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181. A nurse is teaching a group of nurses about neuropharmacology. The nurse asks which classes of drugs act by reducing axonal conduction. Which response by a participant is correct?

a. Antihypertensives
b. Antipsychotics
c. Local anesthetics
d. Antidepressants

c. Local anesthetics

Local anesthetics are the only drugs shown to work by reducing axonal conduction. Antihypertensives, antipsychotics, and antidepressants do not act by reducing axonal conduction.

182. 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. increase receptor activation.

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.

183. 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. Bradycardia

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.

184. 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. inhibiting its release

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.

185. 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. Antagonists

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.

186. 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. "These drugs reduce either reuptake or degradation of the transmitter, causing an increase in receptor activation."

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.

187. A nurse is concerned about renal function in an 84-year-old patient who is taking several medications. What should the nurse assess?

a. Creatinine clearance
b. Sodium levels
c. Potassium levels
d. Serum creatinine

a. Creatinine clearance

The proper index of renal function in older adults is creatinine clearance, which indicates renal function in older patients whose organs are undergoing age-related deterioration. Sodium and potassium levels are not indicative of renal function. Serum creatinine levels do not reflect kidney function in older adults because lean muscle mass, which is the source of creatinine in serum, declines and may be low even with reduced kidney function.

188. A nurse is preparing to teach a forgetful older adult patient about a multiple drug regimen to follow after discharge from the hospital. To help promote adherence, what will the nurse do?

a. Ask the patient to share the teaching with a neighbor or friend soon after discharge.
b. Give the patient detailed written information about each drug.
c. Cluster medication administration times as much as possible.
d. Make sure the patient understands the actions and side effects of each drug.

c. Cluster medication administration times as much as possible.

Unintentional nonadherence often is the result of confusion and forgetfulness. Grouping medications to reduce the number of medication times per day can simplify the regimen and help the patient remember medication times. Enlisting a neighbor, relative, or friend is a good idea, but this person should be included in the teaching. Asking the patient to share what is learned may not be a reasonable expectation of a forgetful patient. Detailed written information may just be more confusing; verbal and written information should be clear and concise. Making sure the patient understands the actions and side effects of medications helps when intentional nonadherence is an issue, but in this case it may just add to the patient's confusion.

189. A nurse is reviewing an older adult patient's chart before giving medications. Which patient information is of most concern?

a. Chronic constipation
b. Increased body fat
c. Low serum albumin
d. Low serum creatinine

c. Low serum albumin

Low serum albumin reduces protein binding of drugs and can cause levels of free drug to rise, increasing the risk of toxicity. Altered gastrointestinal (GI) absorption is not a major factor in drug sensitivity in the older adult, although delayed gastric emptying can delay drug responses. Increased body fat can alter drug distribution, causing reduced responses in lipid-soluble drugs. Low serum creatinine is a function of decreased lean muscle mass and does not reflect kidney function or drug excretion.

190. Based on changes in hepatic function in older adult patients, which adjustment should the nurse expect for oral medications that undergo extensive first pass metabolism?

a. A higher dose should be used with the same time schedule.
b. The interval between doses should be increased.
c. No change is necessary; metabolism will not be affected.
d. The interval between doses should be reduced.

b. The interval between doses should be increased.

The interval between doses of the medication should be increased in older adult patients, because drugs that undergo the first pass effect may not be broken down as well as in an individual with full liver function. A higher dose of the medication is not indicated, because toxic effects could occur. A change in administration may be indicated in older adults, because their metabolism is affected. The interval between doses should not be reduced but increased.

191. A nurse is preparing to give medications to four geriatric patients who are all taking multiple medications. Which patient is most likely to have an adverse drug reaction related to increased drug effects?

a. Obese patient
b. Patient with decreased serum creatinine
c. Patient with chronic diarrhea
d. Thin patient with a chronically low appetite

d. Thin patient with a chronically low appetite

The patient who is thin and has a poor appetite has an increased risk of malnutrition, with significant lowering of serum albumin. This can result in increased free drug levels of protein-bound drugs and can lead to drug toxicity. Obesity, which involves increased adipose tissue, would cause lipid-soluble drugs to deposit in adipose tissue, with a resulting reduction of drug effects. Decreased serum creatinine in an older adult patient may just be a function of a decrease in lean body mass and not of renal function. Chronic diarrhea would accelerate the passage of medications through the GI tract and reduce absorption.

