Question 1

The nurse is caring for a client who had surgery yesterday. When administering omeprazole, the client asks "What is that for? I don't take it at home." Which reply by the nurse is most appropriate?

Accepted Answer

Omeprazole is a proton pump inhibitor (PPI) that suppresses the production of gastric acid by inhibiting the proton pump in the parietal cells of the stomach. In most hospitalized clients without a history of GERD or ulcers, PPIs are prescribed to prevent stress ulcers from developing during surgery or a major illness. Although evidence has shown that two-thirds of clients who receive PPIs do not need them, these medications are still widely prescribed in hospitalized clients. PPIs can be identified by their "-prazole" ending (eg, pantoprazole, lansoprazole, esomeprazole). (Option A) Metoclopramide (Reglan) is not a PPI. It decreases postoperative nausea by promoting gastric emptying. (Option C) PPIs may be associated with an increased risk of Clostridium difficile infection with antibiotic use. (Option D) The client does not take this medication at home. The nurse is assuming that the client has a history of GERD rather than assessing for this condition first. Educational objective: PPIs such as omeprazole are often prescribed to hospitalized clients without GERD or ulcers to prevent stress ulcers from developing during surgery or a major illness.

Question 2

The nurse is caring for a client who started receiving chemotherapy 10 days ago.  Today, the health care provider prescribes filgrastim.  Which of the following is an expected outcome of this medication?

Accepted Answer

Chemotherapy can cause suppression of rapidly reproducing cells, including bone marrow suppression. This can result in decreased red blood cells, white blood cells, and platelets, all manufactured in the bone marrow. It is most likely to be seen with chemotherapy (versus radiation), with the lowest counts (the nadir) usually at 7-10 days after therapy initiation. Leukopenia is a decrease in total circulating white blood cell count (<4,000/mm³) and neutropenia is a decrease in circulating neutrophils (usually <1500/mm³). Filgrastim (Neupogen) and pegfilgrastim (Neulasta) stimulate neutrophil production and are given prophylactically or if the client has an infection and more neutrophils are needed to fight it (Option C). (Option A) Cancer chemotherapy causes cell lysis, which results in tumor lysis syndrome due to massive release of nucleic acid and its metabolic product, uric acid. Uric acid deposition leads to acute kidney injury. Medications such as allopurinol or rasburicase and aggressive IV hydration are used to prevent this complication. (Option B) Anemia is also common with chemotherapy. Epoetin (Procrit), a form of erythropoietin, stimulates the body to make additional red blood cells. (Option D) Low platelet count is not considered an urgent need until it is at <50,000/mm³. Usually, platelet transfusions are given. Educational objective: Bone marrow suppression from chemotherapy can cause decreased red blood cells, white blood cells, and platelets. Erythropoietin is used to increase red blood cell production, and filgrastim is administered to stimulate neutrophil production.

Question 3

A client is receiving chemotherapy for acute myeloid leukemia.  The health care provider prescribes allopurinol to prevent tumor lysis syndrome (TLS).  Which laboratory value indicates a therapeutic response to the medication?

Accepted Answer

11ecbb05_cc84_ab51_b433_55199b67a01d_MD0009_00 A potential complication of chemotherapy is acute tumor lysis syndrome (TLS), a rapid release of intracellular components into the bloodstream. Massive cell lysis releases intracellular ions (potassium and phosphorus) and nucleic acids into the bloodstream. Catabolism of the nucleic acids produces uric acid, resulting in severe hyperuricemia. Released phosphorus binds calcium, producing calcium phosphate mixture but lowering serum calcium levels. Both calcium phosphate and uric acid are deposited into the kidneys, causing renal injury. Allopurinol (Zyloprim) blocks the nucleic acid catabolism and prevents hyperuricemia but would not affect potassium, phosphate, and calcium levels. Chronic gout and uric acid calculi also require the administration of allopurinol to decrease uric acid accumulation. A normal blood uric acid level for an adult male is 4.4-7.6 mg/dL (262-452 µmol/L) and female is 2.3-6.6 mg/dL (137-393 µmol/L). (Option A) The normal calcium level for adults is 8.6-10.2 mg/dL (2.15-2.55 mmol/L). The client with this complication would experience hypocalcemia. (Option B) The normal phosphate level for adults is 2.4-4.4 mg/dL (0.78-1.42 mmol/L). In this condition, the phosphate level would show hyperphosphatemia. (Option C) The normal potassium level for adults is 3.5-5.0 mEq/L (3.5-5.0 mmol/L). Hyperkalemia is usually present in a client with this chemotherapy-induced complication. Educational objective: The therapeutic effect of allopurinol (Zyloprim) is to decrease hyperuricemia caused by TLS. Laboratory values of significance in TLS include rising blood uric acid, potassium, and phosphate levels, with decreasing calcium levels.

Question 4

The clinic nurse reviews the medical record of a client who was prescribed etanercept, a tumor necrosis factor (TNF) inhibitor. Which test result is most important for the nurse to check before initiating this treatment?

