vessels. These vessels may tear, bleed, & lead to cerebral vascular bleeding.
Rationale 4: There have been no activities to support the development or occurrence of stress fractures.

An elderly pt with a history of sodium retention arrives to the clinic with the complaints of “heart skipping beats” & leg tremors. Which of the following should the nurse ask this pt regarding these symptoms?

1. “Have you stopped taking your digoxin medication?”
2. “When was the last time you had a bowel movement?”
3. “Were you doing any unusual physical activity?”
4. “Are you using a salt substitute?”

Answer: 4
Rationale 1: Although this pt may be prescribed digoxin this is not the primary focus of this question.
Rationale 2: The pt’s bowel habits are not of concern at this time.
Rationale 3: The cardiac & musculoskeletal discomforts being reported are not consistent with physical exertion.
Rationale 4: The pt has a history of sodium retention & might think that a salt substitute can be used. Advise pts who are taking a potassium supplement or potassium-sparing diuretic to avoid salt substitutes, which usually contain potassium.
A 28-year-old male pt is admitted with diabetic ketoacidosis. The nurse realizes that this pt will have a need for which of the following electrolytes?
1. sodium
2. potassium
3. calcium
4. magnesium
Answer: 4
Rationale 4: One risk factor for hypomagnesaemia is an endocrine disorder, including diabetic ketoacidosis.
An elderly pt with peripheral neuropathy has been taking magnesium supplements. The nurse realizes that which of the following symptoms can indicate hypomagnesaemia?
1. hypotension, warmth, & sweating
2. nausea & vomiting
3. hyperreflexia
4. excessive urination
Answer: 1
Rationale 1: Elevations in magnesium levels are accompanied by hypotension, warmth, & sweating.
Rationale 2: Lower levels of magnesium are associated with nausea & vomiting.
Rationale 3: Lower levels of magnesium are associated & hyperreflexia.
Rationale 4: Urinary changes are not noted.
The pt has been placed on a 1200 mL daily fluid restriction. The pt’s IV is infusing at a keep open rate of 10 mL/hr. The pt has no additional IV medications. How much fluid should the pt be allowed from 0700 until 1500 daily?
Answer: 540
Rationale: Fluid allowed is calculated by figuring the total daily IV intake (in this case 10 mL/hr × 24 hours = 240 mL/day), subtracting that total from the daily allowance (in this case 1200mL – 240 mL = 960mL). The amount calculated is then distributed as 50% for the traditional day shift, 25%-35% for the traditional evening shift, & the remainder for the traditional night shift. In this case, 50% of 960 is 540 mL.
The pt who has a serum magnesium level of 1.4 mg/dL is being treated with dietary modification. Which foods should the nurse suggest for this pt? Select all that apply.
1. bananas
2. seafood
3. white rice
4. lean red meat
5. chocolate
Answer: 1,2,5
Rationale: Serum magnesium level of 1.4 mg/dL suggests mild hypomagnesaemia, so this pt should be counseled to eat foods high in magnesium. Foods high in magnesium include green leafy vegetables, seafood, milk, bananas, citrus fruits, & chocolate. White rice & lean red meat are not included.
The pt has a serum phosphate level of 4.7 mg/dL. Which interdisciplinary treatments would the nurse expect for this pt? Select all that apply.
1. IV normal saline
2. calcium containing antacids
3. IV potassium phosphate
4. encouraging milk intake
5. increasing vitamin D intake
Answer: 1,2
Rationale: Serum phosphate level of 4.7 mg/dL indicates hyperphosphatemia. IV normal saline promotes renal excretion of phosphate.
The pt, newly diagnosed with diabetes mellitus, is admitted to the emergency department with nausea, vomiting, & abdominal pain. ABG results reveal a pH of 7.2 & a bicarbonate level of 20 mEq/L. Which other assessment findings would the nurse anticipate in this pt? Select all that apply.
1. tachycardia
2. weakness
3. dysrhythmias
4. Kussmaul’s respirations
5. cold, clammy skin
Answer: 2,3,4
Rationale: Further assessment findings of this condition are weakness, bradycardia, dysrhythmias, general malaise, decreased level of consciousness, warm flushed skin, & Kussmaul’s respirations.Rationale: These ABG results, coupled with the pt’s recent diagnosis of diabetes mellitus & history of vomiting would lead the nurse to suspect metabolic acidosis. Further assessment findings of this condition are weakness, bradycardia, dysrhythmias, general malaise, decreased level of consciousness, warm flushed skin, & Kussmaul’s respirations.

