Question 1

The nurse provides medication teaching to a client with primary adrenal insufficiency (Addison's disease) who is prescribed hydrocortisone 10 mg by mouth 3 times a day. Which instructions should be included in the client's teaching plan? Select all that apply.

Accepted Answer

Clients taking long-term corticosteroid replacement should be taught the following: Do not discontinue glucocorticoid therapy abruptly. Abrupt discontinuation could lead to addisonian crisis, a life-threatening complication (Option A). Report any signs and symptoms of infection to the HCP immediately. Corticosteroid use can cause immunosuppression, and infection can develop quickly and spread rapidly. Corticosteroids' anti-inflammatory effects may also mask signs of infection such as inflammation, redness, tenderness, heat, fever, and edema (Option C). Stay attuned to signs and symptoms of stress and increase dose of corticosteroid during times of stress. A stress response (surgery, trauma) can cause a sudden decrease in cortisol levels, triggering addisonian crisis (Option F). A side effect of corticosteroid therapy is hyperglycemia. Report signs of hyperglycemia, including increased urine, hunger, and thirst. Clients with diabetes mellitus must be vigilant in checking blood glucose levels (Option D). Corticosteroids are catabolic to bone (osteoporosis) and muscle (muscle weakness). A diet high in calcium (at least 1500 mg/day) and protein (1.5 g/kg/day) but low in fat and simple carbohydrates is recommended. Cataracts are a side effect of corticosteroids, particularly glucocorticoid therapy. Make an appointment with an optometrist yearly to assess for cataracts (Option B). Corticosteroid medications can cause gastric irritation and should not be taken on an empty stomach (Option E). Recognize signs and symptoms of Cushing syndrome and report to the PHCP. Develop a regular HCP-approved exercise program. Educational objective: Corticosteroids are the primary drugs used to treat Addison's disease. It is imperative that the nurse teach the client about this medication, including points such as never to stop it abruptly, notify the HCP of signs and symptoms of infection, and monitor blood glucose closely if diabetes is a comorbid condition.

Question 2

The nurse in an outpatient clinic is caring for a client with Addison disease who has been taking hydrocortisone 20 mg daily for the last 8 years. Which client data is most important to report to the health care provider?

Accepted Answer

Addison disease (primary adrenocortical insufficiency) is characterized by a deficiency in all three types of adrenal steroids (ie, glucocorticoids, androgens, mineralocorticoids), most commonly caused by an autoimmune response. Corticosteroid therapy (eg, hydrocortisone, dexamethasone, prednisone) is the primary treatment for Addison disease. Long-term use of corticosteroids can cause immunosuppression, and the anti-inflammatory effects may also mask signs of infection (eg, inflammation, redness, tenderness, heat, fever, edema). Signs and symptoms of infection (eg, low-grade fever) should be reported to the health care provider immediately as infection can develop quickly and spread rapidly (Option B). In addition, physiological stress such as infection can trigger Addisonian crisis, a life-threatening complication of Addison disease that would require an increase in the corticosteroid dose. (Options A, C, and D) Side effects of long-term corticosteroid therapy mimic the signs and symptoms of Cushing syndrome, including buffalo hump, moon-shaped face, and hypokalemia. Increased weight, blood pressure, and blood glucose levels can also occur; however, these effects are not as life-threatening as infection. Educational objective: In clients taking corticosteroids, it is imperative to notify the health care provider of signs and symptoms of infection, even a low-grade fever. The anti-inflammatory properties of corticosteroids can mask signs of infection, and their immunosuppressive effects can cause the infection to develop and spread quickly.

Question 3

A diabetic client is prescribed metoclopramide. Which of the following side effects must the nurse teach the client to report immediatelyto the health care provider? Select all that apply.

