Why shouldn't a pt be given more insulin per dose so she doesn't have to take it as often? What are factors the nurse could educate the patient about?
Delaying insulin injections will make her blood glucose levels skyrocket, while taking two doses at once as she is doing will result in low blood sugar.
Pre-meal plasma glucose should be between 90-130 mg/dL, while peak post-meal glucose should read no higher than <180 mg/dL.
Which high-risk patient should a nurse monitor most carefully after medications have been administered?
The high-risk patients a nurse should monitor most carefully are those that take multiple drugs, and those with liver and kidney impairment. Elderly and pediatric patients also merit close monitoring. Edit
A female patient comes into the clinic and is prescribed tetracycline. She tells the nurse. "I'm allergic to tetracycline. I always get a yeast infection when I take it." What's the nurse's best response"
What the patient is experiencing is not an allergic reaction. Ask for order of anti-fungal. Fluconazole. Edit
What is the prime example of a drug affected by the first-pass effect?
Nitroglycerine. First-pass effect refers to the rapid hepatic inactivation of certain oral drugs. When oral drugs are absorbed from the GI tract, they are carried directly to the liver in the hepatic portal vein. To circumvent the first-pass effect, a drug that undergoes rapid hepatic metabolism is often administered parenterally. Edit
What should a nurse be concerned with the interaction between Coumadin (warafin) and aspirin (acetylsalicyclic exam)?
Hemmorhage. Warfarin (Coumadin), used to prevent thrombosis, is a vitamin K antagonist, and is the only anti-coagulant currently available in the US. (Like heparin, warfarin is used to prevent thrombosis. In contrast to heparin, warfarin has a delayed onset, which makes it inappropriate for emergencies.)
Aspirin (and other acetylsalicylates) inhibits platelet aggregation. By blocking aggregation, aspirin can suppress formation of the platelet plug that initiates hemostasis. It can also work on the GI tract to cause ulcers, thereby initiating bleeding.
Hence, when the antifibrin effect of warfarin is coupled with the antiplatelet and ulcerogenic effects of aspirin, the potential for hemorrhagic disaster is substantial.
What can a nurse expect to happen after a patient takes two drugs that compete for plasma albumin receptor sites?
When 2 drugs compete for plasma protein binding, the plasma concentration of both increase. This could intensify the effects of the drugs, and could even lead to toxicity. But, the book says that for most drugs the unbound drug is excreted rapidly, so the increase in plasma levels of the drug is rarely sustained. Edit
What could a nurse educate a patient about in regards to the development of drug tolerance?
Tolerance is a decreased responsiveness to a drug as a result of repeated drug administration.
1. Pharmacodynamic tolerance is associated with long-term administration of drugs such as morphine and heroin.
2. Metabolic tolerance results from accelerated drug metabolism, brought about by the ability of certain drugs (eg barbituates) to induce syntheses of hepatic drug-metabolizing enzymes.
3. 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.
Development of tolerance will necessitate an increase in dose to maintain the same therapeutic effect.
Two hours after taking a dose of penicillin, a patient complains of slight shortness of breath, RR of 28/min. Later, a nurse observes pruritus and urticaria, BP 92/48 and RR 36/min. What is the nurse's first response?
Patient is experiencing anaphylactic shock. First response would be to inject dose of epinephrine. Epinephrine, injected IM, is the treatment of choice for anaphylactic shock. Benefits derive from activating three types of adrenergic receptors: alpha1, beta1, and beta2. By activating these receptors, epinephrine can reverse the most severe manifestations of the anaphylactic reaction. Edit
What is important to remember in regards to pregnant patients medications prescribed for chronic asthma?
Despite the imposing challenge of balancing risks versus benefits, drug therapy during pregnancy cannot and should not be avoided. The health of the fetus depends on the health of the mother. Hence, conditions that threaten the mother's health must be addressed—for the sake of the baby as well as the mother. Chronic asthma is a good example. Uncontrolled maternal asthma is far more dangerous to the fetus than the drugs used to treat it. Edit
What clarification should be provided to a breast-feeding patient who is concerned about taking a medication her prescriber assures her is safe?
Take drugs immediately after breast-feeding.
Avoid drugs that have a long half-life.Choose drugs that tend to be excluded from milk and are least likely to affect the infant.Avoid drugs known to be hazardous.
Which lab finding would the nurse associate with the greatest risk of increased drug effects in the geriatric patient who is taking a drug that is highly protein bound?