Hyponatremia signs and symptoms
Respiratory
shallow, ineffective respiratory movements as a late manifestation related to skeletal muscle weakness
Hyponatremia neurmuscular
generalized muscle weakness that is worse in the extremities
Diminished deep tendon reflexes
Hyponatremia Cereberal function
headache, personality changes, confusion, seizures, coma
Hyponatremia gastrointestinal
increased motility and hyperactive bowel sounds
nausea
abdominal cramping and diarrhea
Hyponatremia Renal
decreased urinary specific gravity
increased urinary output
Hyponatremia Interventions
Monitor cardiovascular, respiratory, neuromuscular, cerebral, renal, and gastrointestinal status
hyponatremia/hypovolemia: IV sodium chloride infusion
hyponatremia/hypervolemia: osmotic diuretics
if caused by inappropriate or excessive secretion of antidiuretic hormone, Use lithium or Demeclocycline
Instruct to take in more sodium
Monitor lithium levels for toxicity
Hypernatremia
levels above 145
caused by
corticosteroids
cushing syndrome, renal failure, hyperaldosteronism
Excessive oral sodium, excessive IV infusion, Decreased water intake, increased water loss,increased metabolism, fever, hyperventilation, infection, excessive diaphoresis, watery dirrahea, diabetes insipids
Hypernatremia signs and symptoms
Cardiovascular
heart rate and blood pressure responde to vascular volume status
Hypernatremia Respiratory
Pulmonary edema if hypervolemia present
hypernatremia neuromuscular
Early: spontaneous muscle twitches; irregular muscle contractions
Late: skeletal muscle weakness, deep tendon reflex diminished or absent
Hypernatremia central nervous system
altered cerebral function is most common manifestations
Normovolemia and hypovolemia agitation, confusion, seizures
hypovolemia lethargy, stupor, coma
hypernatremia renal
increased urinary specific gravity
decreased urinary ouput
hypernatremia integumentary
dry skin
Presence of absence of edema, depending on fluid volume changes
hypernatremia Interventions
monitor cardiovascular, respiratory, neuromuscular, cerebral, renal, and integumentary status.
Adminsiter IV if caused by fluid loss
if caused by inadequate renal excreation of sodium, administer diurectics that promote sodium loss
restrict sodium intake as prescribed
hypocalcemia
decrease in ionized fraction of calcium
hyperproteinemia,alkalosis, calcium binders chelators
acute pancreatitis, hyperphospatemia, immobility
Removal or destruction of parathyroid glands
hypocalcemia cardiac
decreased heart rate
hypotension, diminished peripheral pulses
Prolonged ST interval, prolonged QT interval
hypocalcemia respiratory
not directly affected but, respiratory failure and arrest may result from decreased respiratory movement because of muscle tetany or seizures
hypocalcemia neuromuscular
irritable skeletal muscles Twitches, cramps, tetany, seizures
painful muscles spasms in the calf or foot during periods of inactivity
paresthesias followed by numbness that may affect the lips, nose, and ears in addition to the limbs
Positive Trousseau’s and Chvostek’s signs
hyperactive deep tendon relexes
anxiety, irritability
hypocalcemia gastrointestional
increased gastric motility; hyperactive bowel sounds
abdominal cramping, diarrhea
hypocalcemia Interventions
monitor cardiovascular, respiratory, neuromuscular, and gastrointestional status; place the client on a cardiac monitor
administer calcium supplements orally or calcium intravenously
Warm injection to body temperature before administration and administer slowly; monitor for ECG changes, observe for infiltration, and monitor for hypercalcemia
administer medications that increase absorption of calcium
hypercalcemia respiratory
ineffective respriatory movement as a result of profound skeletal muscle weakness
hypercalcemia intervention
monitor cardiovascular, respiratory, neuromuscular, renal, and gastrointestional status; place on cardiac monitor
Discontinue IV infusions of solutions containing calcium and oral medications containing calcium and vitamin D
discontinue thiazide diuretics and replace with diurectics that enhance the excretion of calcium
administer medications as prescribed that inhibit calcium resorption from the bone, such a phosphorus, calcitonin (Calcimar), bisphosphonates, and prostaglandin synthesis inhibitors (aspirin, nonsteroidal antiinglammatory drugs)
hypomagnesemia normal values 1.6 to 2.6mg/dL
casuses increased magnesium intake
antacids and laxatives, Excessive IV infusion
Decreased renal excretion as a result of renal insufficiency
hypomagnesemia Interventions
IV administration of calcium chloride or calcium gluconate to reverse the effects of magnesium on cardiac muscle.
restrict dietary intake of magnesium
avoid use of laxatives and antacids.
VITAMINS!!!!!!!!!!!!!!!!
VITAMINS!!!!!!!!!!!!!!!!!!!!!
Who should take Vitamins?
Vitamin B12 for all people over 50
folic acid for all women of child-bearing age
Vitamin D + calcium for postmenopausal women and other people at risk for fractures
Vitamin A deficient
Night blindness
Goal of TPN therapy
Correct nutritional deficit by meeting calorie, protein, vitamin, and mineral requirement that cannot be met orally
what is the least amount of time patient should receive TPN?
frequently as 3 days prior to major surgery OR at least 5 days
3 basic components of TPN
1) lipids 2) amino acid 3)dextrose
Why is insulin added to the bag?
patient having difficulty metabolizing the large dextrose load provided in the TPN. Insulin pulls the dextrose out of the blood and into the cell.
what is the max. concentration of dextrose that can be infused peripherally?
10% dextrose
what is the max. concentration of dextrose that can be infused/ administered centrally?
up to 35%
how long may a central line remain in place?
as long as 6 months
how long may a peripheral line remain in place
72 hours
why should a TPN be started slowly then gradually increased?
given a patient a chance to adjust to the increase dextrose load
why shouldn’t a TPN be abruptly stopped?
It can cause low blood glucose which can caused ie sweaty & dizziness bc the pancreas does not respond immediately and still produce insulin based on the previous dextrose load.
the color of MVI when added to TPN is ..
off white or banana color
another name for TPN
hyperalimentation
sterile water added to TPN for
adjust the volume of the solution for final volume & prevent dehydration
what are the concentration of dextrose?
5-70% concentration – usually 50-70% sol are used for TPN
reasons for the needed of TPN administration?
patient who 1) cannot eat : head/neck surgery, camatose, before/after surgery. 2) will not eat : chronic or psychological disorder and geriatric 3) should not eat : esophageal obstruction or inflammatory bowel disease. 4) cannot eat enough: 3rd/4th degree cancer, burn or trauma mental or full blown
the difference btw hospital and home health care setting
TPN is prepared in a 24 hours supply at hospital setting while in home health care or home infusion setting the pharmacy will prepare a max of 7 days supply
CANCER!!!!!!!!!!!!!!!!
CANCER Chapter 102
Cytotoxic agents
1) alkylating agents
2)platinum compounds
3)antimetabolites
4)hypomethylating agents
5)antitumor antibiotics
6)mitotic inhibitors
7)topoisomerase inhibitors
Alkylating Agent
non specific, make them alkalinic. Cell kill results primarily from alkylation of DNA.
Bone marrow suppression, infusion reaction
hemorrhagic cysitits
Platinum Compounds
Non-specific, produce cross links to DNA.
Bone Marrow Suppression, nephrotoxicity
Antimetabolites
Metabolites are needed for cell production, this is ANTI
These are S-phase specific
Causes Bone Marrow suppression, mucositis
Antimetabolites- Pyrimidine Or Purine Analogs
Required for cell proliferation and synthesizing…
Cause death of cell @ S-phase
Bone marrow suppression, diarrhea, hand-and-foot syndrome, oral and GI ulceration, neurotoxicity
Antitiumor Antibiotics
Every cancer is treated with these and they cause nerve damage-foot drop, which means they trip/fall a lot
it heals itself when the medication has stopped
Nurse should monitor- cardiotoxicity
Mitotic inhibitors
M-phase (some) specific, and some are G2 & M phase.
Peripheral neuropathy, bone marrow suppression
Inhibit myotic phase
Most common Mitotic inhibitor
TAXOL- causes foot drop, muscle weakness, fatigue
Topoisomerse inhibitor
Most sensitive in G2 phase!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
How to protect yourself at home with someone taking these agents
Flush toilet twice
Have a bathroom only for them
Use chlorseptic wipes
Protect yourself from waste products
All of these cytotoxic agents can or will cause:
Anemia, alopecia, and infection (neutropenia) they are eliminated via kidney/fecal so they need to take in MORE WATER
The antidote for extravasation
HYALURONIDASE
Antineoplastic
Mutagenic
Teratorgenic
Carcinogenic
Methotrexate:
a folic acid analog, prevents conversion of folic acid to its active form. Cell kill results primarily from disruption of DNA synthesis