Accepted Answer

Metoclopramide (Reglan) is prescribed for the treatment of delayed gastric emptying, gastroesophageal reflux (GERD), and as an antiemetic. Similar to antipsychotic drugs, metoclopramide use is associated with extrapyramidal adverse effects, including tardive dyskinesia (TD). This is especially common in older adults with long-term use. The client should call the health care provider immediately if TD symptoms develop, including uncontrollable movements such as: Protruding and twisting of the tongueLip smackingPuffing of cheeksChewing movementsFrowning or blinking of eyesTwisting fingersTwisted or rotated neck (torticollis) Protruding and twisting of the tongue Lip smacking Puffing of cheeks Chewing movements Frowning or blinking of eyes Twisting fingers Twisted or rotated neck (torticollis) (Options B and C) Common side effects of metoclopramide such as sedation, fatigue, restlessness, headache, sleeplessness, dry mouth, constipation, and diarrhea need not be reported to the health care provider. Educational objective: Both antipsychotic medication and metoclopramide use can be associated with significant extrapyramidal side effects (eg, tardive dyskinesia). The nurse should teach the client the importance of immediately communicating these to the health care provider.

Question 4

The nurse is caring for a client with diabetes who is being discharged with a prescription for glyburide. Which statement by the client indicates a need for further instruction?

Accepted Answer

The major adverse effects of sulfonylurea medications (eg, glyburide, glipizide, glimepiride) are hypoglycemia and weight gain. Weight gain should be addressed. Clients taking glyburide should be taught to use sunscreen and protective clothing as serious sunburns can occur. (Option A) Clients taking sulfonylureas should avoid alcohol as it lowers blood glucose and can lead to severe hypoglycemia. (Option B) Hypoglycemia (serum glucose <70 mg/dL [3.9 mmol/L]) is a major side effect of sulfonylurea medications. A fasting blood glucose <60 mg/dL (3.3 mmol/L) indicates moderate to severe hypoglycemia and the medication needs to be reassessed. (Option C) Even foods labeled "diabetic", "sugar free," or "sugarless" may contain carbohydrates such as honey, brown sugar, and corn syrup, all of which can elevate blood sugar. Educational objective: The major adverse effects of sulfonylurea medications are hypoglycemia and weight gain. Alcohol must be avoided while taking these medications due to the risk of severe hypoglycemia. Glyburide can also make clients sunburn easily.

Question 5

The nurse plans teaching for a client who was newly prescribed levothyroxine sodium after thyroid removal. Which instructions will the nurse include in the teaching plan? Select all that apply.

Accepted Answer

Levothyroxine sodium (eg, Levoxyl, Levothroid, Synthroid) is used to replace thyroid hormone in clients with hypothyroidism (inadequate thyroid hormone) and for those who have had their thyroid removed. These clients must understand that this medication must be taken for the rest of their lives (Option E). A client's dose is adjusted based on serum TSH levels to prevent too much or too little hormone. Clients must be taught to report signs of excess thyroid hormone such as heart palpitations/tachycardia, weight loss, and insomnia (Option C). (Option A) Clients with hypothyroidism experience lethargy and somnolence. Hormone replacement therapy will increase metabolic activity and alertness. (Option B) This medication is a hormone that is normally present in the body, so it is safe to take during pregnancy. The dose may need to be altered due to the metabolic demands of pregnancy, but the drug will not harm the fetus. (Option D) It is best to take this medication first thing in the morning as it is best absorbed on an empty stomach (1 hour before or 2 hours after a meal). Educational objective: Clients receiving thyroid hormone replacement therapy (levothyroxine sodium) should understand that treatment is lifelong and be taught the signs of excess hormone (eg, tachycardia/palpitations, weight loss, insomnia). The medication is best absorbed on an empty stomach and is safe to take during pregnancy.

Question 6

The clinic nurse evaluates a client's response to levothyroxine after 8 weeks of treatment. What therapeutic responses to the medication should the nurse expect? Select all that apply.

Accepted Answer

The client's therapeutic response to levothyroxine (Synthroid) is evaluated by resolution of hypothyroidism symptoms. The expected response includes improved well-being with elevated mood (Option B), higher energy levels (Option C), and a heart rate that is within normal limits (Option A). The nurse should consult the health care provider if the heart rate is >100/min, or if the client reports chest pain, nervousness, or tremors; this may indicate that the dose is higher than necessary. Pharmacological therapy manages the symptoms of hypothyroidism, but it takes up to 8 weeks after initiation to see the full therapeutic effect. (Option D) In hypothyroidism, the skin is cool, pale, and rough (due to dryness). These characteristics result from decreased blood flow. A therapeutic response to levothyroxine would be skin that is normal. (Option E) The client experiencing a therapeutic response to levothyroxine would experience weight loss due to the increased metabolic rate. However, the client with untreated hypothyroidism would experience weight gain. Educational objective: The expected therapeutic response to levothyroxine (Synthroid) includes an increased sense of well-being with elevated mood, greater energy levels, and a heart rate within normal limits. It takes up to 8 weeks to see the full effect of pharmacological therapy.