Accepted Answer

TNF inhibitor drugs (eg, etanercept [Enbrel], infliximab [Remicade], adalimumab [Humira]) block the action of TNF, a mediator that triggers a cell-mediated inflammatory response in the body. These drugs reduce the manifestations of rheumatoid arthritis (RA) and slow the progression of joint damage by inhibiting the inflammatory response. The medication causes immunosuppression and increased susceptibility for infection and malignancies. Clients should have a baseline TST before initiating therapy and yearly skin tests thereafter. Those with latent tuberculosis (TB) must be treated with antitubercular agents before initiating treatment with these drugs. Otherwise, TB reactivation would occur (Option D). (Option A) CRP is a non-specific test used to detect acute or chronic inflammation in the body. CRP can be used to evaluate the effectiveness of medications that decrease inflammation. An elevation would be expected in clients with RA, especially during a flare, but it is not the most important test result to check before initiating therapy. (Options B and C) LDL cholesterol and PT are unrelated to the administration of these medications. Educational objective: Major adverse effects of biologic disease-modifying TNF inhibitor drugs (eg, etanercept, infliximab, adalimumab) include severe infections and bone marrow suppression. TB reactivation is a major concern. Therefore, all clients must receive a TST to rule out latent TB.

Question 5

A child with cystic fibrosis is to receive a dose of pancrelipase at 12:00 PM.  The client states that he is not hungry and will eat his lunch in an hour.  Which action is appropriate for the nurse to take?

Accepted Answer

Cystic fibrosis affects the pancreatic excretion of digestive enzymes. Without these enzymes, the client is unable to absorb fats, starches, and some proteins from the diet. Pancrelipase provides these enzymes to the client and must be given with every snack and meal so that the client can digest and absorb the nutrients eaten. If the client is not eating when the medication is scheduled, there are no nutrients to digest. Therefore, the dose should be held until the client eats. Educational objective: Pancrelipase is a medication containing lipase, protease, and amylase. In cystic fibrosis, the client's pancreas does not excrete these necessary enzymes. To prevent malabsorption syndrome, the enzymes must be taken with every snack and every meal.

Question 6

The nurse is reviewing prescriptions for the assigned clients.  Which prescription should the nurse question?

Accepted Answer

Dicyclomine (Bentyl) is an anticholinergic/antispasmodic drug prescribed to manage symptoms of intestinal hypermotility in clients with irritable bowel syndrome. Dicyclomine is contraindicated in clients with paralytic ileus as it decreases intestinal motility and would exacerbate the condition (Option B). The nurse should question this prescription and contact the health care provider. (Option A) Tumor lysis syndrome occurs due to rapid lysis of cells and the resulting release of intracellular potassium and phosphorus into serum. Phosphorus binds to calcium, leading to hypocalcemia. The breakdown of cellular nucleic acids causes severe hyperuricemia. IV hydration and hypouricemic medications (eg, allopurinol) are prescribed to promote purine excretion and prevent acute kidney injury. (Option C) Although opioids (eg, morphine) can cause constipation, symptoms can be managed with pharmacologic (eg, docusate sodium, sennoside) and nonpharmacologic interventions (eg, increased activity, increased fiber and fluid intake). Percutaneous nephrolithotripsy breaks and removes kidney stones, and can lead to severe pain. Therefore, pain medication is appropriate. (Option D) Levofloxacin, a fluoroquinolone antibiotic prescribed to treat urinary tract infections, has no known cross-sensitivity to penicillin. However, cross-sensitivity with other fluoroquinolones can occur. Educational objective: Dicyclomine is an antispasmodic drug that decreases intestinal motility and is contraindicated in clients with paralytic ileus.

Question 7

A client has been on long-term therapy with esomeprazole. What is essential for the nurse to ask the client?

Accepted Answer

Long-term therapy with a proton pump inhibitor (PPI) (eg, omeprazole, pantoprazole, esomeprazole) may decrease the absorption of calcium and promote osteoporosis. A bone density test can assess if the client already has osteoporosis. Hospitalized clients also have an increased risk of diarrhea caused by Clostridium difficile. PPIs cause suppression of acid that otherwise would have prevented pathogens from more easily colonizing the upper gastrointestinal tract. This leads to increased risk of pneumonias. (Option A) Drinking extra water and being upright for 30 minutes after taking bisphosphonates (eg, risedronate, alendronate) is necessary to prevent esophagitis. However, this is not necessary with PPI use. (Option B) The medication should be taken prior to meals. (Option D) PPIs do not affect blood pressure. Educational objective: Long-term use of PPIs (eg, omeprazole, pantoprazole, esomeprazole) is associated with osteoporosis, C difficile infection, and pneumonias. Clients should be encouraged to increase calcium and vitamin D intake to help prevent osteoporosis.