Which scheduling approach for the administration of phase-specific anticancer medications is used to achieve maximum therapeutic effectiveness?

A. One day every 12 weeks
B. Short intervals over time
C. The first day of the month
D. At the end of treatment

B. Short intervals over time

Phase-specific agents are toxic to cells that are passing through a particular phase of the cell cycle. To be effective, phase-specific agents must be present as cancer cells cycle through the specific phase in which the drugs act. These agents must be present for an extended time and often are administered by prolonged intravenous infusion or in multiple doses at short intervals over an extended time. Phase-specific agents may not be as effective if given just on the first day of the month, one day every 12 weeks, or at the end of the treatment.

When planning care for a patient who is receiving cyclophosphamide (Cytoxan), it is most important for the nurse to include which intervention to prevent complications of cyclophosphamide (Cytoxan) therapy?

A. Palpate for pedal pulses every 2 hours.
B. Monitor for laryngeal stridor and tetany.
C. Give an antidiarrheal medication.
D. Increase the IV and oral fluid intake.

D. Increase the IV and oral fluid intake.

Cyclophosphamide is an alkylating agent with adverse effects of dose-limiting bone marrow suppression and hemorrhagic cystitis. Bladder injury can be minimized by maintaining adequate hydration through increased fluid intake. It is not necessary to monitor the patient for laryngeal stridor and tetany, palpate pedal pulses, or give an antidiarrheal medication with cyclophosphamide.

Which statement is most important for a nurse to include in patient teaching for a patient who is discharged after receiving high-dose methotrexate (Rheumatrex)?

A. “Leucovorin (folinic acid) must be taken daily at the same time.”
B. “Consume extra fluids to minimize any injury to the kidneys.”
C. “Nausea and loss of appetite may last for several more days.”
D. “You may notice mouth soreness and ulcers in several weeks.”