Question 7

The nurse is providing education to a pregnant client diagnosed with symptomatic hypothyroidism regarding levothyroxine therapy during pregnancy. Which is appropriate teaching for the nurse to include?

Accepted Answer

Hypothyroidism during pregnancy places clients at increased risk for other complications of pregnancy (eg, preeclampsia, placental abruption, preterm labor). Symptoms of hypothyroidism may include fatigue, cold intolerance, constipation, dry skin, and brittle hair/nails. Levothyroxine (Synthroid) is the first-line medication for treatment of hypothyroidism during pregnancy. The client may experience some relief of symptoms beginning approximately 3-4 weeks after initiating levothyroxine therapy (Option D). Hormone levels are usually rechecked every 4-6 weeks until normal thyroid hormone levels are achieved. It may take up to 8 weeks after initiation to see the full therapeutic effect. (Option A) Adequate levels of maternal thyroid hormones are important for fetal brain development, particularly during the first trimester. Levothyroxine should not be stopped during pregnancy, even if symptoms resolve. (Option B) Prenatal vitamins containing iron can affect the absorption of levothyroxine and decrease its effectiveness. The nurse should instruct the client to take levothyroxine in the morning on an empty stomach, at least 4 hours before or after taking a prenatal vitamin. (Option C) As the pregnancy advances, the client's dose of levothyroxine may need to be increased. Thyroid stimulating hormone (TSH) levels are closely monitored during pregnancy, and the client's dose is modified as needed to maintain normal levels. Educational objective: Levothyroxine is the first-line treatment for hypothyroidism during pregnancy to maintain adequate levels of maternal thyroid hormones, which are critical for fetal brain development. Symptoms of hypothyroidism typically begin to improve approximately 3-4 weeks after initiating levothyroxine. Therapy should not be stopped, even if symptoms resolve.

Question 8

A client with type I diabetes mellitus is prescribed an insulin pump.  The nurse reinforces the diabetic educator's teaching regarding transitioning from multiple daily injections to continuous subcutaneous insulin infusion (CSII) therapy.  Which statement indicates that the client understands the advantages of using this therapy?

Accepted Answer

11ecbb05_cc7c_1fcf_b433_15b467dcdc74_MD0009_00 An insulin pump is a small, battery-operated device about the size of a pager. The infusion set holds a syringe (reservoir) filled with rapid-acting insulin (175-315 units) and delivers the drug from the pump to the client through a needle or catheter that is usually secured to the abdomen with an adhesive patch. The pump delivers insulin in 2 ways: As a steady, measured, and continuous dose (basal rate) 24 hours a day As an intermittent dose (bolus) administered manually at mealtime to cover carbohydrate intake and as a supplemental dose to correct pre- or postprandial hyperglycemia. CSII therapy delivers the insulin more accurately than injections, so the client experiences fewer swings in blood glucose levels and hypoglycemic episodes, as compared with the administration of insulin using a needle and syringe, or pen. (Option A) Although the pump can calculate and deliver a more precise dose to regulate blood glucose levels more effectively, a bolus dose must be administered manually at mealtime to cover carbohydrate intake. (Option C) Pumps used most commonly (open-loop) cannot respond to changes in the client's glucose levels. The American Diabetes Association recommends that clients using CSII check their blood glucose levels 4-8 times a day: fasting, pre-meal, 2-hours postprandial, bedtime, at 3:00 AM weekly, when experiencing symptoms of hypoglycemia, after treating low blood sugar, and before exercise. Some insulin pumps (closed-loop system) are equipped with continuous blood glucose monitoring (CBGM) systems, which can detect blood glucose levels without a fingerstick. However, CBGM does not completely eliminate the need to test blood sugar because some machines must be calibrated every day to validate accuracy. (Option D) Use of the insulin pump facilitates tighter glucose control, leading to more normal metabolism. However, if the client continues to take in more calories than needed for a given amount of activity or exercise, glucose that is not used by the cells accumulates as fat and results in weight gain. Educational objective: A client prescribed CSII is taught how to self-manage the insulin pump. Key points include the importance of checking blood glucose levels at least 4 times a day, how to administer a bolus dose at mealtime to cover carbohydrate intake, how to administer a supplemental bolus dose to correct pre- and postprandial hyperglycemia, and the importance of balancing diet and exercise to avoid excess weight gain.