Low Albumin (textbook p.96) "Because of reduced albumin levels, protein binding of drugs decreases, causing levels of free drug to rise. As a result, drug effects may be more intense" Edit
Optimal dosage of a cholinesterase inhibitors for patients with myasthenia gravis is indicated by what factor?
Start with small dose of cholinesterase inhibitor and then work way up
May need to modify dosage in anticipation of exertion
signs of undermedication: ptosis (drooping eyelid), difficulty swallowing
Signs of overmedication: excessive salivation and other muscarinic responses
Optimal dosage dependent on optimal level of muscle function...signs of improvement of muscle Function: increased ease of swallowing and increased ability to raise eyelids
After assessing a patient prior to the administration of neostigmine (prostigmine) for the treatment of myasthenia gravis, the nurse notices that the patient has greater muscle strength than an hour before. What is the nurse's interpretation of this assessment information?
This response indicates that the current dose is at an optimal level. Nurse should continue to monitor pt's strength before and after admin, taking note of s/s of over- or undermedication Edit
How would one differentiate between a myasthenic crisis and a cholinergic crisis?
Give tensilon (edronphonium)
If edrophonium-induced elevation of Ach levels alleviates symptoms, the crisis is myasthenic.
Conversely, if edrophonium intensifies symptoms, the crisis is cholinergic.
Since the symptoms of cholinergic crisis will be made even worse by edrophonium, atropine and oxygen should be immediately available whenever edrophonium is used for this test.
What finding should a nurse anticipate when performing a physical assessment for a patient who is paralyzed with neuromuscular blockers?
Muscle relaxation when used during surgery
Patient may appear to be asleep when blockers used for mechanical ventilation but should treat patient as though they are fully awake
other answer: bradycardia, hypotention, decreased resp. rate or inadequate ventilations, post op. muscle pain, hyperkalemia, malignant hyperthermia
During an endoscopy a patient who has been given succinylcholine (Anectine) develops rigidity in his muscles and the skin feels hot to the touch. The major concern in this pt would be the potential development of what complication?
(p144) Malignant hyperthermia is disease passed down through families that causes a fast rise in body temperature (fever) and severe muscle contractions when the affected person gets general anesthesia Edit
When preparing a pt for a diagnostic procedure in which Succinylcholine (Anectine) will be administered, the nurse should provide what information?
Drug interactions and adverse effects.
other answer: ADRs = bradycardia, hypotention, decreased resp. rate or inadequate ventilations, post op. muscle pain, hyperkalemia, malignant hyperthermia. reassure pt that post-operative muscle pain is not unpleasant because it does not have any CNS effects
What are the benefits of the BBB?
The blood brain barrier is not developed yet at birth and is beneficial because it blocks diseases and other things from entering into the CNSystem but it makes it hard to treat diseases because medications have to go through rather than around capillaries and other cells. Edit
What counsel should a nurse provide to a pt who is concerned about still feeling depressed 2 weeks after beginning an antidepressant medication?
The nurse must advise the patient that symptom relief for antidepressants can take effect from 4-8 weeks and possibly 2 to 3 months for full benefits to be achieved Edit
What is the explanation for a patient with Parkinson's who, after responding well to drug treatment, suddenly develops a relapse of symptoms?
Long term treatment can be associated with a motor fluctuation considered an "off" period in which there is a loss of symptom relief. These off periods can be reduced with three types of drugs: dopamine agonists, COMT inhibitors and MAO-B inhibitors. Evidence is strongest for entacapone which is a COMT inhibitor. Edit
How does cholinesterase inhibitors work in the Alzheimer's patient?
Cholinesterase inhibitors prevent the breakdown of acetylcholine (by acetyl cholinesterase) which increases the availability of Ach at cholinergic synapses. In Alzheimer's disease, this enhances transmission by central cholinergic neurons that have not yet been destroyed. Cholinesterase inhibors do not cure Alzheimers, and they do not stop disease progression (except for possible slowed progression of a few months. Edit
A nurse is administering medications to a pt with a history of seizures and notices that the patient exhibits nystagmus, diplopia, and a serum phenytoin level of 25 mcg/mL. The nurse should anticipate which additional clinical finding?
Ataxia (loss of full control of the body), sedation, cognitive impairment. Edit
What is the priority nursing action when a pt that is about to begin valproic acid (Depakote) informs her that he drinks a 6Pk of beer daily and 2-3 6Pks on the wknd?