A. “Leucovorin (folinic acid) must be taken daily at the same time.”

It is most important that leucovorin (folinic acid) be taken as a rescue medication 24 hours after high-dose methotrexate. High-dose methotrexate exposes normal cells to significant toxicity, and they can be saved by the administration of leucovorin, which bypasses a metabolic block caused by methotrexate. Failure to administer leucovorin in the right dose at the right time can be fatal. Leucovorin rescue is more important than informing the patient to increase fluid intake and that nausea, loss of appetite, and mouth ulcers may occur as adverse effects.

A patient is receiving cisplatin (Platinol-AQ). Which finding, if noted in the patient, would indicate a complication requiring follow-up by a nurse?

A. Difficulty sleeping
B. Numbness in the fingers and toes
C. Breast fullness and tenderness
D. Heartburn and dyspepsia

B. Numbness in the fingers and toes

Cisplatin is a platinum-containing anticancer medication with adverse effects of peripheral sensory neuropathy. Symptoms may be manifested as numbness and tingling in the fingers and toes and difficulty with fine motor activities, such as buttoning clothing and writing.
Difficulty sleeping, breast tenderness, and heartburn are not associated with the adverse effects of cisplatin.

Before an infusion of paclitaxel (Taxol), a nurse should administer which medication to prevent a complication?

A. Famotidine (Pepcid)
B. Diphenhydramine (Benadryl)
C. Furosemide (Lasix)
D. Acetaminophen (Tylenol)

B. Diphenhydramine (Benadryl)

Paclitaxel is a taxane anticancer agent that can cause severe hypersensitivity reactions, manifested by hypotension, dyspnea, and urticaria. Reactions can be minimized by administration of a histamine1 receptor antagonist (diphenhydramine), a histamine2 receptor antagonist (cimetidine), and a glucocorticoid (dexamethasone). No therapeutic effects are obtained with famotidine, acetaminophen, or furosemide pretreatment.

Vaccines
Vaccines
Gardasil
It is a quadrivalent vaccine
Used to prevent cancers, precancerous lesions, and genital warts in females and males.
Indicated for girls and women 9-26 years of age (to prevent cancers by HPV types 16&18)
*Cervical cancer
*Vulvar cancer
*Vaginal cancer
Next paragraph, it lists males also ages 9-26 for genital warts and anal cancer (p869)
Gardasil
Not recommended for women who are pregnant, but women who are breastfeeding can receive the vaccine
Gardasil Route, site, Immunization Schedule
IM, Deltoid upper arm or high anterolateral thigh.
Three doses over a 6 month period
*initial shot
*two months after the 2nd shot
*6 months from the first shot, 3rd shot
Active Immunity
Develops in response to infection or administration of a vaccine or toxoid.
Active immunity takes weeks or months to develop, but it is LONG lasting
Passive Immunity
Passive immunity is by giving a patient preformed antibodies (immune globulins)
Passive immunity protects immediately, but persists for only as long as the antibodies remain in the body
Immunization/vaccination
Immunization refers to production of both Active/Passive immunity whereas vaccination only refers to active immunity
Live Virus Vaccines are:
MMR, Varicella, Influenza, Rotavirus (These should all be avoided in children who are immunosuppressed)-
Flu-prevention
Annual vaccination is recommended for all children ages 6 months-18 years (as well as adults).
IM, Intradermal, intranasal
Who identifies 3 strains of Influenza?
CDC, FDA, and WHO
Precautions/Contraindications for the influenza vaccine
Acute febrile illness (should defer until sx abate)
Contraindicated for persons with hypersensitivity to eggs. +
People who have experienced GBS
Severe allergy to chicken eggs
Severe reaction to past flu shots
Who is at high risk for the flu?
Children younger than 5, especially younger than 2
children age 18 or under receiving long-term aspirin therapy
Pregnant women
People age 65 +
People who are morbidly obese
People who live in nursing homes and other long-term care facilities
American Indians/Alaskan natives
Immunosuppressed (HIV)
People with certain chronic conditionsNOTE: people that are high risk should receive the inactivated

Treatment for the Flu (Tamiflu)
Treatment must begin no later than 2 days after symptom onset because benefits decline greatly when treatment is delayed.
AIDS
HIV
Protease Inhibitors Adverse effects
Hyperglycemia
Fat Maldistribution
Hyperlipidemia
Increased bleeding in hemophilias
Reduced bone mineral density
Elevation of Serum Transaminases

Which administration instruction should the nurse give a patient scheduled to start receiving the HIV fusion inhibitor enfuvirtide (Fuzeon)?

A.”Rotate injection sites in the arm, thigh, and abdomen.”
B. “Take only when you consume low-fat meals.”
C. “Dosing is optimal 30 minutes before meals.”
D. “Injection-site reactions are usually uncommon.”

A.”Rotate injection sites in the arm, thigh, and abdomen.”

The primary action of enfuvirtide is to block the entry of HIV into CD4 T cells. It is administered through subcutaneous injection, and the injections should be rotated in the upper arm, thigh, and abdominal areas of the body. Injection-site reactions of pain, tenderness, erythema, and induration occur in almost every patient. Enfuvirtide is not an oral medication; dosing before meals or with low-fat meals is not a relevant instruction.