Question 9

The nurse is speaking to a client who takes desmopressin nasal spray for diabetes insipidus. Which statement by the client is most important for the nurse to report to the health care provider?

Accepted Answer

Desmopressin is a medication often used to treat central diabetes insipidus, a disease characterized by reduced antidiuretic hormone (ADH) levels that may result in dehydration and hypernatremia. Desmopressin mimics the effects of naturally occurring ADH, which increases renal water resorption and concentrates urine. However, this effect also increases the risk for water intoxication from decreased urine output. Clients receiving desmopressin must have their fluid and electrolyte status closely monitored for symptoms of water intoxication/hyponatremia (eg, headache, mental status changes, weakness). The nurse should immediately notify the health care provider (HCP) of client reports of water intoxication symptoms, as severe hyponatremia may progress to seizure, neurologic damage, or death (Option D). (Option A) Clients on desmopressin are often on fluid restriction as part of therapy. Frequent reinforcement may be necessary. (Option B) Rhinitis and upper respiratory infection (eg, a cold) can decrease the effectiveness of desmopressin nasal spray therapy and may require dosage adjustments by the HCP. However, dosage adjustments can be addressed after symptoms of water intoxication. (Option C) Side effects of desmopressin nasal spray include nasal irritation, congestion, and pain. If the client cannot tolerate side effects of nasal spray, oral dosing may be prescribed by the HCP. Educational objective: Clients taking desmopressin for diabetes insipidus are at risk for water intoxication and hyponatremia. Client reports of headache, mental status change, and/or muscle weakness may indicate hyponatremia from water intoxication and should be reported to the health care provider immediately.

Question 10

A nurse is caring for a client with an exacerbation of chronic obstructive pulmonary disease (COPD) and a history of type 2 diabetes mellitus requiring insulin.  The client has been prescribed prednisone.  The nurse anticipates which need?

Accepted Answer

Corticosteroids (eg, methylprednisolone, prednisone, dexamethasone) are given to combat inflammation in the lungs in clients with COPD exacerbation. All glucocorticoids can cause an increase in blood sugar. This may lead to the need for a higher dose of insulin based on the client's blood sugar level. (Option A) Most glucocorticoids have some mineralocorticoid activity, causing fluid retention and worsening hypertension. (Option B) Prednisone is started at a higher dose and then gradually decreased for COPD exacerbation and most other conditions. A slow taper will prevent adrenal crisis. (Option D) Intake and output are not affected by corticosteroids. Educational objective: Corticosteroids commonly cause hyperglycemia and worsen hypertension. When taken in combination with NSAIDs, they can increase the risk of peptic ulcer disease. Corticosteroids in general are started at high doses and slowly tapered to reduce the risk of sudden adrenal crisis.

Question 11

An elderly client with type 2 diabetes is admitted to the medical unit due to urosepsis. The client is wearing an insulin pump for continuous subcutaneous insulin infusion therapy. The client's significant other reports that the client self-manages the insulin pump extremely well and keeps blood glucose in the specified target range. What is the admitting nurse's priority action?