192. A nurse is caring for an older adult patient during the immediate postoperative period after a total hip replacement. The surgeon has ordered meperidine (Demerol) for severe pain. What will the nurse do?

a. Administer the medication as prescribed and initiate a fall risk protocol.
b. Ask for a PRN order for diphenhydramine (Benadryl) for the expected side effect of itching.
c. Request an order for morphine instead of meperidine (Demerol).
d. Suggest to the surgeon that the patient receive diazepam (Valium) to reduce anxiety and the need for narcotics.

c. Request an order for morphine instead of meperidine (Demerol).

In older adults, meperidine is not effective at usual doses and causes more confusion than in younger patients. Morphine is recommended for severe pain. A fall risk protocol is appropriate, but the drug ordered is not. Diphenhydramine is not recommended for older adult patients, because it causes blurred vision. Both diphenhydramine and diazepam have central nervous system (CNS) sedative effects, which will compound the CNS effects of the narcotic. Diazepam also produces prolonged sedation in older adults.

193. An older adult patient is admitted to the hospital for treatment of an exacerbation of a chronic illness. Admission laboratory work reveals an extremely low serum drug level of the drug used to treat this condition. The patient has brought the medication to the hospital, along with other medications taken. The patient's renal and hepatic function tests are normal. What might the nurse suspect as a likely cause of this finding?

a. Financial concerns
b. Inability to open drug containers
c. Increased tolerance to the drug's effects
d. Patient's conviction that the drug is unnecessary

a. Financial concerns

Older adult patients who have financial concerns about paying for medications often take less of the drug or take it less often to make the drug last longer. A patient unable to open the drug container would not get any medication and would not have a detectable serum drug level. A patient with increased tolerance to a drug's effects would require more of the drug to get effects. A patient convinced that the drug is not needed would probably not fill the prescription.

194. A nurse is teaching a group of nursing students about administering medications to older adult patients. Which statement by a student indicates a need for further teaching?

a. "Alteration in hepatic function requires more frequent drug dosing."
b. "Changes in GI function in older adult patients lead to lower serum drug levels."
c. "Most adverse drug reactions in older adult patients are related to altered renal function."
d. "Most nonadherence among older adult patients is intentional."

a. "Alteration in hepatic function requires more frequent drug dosing."

Changes in hepatic function in older adult patients lead to decreased metabolism, meaning that drugs metabolized by the liver have prolonged half-lives and should be given less frequently. Altered GI function does not have much effect in this population, but most known effects from this cause are related to poor absorption and less available drug. Alterations in renal function are the cause of most adverse drug effects in the older adult. In most cases, nonadherence to drug regimens is intentional, usually because the patient doesn't believe that the drug is needed or that the dose prescribed is not necessary.

195. A nurse is obtaining a drug history from an older adult patient who is taking multiple medications prescribed by different providers. Which two medications taken together are a reason for concern?

a. Acetaminophen (Tylenol) and oxycodone
b. Amitriptyline (Elavil) and diphenhydramine (Benadryl)
c. Fexofenadine (Allegra) and an over-the-counter laxative
d. Zolpidem (Ambien) and sertraline (Zoloft)

b. Amitriptyline (Elavil) and diphenhydramine (Benadryl)

Both amitriptyline and diphenhydramine are on the BEERS list, amitriptyline for anticholinergic effects and diphenhydramine because it causes blurred vision. Additionally, they both have CNS effects that can compound each other when the drugs are given together. Acetaminophen and oxycodone are both acceptable and may be given together. Fexofenadine is a second-generation antihistamine with fewer side effects, and it is not contraindicated for use with a laxative. Zolpidem is a sedative that has less risk of physical dependence and less risk of confusion, falls, and cognitive impairment; sertraline is a safer antidepressant, because it has a shorter half-life than others.