When starting a pt on Valproic Acid baseline liver function must be taken and continually monitored due to the risk of developing hepatotoxicity (ie liver failure). Advice pt to quit drinking or council with physician about switching med's. Liver is highest priority. Edit
A pt who sustained a head injury 7 years prior has been on anti epileptic meds and seizure free since 8 months after the accident. He now wants to d/c the rxs. The nurse's response would be based on which rationale about anti epileptic meds?
INFORM THEM THAT IT IS IMPORTANT TO NOT STOP QUICKLY, TAPERING IS MOST IMPORTANT. Edit
What is the priority for teaching a 24 yr old pt who has been prescribed an anti epileptic medication?
Promoting Patient Adherence:
Epilepsy is a chronic condition that requires regular and continuous therapy. As a result, seizure control is highly dependent on patient adherence. In fact, it is estimated that nonadherence accounts for about 50% of all treatment failures. Accordingly, promoting adherence should be a priority for all members of the healthcare team.
A patient received lidocaine as an axillary block for a surgical procedure. A nurse checks the pulse rate 5 minutes after administration and determines that the pulse is slightly irregular and slow. The nurse's analysis of this patient's response would be which of the following?
Lidocaine, a local anesthetic, has speed systemically Edit
A nurse is providing preop teaching the night before a patient's surgery. The patient expresses fear of nausea and vomiting postoperatively from the anesthesia, because he had a bad experience a few years ago. What would be the nurse's best response?
Ask MD to add an order for anti-nausea rx. Ex: Phenergan/ promethezine. Edit
A patient who received an inhalation anesthetic is received into the recovery room. A nurse obtains vital signs during the immediate postoperative assessment. The patient's muscles are tense, and her body temperature is 104° F. What is the nurse's best action?
Collaborate with the prescriber regarding the risk of malignant hyperthermia: Malignant hyperthermia is a rare but potentially fatal reaction that can be triggered by all inhalation anesthetics (except nitrous oxide). Predisposition to the reaction is genetic. Malignant hyperthermia is characterized by muscle rigidity and a profound elevation of temperature—sometimes to as high as 43°C (109°F). Left untreated, the reaction can rapidly prove fatal. The risk of malignant hyperthermia is greatest when an inhalation anesthetic is combined with succinylcholine, a neuromuscular blocker that also can trigger the reaction. Edit
A patient is brought to the emergency department in a state of extreme uncontrolled anxiety. The prescriber orders a benzodiazepine. A nurse understands that benzodiazepines are used in this clinical situation based on what principles?
Benzodiazepines are first-choice drugs for anxiety. As discussed in Chapter 34, benefits derive from enhancing responses to gamma-aminobutyric acid (GABA), an inhibitory neurotransmitter. Onset of effects is immediate, and the margin of safety is high. Edit
A patient has been experiencing severe chronic pain for 2 months. The nurse anticipates that the prescriber will order which medication, which would have a more consistent effect for the patient's chronic pain?
A transdermal patch to deliver a steady dose. Anticipate MD will prescribe opiate for around the clock pain management. By prescribing constant doses rather than prn, opiate can maintain pain instead of chasing the pain. Edit
A student nurse is presenting a teaching section for the class on opiates. The student is comparing the potencies of morphine sulfate and fentanyl (Duragesic). Which statements by the student should be included in her teaching session?
Fentanyl [Sublimaze, Duragesic, Fentora, Actiq, Ionsys] is a strong opioid analgesic with a high milligram potency (about 100 times that of morphine). Like other strong opioids, fentanyl overdose poses a risk of fatal respiratory depression. Fentanyl is metabolized by CYP3A4 (the 3A4 isozyme of cytochrome P450), and hence fentanyl levels can be increased by CYP3A4 inhibitors (eg, ritonavir, ketoconazole). Patients taking these inhibitors should be closely monitored for severe respiratory depression and other signs of toxicity. Fentanyl is available in five formulations for administration by three routes: parenteral, transdermal, and transmucosal Edit
A nurse is reviewing discharge instructions with a patient. The patient asks the nurse why the oral dose of the opioid is so much higher than the intravenous dose he has been receiving. What is the nurse's best response?
Because of first-pass metabolism, oral doses of morphine must be larger than parenteral doses to produce equivalent analgesic effects.
Because oral morphine undergoes extensive metabolism on its first pass through the liver, oral doses are usually higher than parenteral doses.
A postoperative patient has received an epidural infusion of morphine sulfate. The patient's respiratory rate decreases to 8, and he has a decreased level of consciousness and miosis. Which medication would the nurse anticipate administering?