Accepted Answer

Change in mental status and confusion is a common presenting symptom of sepsis in the elderly. The nurse should assess the client's cognitive status andlevel of orientation and consciousness. Diminished mental acuity, side effects of medication, and impairment related to a medical condition during hospitalization affect the client's ability to manage the insulin pump safely. Mental status is the key to safe insulin pump use, so if the client is not competent to operate the pump, the nurse should notify the health care provider (HCP) and document the findings in the client's electronic medical record. The HCP will determine if continuing the use of the pump during hospitalization is appropriate. (Option B) Assessing the infusion pump site for signs of infection and intactness of the infusion set is important, but it is not the priority action. (Option C) The HCP prescribes the basal insulin along with the parameters for bolus and correction doses while the client is hospitalized. The nurse should check and document the make and model, pump settings, type of insulin, and the date that the infusion site and set were changed. However, this is not the priority action. (Option D) Consulting with the diabetic resource nurse or educator to determine the client's competency and ability to manage a specific type of pump and provide ongoing client education is an appropriate action. However, this is not the priority. Educational objective: When caring for a hospitalized client wearing an insulin pump, the priority nursing action is to assess the client's mental capacity to determine the ability to self-manage the pump safely.

Question 12

The nurse performs medication reconciliation for a 94-year-old client who has type 2 diabetes, hypothyroidism, and heart failure caused by a previous myocardial infarction.  Due to risks outweighing benefits, the nurse plans to talk with the health care provider about discontinuing which medication?

Accepted Answer

Beers Criteria lists medications that may be inappropriate for the geriatric population due to risks outweighing benefits. The nurse collaborates with the health care provider to minimize polypharmacy and reduce adverse effects (eg, falls, confusion). Sulfonylureas (eg, glyburide) stimulate insulin release via the pancreas and carry a risk for severe and prolonged hypoglycemia in the geriatric population due to potential delayed elimination. Avoidance of these drugs is recommended by the Beers Criteria. Instead, other medications that are at lower risk for hypoglycemia should be used (eg, metformin) (Option C). (Option A) Aspirin is used to prevent platelet aggregation in clients with a history of stroke or myocardial infarction. Aspirin and other nonsteroidal anti-inflammatory medications (eg, ibuprofen) have an increased risk of gastrointestinal bleeding. Therefore, aspirin is used cautiously in the older adult population, and doses should not exceed 325 mg/day. (Option B) Furosemide is a loop diuretic used to treat fluid overload in heart failure, making it an important part of symptom management. This drug may cause dehydration if the client is not ingesting food and fluids well; otherwise, it should be continued. (Option D) Levothyroxine is required to maintain thyroid hormone levels in clients with hypothyroidism. Major side effects typically occur only with improper dosing (eg, elevated levels). Educational objective: The Beers Criteria can be used to identify potentially inappropriate drugs that contribute to adverse events (eg, falls, confusion) and drug toxicity in older adults. Sulfonylureas (eg, glyburide) should be avoided due to potential delayed elimination causing risk for prolonged hypoglycemia.

Question 13

The clinic nurse is teaching a client about levothyroxine, which the health care provider has prescribed for newly diagnosed hypothyroidism. Which statement made by the client indicates that further teaching is needed?

Accepted Answer

Several medications impair the absorption of levothyroxine (Synthroid). Common offenders are antacids, calcium, and iron preparations. Some of these could be present in several over-the-counter multivitamin and mineral tablets. Therefore, clients with hypothyroidism should be instructed to take levothyroxine on an empty stomach, preferably in the morning, separately from other medications. The most common reason for inadequately treated hypothyroidism is deficient knowledge related to the medication regimen (eg, not taking daily, taking with other medications). (Option A) Levothyroxine dosing is adjusted based on blood tests for thyroid-stimulating hormone or other thyroid hormone levels. The dose is not the same for each client. (Option B) Thyroid supplementation with levothyroxine usually requires lifelong therapy. (Option C) Levothyroxine has a long half-life, so dosing is once daily. Educational objective: Levothyroxine should be taken on an empty stomach, preferably in the morning, separately from other medications.

Question 14

The nurse obtains a health history from a client who states, "I skip dinner most nights to lose weight.  I don't want to get low blood sugar, so I don't take my evening dose of metformin when I skip dinner."  Which response by the nurse is appropriate?