196. A nurse is making a home visit to an older adult woman who was recently discharged home from the hospital with a new prescription. The nurse notes that a serum drug level drawn the day before was subtherapeutic. What will the nurse do next?

a. Ask the patient if she has difficulty swallowing pills.
b. Count the pills in the prescription bottle.
c. Notify the provider to request more frequent dosing.
d. Request an order for renal function tests.

b. Count the pills in the prescription bottle.

Intentional nonadherence is common and may occur because older adult patients are not convinced that drugs are needed or that the dose prescribed is correct. Counting the pills would be an appropriate first step as the nurse determines the cause of the low serum drug level, because it provides information about adherence. If the pill count is correct and the patient has taken the drug as prescribed, other causes may have to be investigated. If it is clear that the patient has not been taking enough of the medication, asking about her ability to swallow may be a good follow-up question. The last two options would be steps to discuss with the provider if the patient is taking the medication as prescribed.

197. A thin older adult woman is admitted to the hospital after several days of vomiting, diarrhea, and poor intake of foods and fluids. She has not voided since admission. In preparing to care for this patient, the nurse will look for what laboratory values to help guide medication administration? (Select all that apply.)

a. Creatinine clearance
b. Gastric pH
c. Plasma drug levels
d. Serum albumin
e. Serum creatinine

a. Creatinine clearance
c. Plasma drug levels
d. Serum albumin

Creatinine clearance is the best way to evaluate renal function in the older adult. Plasma drug levels are important for determining if the patient has toxic or subtherapeutic drug levels. Serum albumin may be decreased, especially in patients who are thin, chronically undernourished, or have been vomiting, and the decreased level may result in higher levels of drugs that normally bind to proteins. Gastric pH is not important; most GI changes result in lowered absorption and less free drug. Serum creatinine levels are related to the amount of lean muscle mass, which may be low in older adult patients, and do not reflect renal function.

198. 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. A negative placebo effect when taking the medication

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 in order to get a better effect.

199. 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. Pharmacogenomic differences among individuals

Each patient's genetic makeup can determine how that patient responds to drugs both 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

200. 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. determine whether a patient is a rapid or slow metabolizer of the drug.

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 physiological 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.

201. 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. metabolism of drugs.

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 isozymes. There are known genetic differences in codes for drug target sites, but these are not as numerous as those for metabolic isozymes. 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.

202. A nurse is preparing to care for a patient who is receiving digoxin. To help minimize the potential for 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

d. Serum electrolytes

Patients with low serum potassium are at risk for fatal cardiac dysrhythmias when taking digoxin, and it is essential to know this level before this medication is administered. Knowing a patient's albumin level would be important when giving drugs that are protein bound. The BUN and creatinine levels are indicators of renal function. Hepatic enzymes are important to know when drugs are metabolized by the liver.

203. A patient has been taking narcotic analgesics for chronic pain for several months. The nurse caring for this patient notes that the prescribed dose is higher than the recommended dose. The patient has normal vital signs, is awake and alert, and reports mild pain. What does the nurse recognize about this patient?

a. This patient exhibits a negative placebo effect with a reduced response to the drug.
b. This patient has developed a reaction known as tachyphylaxis because of repeated exposure to the drug.
c. This patient has developed pharmacodynamic tolerance, which has increased the minimal effective concentration (MEC) needed for analgesic effect.
d. This patient produces higher than normal hepatic enzymes as a result of prolonged exposure to the drug.

c. This patient has developed pharmacodynamic tolerance, which has increased the minimal effective concentration (MEC) needed for analgesic effect.

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.

204. 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. a different medication.

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.

205. 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. most known drug effects are based on drug trials in men.

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.

206. 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. Older adults
c. Infants

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.

207. 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. Administer the drug and tell the patient to report further nausea.

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.