PI (Protease inhibitors)
Most effective antiretroviral drug.
All inhibit cytochrome P450
Never use alone

A patient who has HIV and is taking the nucleoside/nucleotide reverse transcriptase inhibitor (NRTI) zidovudine (Retrovir) reports vomiting, abdominal pain, fatigue, and hyperventilation. Which laboratory result is the priority for the nurse to evaluate?

A. Megakaryocytes
B. Red blood cell (RBC) counts
C. CD4 T-lymphocyte counts
D. Arterial blood lactate

D. Arterial blood lactate

Potentially fatal lactic acidosis and hepatic steatosis (fatty liver) can occur with all NRTIs. Measuring arterial blood lactate is a priority for the diagnosis of lactic acidosis. Associated symptoms of nausea, vomiting, abdominal pain, fever, and hyperventilation may occur. Megakaryocytes, RBC counts, and CD4 T-lymphocyte counts also may be measured with NRTI therapy, but alterations in these values are not associated with the complication of lactic acidosis

A patient is receiving the protease inhibitor (PI) amprenavir (Agenerase). Which laboratory results would the nurse evaluate as indicators of adverse effects of this medication? (Select all that apply.)

A. Plasma cholesterol level
B. Serum transaminases
C. Cardiac enzymes
D. Blood glucose level
E. Creatinine level

A. Plasma cholesterol level
B. Serum transaminases
D. Blood glucose levelAll PIs cause hyperglycemia and diabetes, and patients should be instructed to report symptoms of polydipsia, polyphagia, and polyuria. In addition, PIs can increase serum levels of transaminases and should be used with caution in patients with chronic liver disease. Cholesterol should be measured for elevation caused by the use of PIs that results in a risk of cardiovascular events. Altered cardiac enzymes and serum creatinine levels are not associated with adverse effects of PIs.

ANTIBIOTICS
ANTIBIOTICS
What are the USES of Tetracycline antibiotics?
1) Infections
2) Acne
3) Prophylaxis for babies
Tetracycline toxic to
Causes fatty infiltration of the liver (usually by IV route in high doses)
May exacerbate renal impairment
What are some Tetracyclines?
1) Doxycycline
2) Tetracycline
What are SIDE EFFECTS of Tetracycline antibiotics?
1) Discoloration of primary teeth during pregnancy and children under 8
2) Glossitis
3) Phototoxic Reactions (UNIQUE)
4)Overgrowth of candiadis
What are some NURSING CONSIDERATIONS for Tetracycline antibiotics?
1) Tell them to put sun block on
2) Do not take with antacids,milk, or iron
3) DO NOT TAKE BEYOND EXPIRATION DATE. IT WILL HARM THE PATIENT.
4) Give on an empty stomach
Azithromycin absorption
Absorption is increased by food, so dosing may be done with meals
Azithromycin
May pose a risk of bleeding and enhance the effects of warfarin
Azithromycin
Toxic to??? Kidneys???? (I couldn’t find much about this one, pg 1088)
Gentamicin
Aminoglycoside
Toxic to the kidney and inner ear
Antibiotic Superinfections, (Suprainfections)
s/sx (Tetracycline’s)
Severe diarrhea that is life threatening
Candida (yeast) infections in the mouth, pharynx, vagina, and bowel
Vaginal or anal itching
lesions of anogenital region
black, furry appearance on tongue
Penicillin
Penicillin ( -cillin, -lin)
Take w/full glass of water 1hr before meals or 2 hrs. after
Complete the RX
Advise pt. to wear bracelet to show allergy
Safest antibiotics available
Cephalosporin
All have the letters CEF-
Eliminated by kidneys
Poor absorption through GI, so they are administered IM or IV
Three Cephalosporin that cause bleeding
Cefoperazone
Cefotetan
Ceftriaxone
What can occur with IV infusion of Cephalosporin?
Thrombophlebitis
Cephs should be avoided by patients?
Are allergic to it
Have a milk-protein hypersensitivity.
Carnitine deficiency
Advise pts
About alcohol intolerance and warn them not to drink w/Cephs
Vancomycin
Used primarily for
1)C dif
2)MRSA
3)allergy to -cillins
Red Man Syndrome- Vancomycin
Rapid infusion can cause flushing, rash, pruritus, urticarial, tachycardia, hypotension. Infuse Vancomycine slowly over 60 minutes or longer
Carbapenems
Broad antimicrobial spectra
Not absorbed GI, has to be IV or IM
Eliminated by kidneys
Macrolides
Broad spectrum antibiotic inhibit bacterial protein synthesis
C-dif teaching to pt
Instruct patients to report significant diarrhea (more than 5 watery stools per day)

A patient develops flushing, rash, and pruritus during an IV infusion of vancomycin (Vancocin). Which action should a nurse take?

A. Reduce the infusion rate.
B. Administer diphenhydramine (Benadryl).
C. Change the IV tubing.
D. Check the patency of the IV.

A. Reduce the infusion rate.

When vancomycin is infused too rapidly, histamine release may cause the patient to develop hypotension accompanied by flushing and warmth of the neck and face; this phenomenon is called red man syndrome. Diphenhydramine is not necessary if the infusion is administered slowly over at least 60 minutes. Changing the IV tubing would not help the symptoms. The patency of the IV needs to be checked before the administration is started.