Accepted Answer

Metformin is an oral antidiabetic medication used to manage hyperglycemia in clients with type 2 diabetes. Metformin increases the sensitivity of insulin receptors in cells and reduces glucose production by the liver. These actions increase the efficacy of insulin present in the body and prevent large rises in blood glucose after meals. Because metformin does not stimulate insulin secretion by the pancreas, the risk of hypoglycemia is minimal (Option C). Although skipping meals would cause a drop in blood glucose, metformin would not cause further hypoglycemia. (Option A) Investigating the effect that skipping meals and medication has on the client's blood glucose levels may imply affirmation of the incorrect action. The nurse should provide education about the drug action and appropriate means of weight loss. (Option B) Instructing the client to alter the frequency or dose of prescribed medication is outside of the nurse's scope of practice. Alterations to treatment plans require the prescriptive authority of a health care provider. (Option D) Skipping meals to lose weight is not a healthy weight-loss strategy as it causes cellular energy deficits and may lead to hypoglycemia. Educating the client to take medications as prescribed remains the priority. Furthermore, "Why" questions are not appropriate forms of therapeutic communication. Educational objective: Metformin is an oral antidiabetic medication that increases insulin sensitivity and inhibits liver glucose production. Metformin does not increase insulin secretion, so the risk of hypoglycemia is minimal even when meals are skipped.

Question 15

The nurse is administering medications to a client who is being evaluated for a brain malignancy.  The client is scheduled for a CT scan with IV iodinated contrast the next morning.  Which medication should the nurse clarify with the health care provider?

Accepted Answer

A computed tomography (CT) scan is a noninvasive procedure that provides detailed x-ray images of the body. In some cases, iodinated contrast (eg, IV, PO) is administered during the CT scan to enhance visualization of blood vessels or certain organs. For clients with renal impairment, a potential complication of IV iodinated contrast is acute kidney injury (ie, contrast-induced nephropathy). Lactic acidosis is a severe complication of metformin, an antidiabetic medication. Administration of IV iodinated contrast to a client who takes metformin can cause an accumulation of metformin in the bloodstream, which increases the risk for lactic acidosis. As a result, many health care providers will discontinue metformin 24-48 hours before administration of IV contrast and restart the medication after 48 hours, when stable renal function is confirmed (Option C). (Options A, B, and D) Amlodipine is a calcium channel blocker commonly used to treat hypertension. Gabapentin is an anticonvulsant that is also used for neuropathic pain. Phenytoin is an anticonvulsant. None of these medications are known to interact with the iodinated contrast or worsen kidney injury. Therefore, these medications can be safely administered to the client who is scheduled to receive IV iodinated contrast. Educational objective: Iodinated contrast is commonly administered during computed tomography (CT) scans to enhance visualization of certain body structures. Clients who receive IV iodinated contrast while taking metformin are at increased risk for lactic acidosis; therefore, the health care provider may discontinue metformin 24-48 hours before administration of IV contrast and restart the medication after 48 hours.

Question 16

A client who has been on long-term omeprazole therapy for gastroesophageal reflux disease is admitted to the hospital for a urinary tract infection. The nurse recognizes that this client is at highest risk for which complication due to omeprazole use?

Accepted Answer

Long-term use of proton pump inhibitors (PPIs) is common as these medications are available over the counter. PPIs impair intestinal calcium absorption and therefore are associated with decreased bone density, which increases the possibility of fractures of the spine, hip, and wrist. PPIs cause acid suppression that otherwise would have prevented pathogens from more easily colonizing the upper gastrointestinal tract. This leads to increased risk of pneumonias. PPI use may also increase the risk for clostridium difficile-associated diarrhea (CDAD); currently the cause is unclear. A safety alert has been issued by the US Food and Drug Administration (FDA) advising health care providers to consider CDAD for unresolved diarrhea in PPI users. This client would be receiving antibiotics for a urinary tract infection, further increasing the risk for C difficile infection (Option A). (Option B) Gait disturbance (ataxia) is commonly seen with phenytoin toxicity. (Option C) Jaw necrosis is associated with long-term bisphosphonate (eg, alendronate, risedronate) therapy. (Option D) Tremor is seen with lithium toxicity and albuterol (short-acting beta agonist) use. Educational objective: Long-term use of PPIs (Prazoles - omeprazole, lansoprazole, pantoprazole, rebeprazole) has been associated with decreased bone density (calcium malabsorption) and increased risk for C difficile-associated diarrhea and pneumonia.

Question 17

A client with a history of cirrhosis has a new prescription for lactulose 30 mL four times a day.  What does the nurse explain to the client about this medication?