208. A patient is being discharged after surgery. During the admission history, the nurse had 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 the Lortab.
d. Tell the patient to limit his wine intake to one or two glasses per day.

c. Tell the patient not to drink wine while taking the Lortab.

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

209. A nurse is reviewing a medication administration record before administering medications. Which order should 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. Furosemide (Lasix) 20 mg PO daily

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.

210. 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 a(n):

a. allergic reaction.
b. idiosyncratic effect.
c. iatrogenic response.
d. side effect.

d. side effect.

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.

211. A nurse is preparing to give an antibiotic to a patient who reports being allergic to antibiotics. Before giving the medication, it is important for the nurse to do what?

a. Ask whether the patient has taken this antibiotic for other infections.
b. Question the patient about allergies to other medications.
c. Obtain a history of other reactions to other drugs.
d. Request an order for an antihistamine.

a. Ask whether the patient has taken this antibiotic for other infections.

The nurse needs to assess whether the patient is truly allergic to this drug. Allergic reactions require previous exposure to the drug, so the nurse should ask whether the patient has taken this antibiotic before. Obtaining a history of drug allergies and of reactions to medications also is important, but not as important as finding out about possible allergic reactions to a drug about to be given. Antihistamines sometimes are given when patients must take a drug to which they are allergic.

212. A nurse is preparing to administer a drug. Upon reading the medication guide, the nurse notes that the drug has been linked to symptoms of Parkinson's disease in some patients. What will the nurse do?

a. Ask the patient to report these symptoms, which are known to be teratogenic effects.
b. Observe the patient closely for such symptoms and prepare to treat them if needed.
c. Request an order to evaluate the patient's genetic predisposition to this effect.
d. Warn the patient about these effects and provide reassurance that this is expected.

b. Observe the patient closely for such symptoms and prepare to treat them if needed.

A drug that causes diseaselike symptoms is known to be iatrogenic. Nurses should be prepared for this possibility and should 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.

213. 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. "Routine testing and early detection of problems will prevent liver failure."

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 all signs of liver injury and should be reported

214. 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. Contact the provider to discuss an alternative to azithromycin.

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.

215. 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. Monitor the function of all organs potentially affected by the drug.

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.

216. A nursing student is preparing to give a medication that has a black box warning. The student asks the nurse what this means. What will the nurse explain about black box 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 ways to mitigate potential harm from side effects.
d. They provide information about antidotes in the event toxicity occurs.

c. They alert prescribers to ways to mitigate potential harm from side effects.

Black box warnings are used to alert providers to potential side effects and to ways to prevent or reduce harm from these side effects. The black box 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 black box warning provides a concise summary and not a detailed explanation of drug side effects. The black box warning does not include antidotes to toxicity

217. 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. Giving a drug intravenously instead of intramuscularly
c. Giving Nasarel instead of Nizoral
e. Writing a prescription illegibly

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.

218. 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. Developing nonpunitive approaches to track errors
c. Helping patients to be active, informed members of the healthcare team
e. Using electronic medical order entry systems

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.

219. 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. Potentiative effects

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.

220. 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. Naloxone (Narcan) to block the effects of the morphine

221. 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. Alcohol blocking the actions of opioids
d. Cholestyramine blocking the actions of antihypertensive drugs

a. Naloxone (Narcan) blocking morphine sulfate's actions

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.

222. 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. higher; X

An inducing agent stimulates the synthesis of CYP isozymes, 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.

223. 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. "Do you take seizure medication?"

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

224. 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 isozymes to increase drug metabolism.
d. raises the pH of the interstitial fluid to facilitate passage out of the cells.

d. raises the pH of the interstitial fluid to facilitate passage out of the cells.

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 isozyme inducer and therefore has no effect on drug metabolism. It does not alter renal excretion of aspirin.

225. 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 isozymes and alter drug metabolism.

d. Some foods can inhibit CYP isozymes and alter drug metabolism.

Grapefruit juice inhibits CYP3A4, which lowers the metabolism of some drugs, leading to toxic effects of drugs affected by these isozymes. 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.

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