Before administering a cephalosporin to a patient, it is most important for the nurse to assess the patient for an allergy history to what?

A. Soy products
B. Peanuts
C. Penicillins
D. Opioids

C. Penicillins

The cephalosporins are beta-lactam antibiotics similar in structure and actions to the penicillins. They are contraindicated in patients with a history of severe allergic reactions to penicillins. The use of soy products, peanuts, and opioids is unrelated to cephalosporins.

When ceftriaxone is administered intravenously, it is most important for the nurse to avoid mixing it with what?

A. Ringer’s lactate
B. Normal saline
C. Sterile water
D. D5 0.45% NS

A. Ringer’s lactate

Mixing ceftriaxone with calcium causes precipitates to form. Ringer’s lactate contains calcium; therefore it should not be mixed with ceftriaxone. It is safe to mix normal saline, sterile water, and D5 0.45% NS with ceftriaxone.

Which statements about vancomycin (Vancocin) does the nurse identify as true? (Select all that apply.)

A. Vancomycin is the most widely used antibiotic in U.S. hospitals.
B. Vancomycin is effective in the treatment of Clostridium difficile infection.
C. Vancomycin is effective in the treatment of MRSA infections.

A. Vancomycin is the most widely used antibiotic in U.S. hospitals.
B. Vancomycin is effective in the treatment of Clostridium difficile infection.
C. Vancomycin is effective in the treatment of MRSA infections.

A nurse observes a red streak and palpates the vein as hard and cordlike at the intravenous (IV) site of a patient receiving cefepime (Maxipime). Which assessment should the nurse make about the IV site?

A. An allergic reaction has developed to the drug solution.
B. The drug has infiltrated the extravascular tissues.
C. Phlebitis of the vein used for the antibiotic has developed.
D. Local infection from bacterial contamination has occurred.

C. Phlebitis of the vein used for the antibiotic has developed.

IV cephalosporins may cause thrombophlebitis. To minimize this, the injection site should be rotated and a dilute solution should be administered slowly. An allergic response would be shown as itching, redness, and swelling. Infiltration would show as a pale, cool, and puffy IV site. Infection would show as pus, tenderness, and redness.

Stomatitis
​Stomatitis = inflammation of oral tissue often seen as a sign of systemic disease
-​may be accompanied by foul breath and mucosal bleeding​-iron deficiency anemia with dysphagia (Plummer-Vinson syndrome)
​-leukemia, agranulocytosis (also has mouth ulcers)
-mechanical trauma: poorly fitting dentures, improper nipples on bottles
​-xerostomia from drugs, radiation, aging
-​alcohol, tobacco, hot/spicy foods and drinks
​-mouth breathing, cheek biting, jagged teeth, poor orthodontia
​-chemical stomatitis
​-mercury poisoning with marked salivation
​-allergy – intense shiny erythema with swelling, itching, dryness, burning

Signs & Sxs: depend on the cause of the stomatitis.
Gingivitis -​inflammation of the gums with redness, swelling, changes in contours of the gums, pocket formation
-​may see watery exudate and bleeding
​-usually begins in the notch of gum tissue between teeth

Worm parasite treatment
Spaghetti anyone? haha playing…. Treat everyone in the family
KNOW WHEN TO GIVE THESE
AND WHY TO USE
Narcan
Antagonist of MORPHINE
Can reverse the effects of opioid agonists, respiratory depression, coma and analgesia
Must be titrated
Mucomyst
For reducing injury with a Tylenol overdose
Has an unpleasant odor and may induce vomiting
Romazicon
For overdose on Benzodiazepines
PROPOFOL (Diprivan)
3 Questions on this
How does propofol work?
It promotes release of GABA, the major inhibitory neurotransmitter in the brain
Propofol can cause
Respiratory depression and hypotension
Relatively narrow therapeutic range and can cause death
Propofol should be used w/caution in
elderly patients, hypovelmic patients, and patients with compromised cardiac function
Propofol poses a high risk to…
bacterial infection.. Why? is not water soluble
Discard open vials within 6 hours
unopened vials should be stored at 22 Celcius (72 F)
Propofol is
Subject to abuse
Brief sleep and awakens with euphoria
Dilantin (phenytoin)
Most widely used Anti Epileptic drug
Dilantin affects on pregnancy
Category D, should only be used if the benefits outweigh the risk
Can cause (teratogenic effect)
Cleft palate
heart malformation
fetal hydantoin syndrome
growth, motor, and mental deficiency
craniofacial distortion
impaired neurodevelopment
What to teach patients about dilantin
to take with meals to reduce gastric discomfort
to shake oral suspension before dispensing
Warn patients about abrupt cessation of treatment
Myasthenia Gravis Cause
Neuromuscular disorder characterized by fluctuation muscle weakness and rapid fatigue
Myasthenia Gravis Drugs to Treat
Cholinesterase Inhibitors
Always assess the ability to swallow

The nurse is preparing to give neostigmine (Prostigmin). What best describes the action of this drug?