Accepted Answer

Lactulose is a syruplike liquid that decreases intestinal ammonia absorption in clients with liver disease and hepatic encephalopathy. Hepatic encephalopathy occurs when the failing liver does not adequately detoxify ammonia in the body, leading to changes in mental status and death if not adequately and promptly treated. The lactulose dosing frequency should be adjusted to ensure 2-3 soft stools per day with no confusion or lethargy. (Option B) Spironolactone, an aldosterone inhibitor and potassium-sparing diuretic, is typically used in a client with liver failure, ascites, and edema to promote diuresis and to prevent fluid retention. If more diuresis is needed, then intravenous furosemide is used, often in combination with albumin infusion. (Option C) Lactulose does not promote renal excretion of bilirubin. (Option D) A TIPS (transjugular intrahepatic portosystemic shunt) procedure and beta blockers (propranolol) are used to reduce portal pressure in the client with liver failure and esophageal varices. Educational objective: Lactulose controls ammonia levels in hepatic encephalopathy by reducing intestinal absorption of ammonia with excretion in the stool.

Question 18

The nurse evaluates the effectiveness of desmopressin use for diabetes insipidus in a client with a pituitary tumor.  Which client assessment finding indicates that the medication is having the desired effect?

Accepted Answer

Diabetes insipidus (DI) results in low levels of antidiuretic hormone (ADH), which is produced by the hypothalamus and stored in the pituitary gland. The function of ADH is to concentrate urine by signaling the kidneys to retain water in the setting of thirst. When ADH levels are insufficient, the kidneys excrete large quantities of very dilute urine (polyuria). This causes hypernatremia (elevated serum sodium due to deficit of free water) and increased serum osmolality, which lead to excessive thirst (polydipsia). Desmopressin acetate (DDAVP) is a synthetic form of ADH, which can be administered intravenously, orally, or via nasal spray. Effectiveness of therapy with desmopressin would be manifested by decreased urinary output and increased urine specific gravity as the urine becomes less dilute (Option C). (Option A) A client's thirst, not appetite, is affected by DI. (Option B) DI is related to water balance, but not to diabetes mellitus, a disorder of glucose metabolism. (Option D) If desmopressin therapy is effective, the client's urine specific gravity will be higher due to the urine output decreasing and becoming less dilute. Educational objective: Use of desmopressin acetate (DDAVP) in clients with diabetes insipidus will lower urinary output and cause the urine specific gravity to increase.

Question 19

A nurse is assessing a client with type 2 diabetes mellitus who was recently started on pioglitazone. Which client data obtained by the nurse is most important to bring to the attention of the health care provider?

Accepted Answer

Thiazolidinediones (rosiglitazone [Avandia] and pioglitazone [Actos]) are used to treat type 2 diabetes mellitus. These agents improve insulin sensitivity but do not release excess insulin, leading to a low risk for hypoglycemia (similar to metformin). These drugs can worsen heart failure by causing fluid retention and increase the risk of bladder cancer. Heart failure or volume overload is a contraindication to thiazolidinedione use. These medications also increase the risk of cardiovascular events such as myocardial infarction. (Option B) The target blood pressure for a client with diabetes is <140/90 mm Hg. (Option C) The goal HbA1c for diabetic clients is <7%. (Option D) Diabetic retinopathy, a condition treated with retinal photocoagulation, is unrelated to thiazolidinedione use. If the client has a history of bladder cancer, then it should be reported. Educational objective: Thiazolidinediones (rosiglitazone [Avandia] and pioglitazone [Actos]) increase the risk of cardiovascular events (eg, mycoardial infarction, heart failure) and bladder cancer. Thiazolidinedione use increase insulin sensitivity but carries a low risk for hypoglycemia (similar to metformin).

Question 20

Which client finding would be a contraindication for the nurse to administer dicyclomine hydrochloride for irritable bowel syndrome?