Naloxone, Narcan is a structural analog of morphine that acts as a competitive antagonist at opioid receptors, thereby blocking opioid actions. Naloxone can reverse most effects of the opioid agonists, including respiratory depression, coma, and analgesia. Edit
A nurse is providing a community education class on morphine sulfate. Which symptom, chosen by a member of the audience, indicates a need for further teaching with regard to an understanding of adverse effects of morphine sulfate?
In addition to relieving pain, the drug causes drowsiness, mental clouding, anxiety reduction, and a sense of well-being. Through actions in the CNS and periphery, morphine can cause respiratory depression, constipation, urinary retention, orthostatic hypotension, emesis, miosis, cough suppression, and biliary colic. With prolonged use, the drug produces tolerance and physical dependence. Edit
A nurse is acting as a preceptor for a new nurse on the oncology unit. To evaluate the new nurse's understanding of pain, the nurse asks, "Which statement is correct regarding the differences between nociceptive and neuropathic pain?"
Nociceptive pain: Results from injury to tissues
- 2 forms: Somatic (bones, joints, muscles) or visceral pain (organs)
Neuropathic pain: Results from injury to peripheral nerves
- Responds poorly to opioids
A nurse is caring for a patient undergoing chemotherapy. A patient asks for ibuprofen (Motrin) and states, "I didn't bring mine with me. I usually take them about four times a day. The nurse should notify the prescriber and anticipate an order for what?
GIVE SOMETHING THAT DOESN'T INTERFERE WITH STOMACH. DON'T SWITCH MEDS, ASK FOR CBC TEST. Edit
A nurse is caring for a patient with cancer, who manages her mild pain with acetaminophen (Tylenol) and nonsteroidal anti-inflammatory drugs. Her husband asks to speak with the nurse privately and explains that since his wife was diagnosed with cancer 2 years ago, she has been drinking about half a bottle of wine per day, along with a mixed drink before bed. The nurse should obtain from the prescriber an order for which of the following laboratory tests?
a. Liver function tests
b. Ammonia level
c. Platelet count
Hemoglobin and hematocrit level
The prescriber asks a nurse to prepare the patient for an intraspinal injection of an opioid medication. The nurse understands that this route of administration is most beneficial for what?
Analgesia may persist up to 24 hours with an intraspinal injection as opposed to 4-5 hours with IM, IV, and subQ.
Intraspinal administration is reserved for pts w/ intractable pain that cannot be controlled w/ less invasive routes. High opioid concentrations are achieved ay receptors on pain pathways in the spinal cord. Intraspinal administration is especially useful for pts w/ severe pain in the lower body.
How is breakthrough pain different from end-of-dose pain?
Breakthrough pain develops quickly, reaches peak intensity in minutes, and may persist from minutes to hours. Breakthrough pain may occur spontaneously, or it may be precipitated by coughing or other movements. End-of-dose pain occurs b/c analgesic levels are lowest at that time. Edit
A nurse is providing patient education to a group of elderly cancer patients. The nurse states that which of the following major problems may occur in the management of an elderly patient with cancer pain?
1. Undertreatment of pain
Elders are denied adequate meds for two reasons: difficulties with assessment and erroneous ideas about old age
Providers believe (incorrectly) that dosages should be low
2. Heightened drug sensitivity
Elderly more sensitive to drugs than younger adults, mainly due to decline in organ function (hepatic metabolism and renal excretion decline with age)
Drugs accumulate in body, causing responses to be intense and prolonged.
3. Increased risk of side effects and adverse effects
Elderly experience more side effects than younger adults b/c drug elimination is impaired, posing a risk that drug levels may rise dangerously high
A nurse cares for an alert patient with cancer who has been on large doses of opioids for several months. When the patient is hospitalized and placed on patient-controlled analgesia with morphine, the nurse is concerned about the risk of respiratory depression. The primary nursing action should be what interventions?
Give the patient Narcan. Edit
Which of the following best demonstrates the nurse's understanding of how genetics influence drug response when considering individual variations in drug responses?
Causes of altered responses related to genetics (pharmacogenomics):
o Alteration of drug-metabolizing enzymes
o Alteration of structure of drug receptors and other target molecules
o Gender & Race
The nurse is administering morning medications. A patient questions the nurse, "How does the drug know where to go?" The nurse's best response to the patient is based on the understanding that a drug that elicits only those responses for which it is given is considered_________?
Prior to the administration of penicillin, a nurse reviews medication literature regarding precautions associated with penicillin. For which patient would the nurse most likely consider these precautions warranted?