A. It inhibits acetylcholine at all cholinergic synapses.
B. It prevents inactivation of acetylcholine.
C. It prevents activation of muscarinic receptors.
D. It stimulates activation of adrenergic receptors.

B. It prevents inactivation of acetylcholine.

Neostigmine is a cholinesterase inhibitor. As such, it prevents the inactivation of acetylcholine, allowing it to linger at the synapses. It lacks selectivity and thus intensifies transmission at all cholinergic junctions.

What best describes the rationale for using neostigmine (Prostigmin) in the treatment of myasthenia gravis?

A. It promotes neuromuscular blockade in the periphery.
B. It promotes emptying of the bladder and sphincter relaxation.
C. It reduces intraocular pressure and protects the optic nerve.
D. It increases the force of skeletal muscle contraction.

D. It increases the force of skeletal muscle contraction.

Neostigmine is a cholinesterase inhibitor; therefore, at therapeutic doses it increases the force of contraction of skeletal muscles. Myasthenia gravis is a neuromuscular disease characterized by muscle weakness.

The nurse is caring for a patient with a suspected overdose of pancuronium, which was used during surgery. Which drug does the nurse anticipate will be used as a reversal agent?

A. Neostigmine (Prostigmin)
B. Atropine (Sal-Tropine)
C. Pralidoxime (DuoDote)
D. Dobutamine (Dobutrex)

A. Neostigmine (Prostigmin)

Because neostigmine inhibits cholinesterase, it allows acetylcholine to accumulate at synapses. This action can help reverse neuromuscular blockade in postoperative patients, especially when a nondepolarizing neuromuscular blocker, such as pancuronium, has been used.

Parkinson
Neurodegenerative disorder that produces characteristic motor symptoms
Most effective treatment
Levodopa combined with carbidopa

What is the goal of pharmacologic therapy in the treatment of Parkinson’s disease?

A. To increase the amount of acetylcholine at the presynaptic neurons
B. To reduce the amount of dopamine available in the substantia nigra
C. To balance cholinergic and dopaminergic activity in the brain
D. ITo block dopamine receptors in both presynaptic and postsynaptic neurons

C. To balance cholinergic and dopaminergic activity in the brain

Parkinson’s disease results from a decrease in dopaminergic (inhibitory) activity, leaving an imbalance with too much cholinergic (excitatory) activity. With an increase in dopamine, the neurotransmitter activity becomes more balanced, and symptoms are controlled.

Which statement should the nurse include in the teaching plan for a patient being started on levodopa/carbidopa (Sinemet) for newly diagnosed Parkinson’s disease?

A. Take the medication on a full stomach.
B. Change positions slowly.
C. The drug may cause the urine to be very dilute.
D. Carbidopa has many adverse effects.

B. Change positions slowly.

Postural hypotension is common early in treatment, so the patient should be instructed to change positions slowly. Administration with meals should be avoided, if possible, because food delays the absorption of the levodopa component. If the patient is experiencing side effects of nausea and vomiting, administration with food may need to be considered. The levodopa component in Sinemet may darken the color of the urine. Carbidopa has no adverse effects of its own

A patient with a history of Parkinson’s disease treated with selegiline (Eldepryl) has returned from the operating room after an open reduction of the femur. Which physician order should the nurse question?

A. Decaffeinated tea, gelatin cubes, and ginger ale when alert
B. Docusate 100 mg orally daily
C. Meperidine 50 mg IM every 4 hours as needed for pain
D. Acetaminophen 650 mg every 6 hours as needed for temperature

C. Meperidine 50 mg IM every 4 hours as needed for pain

Selegiline can have a dangerous interaction with meperidine, leading to stupor, rigidity, agitation and hyperthermia; therefore, this order should be questioned. Foods that contain tyramine should be restricted, but there is no contraindication to the fluids that have been ordered. Docusate and acetaminophen are not contraindicated for use with selegiline.

LIDOCAINE
Topical or Injection
Anesthesia is more rapid, more intense and more prolonged
Indiviuals allergic to ester-type anesthetics are not cross-allergic to it.
If plasma levels get too high CHS and Cardio toxicity can result
Inactivated by liver
0.5% to 5% concentrations
Some injections contain epinephrine
Novacaine
Not effective topical, must be given by injection

The nurse is caring for a patient who is to receive a local anesthetic with lidocaine and epinephrine. What is the primary purpose of the epinephrine?

A. To reduce the risk of an allergic reaction
B. To improve transport of anesthetic into the axon
C. To delay systemic absorption of the anesthetic
D. To suppress excitability of the myocardium

C. To delay systemic absorption of the anesthetic

As a vasoconstrictor, epinephrine reduces local blood flow and delays systemic absorption of the anesthetic. This prolongs the effects of the anesthetic at the site of action and reduces the risk of systemic toxicity.

Which of these local anesthetic agents is most likely to cause an allergic response?

A. Procaine (Novocain)
B. It Lidocaine (Xylocaine)
C. Bupivacaine (Marcaine)
D. Articaine (Septocaine)

A. Procaine (Novocain)

Procaine is an ester-type anesthetic. Ester anesthetics pose a greater risk of allergic reactions than the amide-type anesthetics. All the other choices are amide anesthetics.