Accepted Answer

Dicyclomine hydrochloride (Bentyl) is an anticholinergic medication. Anticholinergics are used to relax smooth muscle and dry secretions. Anticholinergic side effects include pupillary dilation, dry mouth, urinary retention, and constipation. Therefore, the classic contraindications are closed-angle glaucoma, bowel ileus, and urinary retention. The urge to urinate is normally present at 300 mL; pain is usually felt around 500 mL. This client has urinary retention and should not have the bladder smooth muscle further relaxed. (Option B) Anticholinergic drugs do not affect the blood count. The normal reference range for hemoglobin is 11.7-15.5 g/dL (117-155 g/L) for females and 13.2-17.3 g/dL (132-173 g/L) for males. (Option C) The common eye contraindication is narrow-angle glaucoma as it could worsen the condition. Cataracts are a clouding of the lens and are not related to drainage flow. glaucoma Cataracts (Option D) Diarrhea is an expected finding with irritable bowel syndrome or other increased peristalsis and is a common reason for the drug to be prescribed. Anticholinergic drugs are contraindicated in the presence of a bowel ileus or atony as constipation is a side effect and further relaxation of the intestines could worsen these conditions. Educational objective: Anticholinergic drugs are contraindicated when smooth muscle relaxation is already a concern. Commonly cited contraindications include narrow-angle glaucoma, urinary retention (including benign prostatic hyperplasia), and bowel ileus/obstruction.

Exam 8: Pharmacology

The nurse provides medication teaching to a client with primary adrenal insufficiency (Addison's disease) who is prescribed hydrocortisone 10 mg by mouth 3 times a day. Which instructions should be included in the client's teaching plan? Select all that apply.

The nurse in an outpatient clinic is caring for a client with Addison disease who has been taking hydrocortisone 20 mg daily for the last 8 years. Which client data is most important to report to the health care provider?

A diabetic client is prescribed metoclopramide. Which of the following side effects must the nurse teach the client to report immediatelyto the health care provider? Select all that apply.

The nurse is caring for a client with diabetes who is being discharged with a prescription for glyburide. Which statement by the client indicates a need for further instruction?

The nurse plans teaching for a client who was newly prescribed levothyroxine sodium after thyroid removal. Which instructions will the nurse include in the teaching plan? Select all that apply.

The clinic nurse evaluates a client's response to levothyroxine after 8 weeks of treatment. What therapeutic responses to the medication should the nurse expect? Select all that apply.

The nurse is providing education to a pregnant client diagnosed with symptomatic hypothyroidism regarding levothyroxine therapy during pregnancy. Which is appropriate teaching for the nurse to include?

The nurse is speaking to a client who takes desmopressin nasal spray for diabetes insipidus. Which statement by the client is most important for the nurse to report to the health care provider?

A nurse is caring for a client with an exacerbation of chronic obstructive pulmonary disease (COPD) and a history of type 2 diabetes mellitus requiring insulin. The client has been prescribed prednisone. The nurse anticipates which need?

The nurse performs medication reconciliation for a 94-year-old client who has type 2 diabetes, hypothyroidism, and heart failure caused by a previous myocardial infarction. Due to risks outweighing benefits, the nurse plans to talk with the health care provider about discontinuing which medication?

The clinic nurse is teaching a client about levothyroxine, which the health care provider has prescribed for newly diagnosed hypothyroidism. Which statement made by the client indicates that further teaching is needed?

The nurse obtains a health history from a client who states, "I skip dinner most nights to lose weight. I don't want to get low blood sugar, so I don't take my evening dose of metformin when I skip dinner." Which response by the nurse is appropriate?

The nurse is administering medications to a client who is being evaluated for a brain malignancy. The client is scheduled for a CT scan with IV iodinated contrast the next morning. Which medication should the nurse clarify with the health care provider?

A client who has been on long-term omeprazole therapy for gastroesophageal reflux disease is admitted to the hospital for a urinary tract infection. The nurse recognizes that this client is at highest risk for which complication due to omeprazole use?

A client with a history of cirrhosis has a new prescription for lactulose 30 mL four times a day. What does the nurse explain to the client about this medication?

The nurse evaluates the effectiveness of desmopressin use for diabetes insipidus in a client with a pituitary tumor. Which client assessment finding indicates that the medication is having the desired effect?

A nurse is assessing a client with type 2 diabetes mellitus who was recently started on pioglitazone. Which client data obtained by the nurse is most important to bring to the attention of the health care provider?

Which client finding would be a contraindication for the nurse to administer dicyclomine hydrochloride for irritable bowel syndrome?