Any pt that has ever had any type of rxn to penicillin, not just pts with allergy Edit
A patient is receiving morphine sulfate 4 mg intravenously every 3 hours for pain. The nurse understands that the half-life for morphine sulfate is approximately 3 hours. Which statement made by the nurse best demonstrates understanding of the meaning of half-life?
The body stores of morphine will decrease by 50% every 3 hours - regardless of how much morphine is in the body. If there is 4 mg of morphine in the body, 2 mg of morphine will be lost in 3 hours. Edit
A patient with a history of hypertension is admitted for a procedure. If the patient's arterial pressure decreases, which clinical manifestation would the nurse expect to see?
The nurse would expect to see the patient's heart rate increase. This is because the drop in arterial pressure (AP) triggers the baroreceptor reflex to (1) constrict arterioles, "thereby increasing peripheral resistance"; (2) constrict veins, thus "increasing venous return"; and (3) accelerate "heart rate by increasing sympathetic impulses to the heart and decreasing parasympathetic impulses." The overall effect will be to increase heart rate. Edit
A patient who has been taking lisinopril (Zestril) for 2 weeks complains of a dry cough. What patient education should the nurse provide regarding this complaint?
Lisinopril is an ACE inhibitor. As a class, these drugs can cause a "persistent, dry, irritating, nonproductive cough. Instruct them to consult the prescriber if cough is bothersome. It may be necessary to discontinue the ACE inhibitor." Edit
A nurse counsels an elderly patient who is just beginning verapamil (Calan) therapy. The nurse should include which pertinent and important side effect in the patient's education?
Patient teaching about the potential for dizziness. Constipation can occur frequently with verapamil, especially in the elderly. The patient can minimize this adverse effect "by increasing dietary fiber and fluids." The constipation is a result of calcium channel blockade in the smooth muscle of the intestine. Edit
The prescriber orders propranolol (Inderal) for a patient with a blood pressure reading of 200/106 mm Hg. An electrocardiogram taken shortly afterward shows an atrioventricular (AV) block. The nurse should immediately hold the propranolol and report this finding to the prescriber for which reason?
Hold med: AV block is adverse effect of propanolol Edit
The nurse is teaching a community education class on hypertension. Which statement about secondary hypertension compared with primary (essential) hypertension most accurately reflects these disease processes?
Because secondary hypertension results from an identifiable cause, it may be possible to treat that cause directly, rather than relying on antihypertensive drugs for symptomatic relief. As a result, some individuals can actually be cured. For example, if hypertension occurs secondary to pheochromocytoma (a catecholamine-secreting tumor), surgical removal of the tumor may produce permanent cure. When cure is not possible, secondary hypertension can be managed with the same drugs used for primary hypertension. Edit
As people age, their systolic blood pressure tends to rise. What is the primary cause of this increase in the systolic measurement?
The underlying cause is increased stiffness (reduced compliance) in large arteries- owing to progressive replacement of elastin with collagen in the arterial wall. Edit
A newly admitted patient diagnosed with heart failure has just been started on an angiotensin-converting enzyme (ACE) inhibitor. He asks whether the drug will have a long-term effect on his general cardiovascular health. What is your response?
ACE INHIBITORS HELP PRESERVE/PROTECT HEART MUSCLE. ITS GOING TO HELP PROTECT YOUR HEART. Edit
The nurse is preparing to administer digoxin IV to treat a patient's heart failure. Which action is essential for the nurse to perform?
When digoxin is given IV, cardiac status should be monitored continuously for 1-2 hours. Have resusicitation equipment on hand, because digoxin IV slows the heart down. Edit
The nurse is teaching a class to cardiac rehabilitation patients. To test their knowledge, the nurse poses the question, "Which class of drugs is considered one of the treatments of choice for acute anginal attacks?"
Ex, Nitroglycerin: The drug is effective, fast acting, and inexpensive. Nitroglycerin remains the drug of choice for relieving acute anginal attacks
A nurse is providing education about the various routes of administering nitroglycerin (NTG). Why can sublingual NTG can be used in lower dosages than drugs given by other routes?
Unlike orally administered drugs, which must pass through the liver on their way to the systemic circulation (most of each dose is destroyed on its first pass through the liver Pg. 583 when given orally), sublingual nitroglycerin bypasses the liver, and thereby temporarily avoids inactivation. Because the liver is bypassed, sublingual doses can be low (between 0.3 and 0.6 mg). Edit