The nurse is caring for a patient who is receiving lidocaine (Xylocaine) by epidural injection. Which nursing intervention is most important when caring for this patient?

A. Keeping the patient in a supine position for about 12 hours.
B. Monitoring the patient’s blood pressure throughout the epidural infusion.
C. Preparing a double tourniquet for use during the infusion.
D. Reducing the intravenous (IV) infusion rate to prevent hypertension.

B. Monitoring the patient’s blood pressure throughout the epidural infusion.

Hypotension is the most common complication with epidural anesthetics. Monitoring of the blood pressure is an essential nursing intervention. Supine positioning is not required for epidural injections (spinal only). A double tourniquet is used for regional anesthesia. Hypertension is not an anticipated outcome.

General Anesthetics
Nitrous Oxide
Very low anesthetic potency
very high analgesic potency
Virtually impossible to produce surgical anesthesia by using alone
Not toxic to CNS
Major concern is post op N/V
Benzodiazepines (versed) pre-surgical use:
When used in combination with an opioid analgesic it produces conscious sedation suitable for endoscopic procedures
Opioid Assessment priorities
Pain Assessment
Vital Signs
Identifying High risk patients
Fentanyl Patches
Warn patients to avoid exposing the patch to direct heat because it can accelerate fentanyl release
Should not be used in children under the age of 2, or anyone weighing less than 110 lbs.
Replace patch every 72 hours
Used or damaged patches should be flushed down the toilet and unused patches should be stored out of reach of children
Aspirin- When used for migraines what med helps it work?
When combined with metoclopramide, it works better than a migraine med and causes less side effects
Adverse side effects of aspirin
Gastric ulceration, bleeding, renal impairment
If aspirin causes GI problems, what other drug can the patient switch to in RA?
Second generation NSAIDS
Methotrexate- How often to give
If she is talking about RA
It is Injections once a week
Gout, the first line of treatment or for flare-ups?
NSAIDS and Glucocorticoids
Allopurinol adverse effects
Hypersensitivity syndrome, characterized by rash, fever, eosinopohila…

A nurse is teaching a patient with chronic tophaceous gout who is scheduled to start taking allopurinol (Zyloprim). Which of these statements should the nurse include in the teaching?

A.”You’ll see the joint swelling reduced in your toe in just a few days.”
B. “You may notice an increase in your pain attacks in the first month.”
C. “We need to collect periodic hair samples to measure uric acid levels.”
D. “It’ll be important to minimize fluid intake so the kidneys can rest.”

B. “You may notice an increase in your pain attacks in the first month.”

Allopurinol inhibits xanthine oxidase to reduce uric acid levels in chronic tophaceous gout. During the first months of treatment, it may increase the incidence of acute gouty arthritis. Allopurinol lacks anti-inflammatory and analgesic actions and is not useful in an acute gout attack. Plasma levels of uric acid are evaluated. To prevent renal injury, fluid intake should be increased.

The nurse teaches a patient with gout that naproxen (Naprosyn) is an agent of first choice for treatment over colchicine. The nurse should use which rationale for the teaching?

A.Naproxen achieves more predicable pain relief with fewer side effects.
B. Treatment with naproxen must continue over a long period to restore joint function.
C. Naproxen causes less impairment of carbohydrate metabolism and less risk of hyperglycemia.
D. Naproxen reduces uric acid levels sooner and with less risk to the kidneys.

A.Naproxen achieves more predicable pain relief with fewer side effects.

Naproxen is a nonsteroidal anti-inflammatory drug (NSAID) that is used to suppress inflammation in gout. Compared with colchicine, NSAIDs are better tolerated and have more predictable effects. Because safe, effective alternatives are available, the use of colchicine has declined. The treatment time with NSAIDs is brief, because pain relief occurs within 24 hours and swelling subsides over a few days. Hyperglycemia is more of a concern when glucocorticoids are used. NSAIDs do not affect uric acid levels.

The nurse should be concerned about which finding in a patient on long-term, low-dose colchicine therapy to prevent gout?

A. White blood cell (WBC) count of 6500/mcL
B. Platelet count of 200,000/mcL
C. Complaints of muscle pain and weakness
D. Complaints of headache

B. Platelet count of 200,000/mcL

Long-term, low-dose therapy with colchicine can cause rhabdomyolysis, which is manifested by complaints of muscle tenderness, pain, and weakness. Because the drug causes myelosuppression, patients should be monitored for leukopenia and thrombocytopenia. Both the WBC count and platelet count are within normal limits. Headache is not an adverse effect of colchicine.

Celebrex used for
OA, RA, Ankylosing spondylitis, acute pain, dysmenorrhea
Also familial adenomatous polyposis
Celebrex adverse effects
dyspepsia and abdominal pain
Does not decrease platelet aggregration or promote bleeding, so cardiovascular events are of concern
Celebrex caution use with:
Warfarin
Lithium
Fluconazole
Tylenol max dose in a day
Up to 4,000 mg/day
When taken with alcohol
Liver injury
Ritalin teaching
Caffeine Teaching
ADHD

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