Question 8

The emergency department nurse prepares a male client for surgery.  The client was admitted with a traumatic open fracture of the femur, hematocrit of 36% (0.36), and hemoglobin of 12 g/dL (120 g/L).  Which prescription should the nurse validate with the health care provider before administration?

Accepted Answer

The Joint Commission Surgical Improvement Project CORE measure set has shown that preventives (eg, heparin, enoxaparin, aspirin) in select surgical procedures, given 24 hours before and after surgery, reduce the risk of venous thromboembolism.  However, the estimated blood loss in a client with a fracture can be significant depending on the site (eg, 250-1200 mL).  Although this client's admission hematocrit (36% [0.36]) and hemoglobin (12 g/dL [120 g/L]) are only slightly low for an adult male (normal: 39%-50% [0.39-0.50], 13.2-17.3 g/dL [132-173 g/L]), the blood loss may not yet be evident.  Therefore, the nurse would validate the prescription for enoxaparin (Lovenox) with the health care provider before administration.
Medications commonly prescribed for a client with an open fracture include:
Cefazolin (Ancef), a bone-penetrating cephalosporin antibiotic that is active against skin flora (Staphylococcus aureus); it is given prophylactically before and after surgery to prevent infection (Option A)
Cyclobenzaprine (Flexeril), a central and peripheral muscle relaxant given to treat pain associated with muscle spasm; carisoprodol (Soma) or methocarbamol (Robaxin) can also be prescribed
Tetanus and diphtheria toxoid, an immunization given prophylactically to prevent infection (Clostridium tetani) if immunizations are not up to date (>10 years), unavailable, or unknown (Option D)
Ketorolac (Toradol), a nonsteroidal anti-inflammatory drug given to decrease inflammation and pain
Opioids (eg, morphine, hydrocodone [Vicodin]), given for analgesia (Option C)
Educational objective:
Medications commonly prescribed for a client with an open fracture to prevent infection and treat pain and muscle spasm include cefazolin (Ancef), tetanus toxoid, ketorolac (Toradol), opioids, and cyclobenzaprine (Flexeril)

Question 9

The nurse is caring for a client diagnosed with endometrial cancer who is receiving brachytherapy. Which interventions should the nurse implement while caring for this client? Select all that apply.

Accepted Answer

Internal radiation (brachytherapy) involves direct application of a radioactive implant to the cancerous site or tumor for a short time, usually 24-72 hours. This technique is used to treat cervical and endometrial cancer and delivers a high dose of radiation to the cancerous tissues with a limited dose to adjacent normal tissues. Implementation of the following nursing measures is vital as the client receiving brachytherapy emits radiation. Following the principles of time, distance, and shielding provides staff and visitors protection from exposure to radiation. Time spent near the radiation source is restricted. The guideline is to limit staff time spent in the room to 30 minutes per shift. Cluster nursing care to minimize exposure to the radiation source Rotate daily staff responsibilities to limit time spent in the client room All staff and visitors must keep the maximum distance possible from the radiation source. Maintaining a distance of at least 6 feet is an established standard. Assign the client to a private room with a private bath Keep the door to the room closed Ensure that a sign stating, "Caution, Radioactive Material" is affixed to the door Instruct the client to remain on bedrest to prevent dislodgement of the implant Shielding with lead diminishes exposure to radiation. All staff providing nursing care that requires physical contact must wear a lead apron. (Option B) The client receiving brachytherapy for endometrial cancer is instructed to remain on bedrest while the radiation implant is in place. If the implant dislodges from the vaginal cavity, the implant is never touched with the hands; instead, long-handled forceps are used to pick it up for placement in a lead container. Educational objective: Following the principles of time, distance, and shielding provides staff protection from exposure to internal radiation emissions. Staff should spend no more than 30 minutes in a client's room; should remain at least 6 feet away from the radiation source; and should wear lead aprons when providing direct client care.

Question 10

A parent rushes a 4-year-old child to the emergency department after finding the child sitting on the kitchen floor holding an empty bottle of aspirin. The parent has no idea how many tablets were left in the container. The child is sniffling and quietly crying. The nurse anticipates initially implementing which treatment?

Accepted Answer

Activated charcoal is an important treatment in early acetylsalicylic acid (ASA) toxicity; it is recommended for gastrointestinal decontamination in clients with clinical signs of ASA poisoning (disorientation, vomiting, hyperpnea, diaphoresis, restlessness) as well as in those who are asymptomatic. Activated charcoal binds to available salicylates, thus limiting further absorption in the small intestine and enhancing elimination. (Option B) Similar to syrup of ipecac, gastric lavage is associated with risk of aspiration. In addition, there is no convincing evidence that it decreases morbidity. It is not routinely recommended but may be performed for the ingestion of a massive or life-threatening amount of drug. If necessary, it should be administered within 1 hour of ingestion and requires a protected airway and possible sedation. (Option C) IV sodium bicarbonate is an appropriate treatment for aspirin toxicity after the administration of activated charcoal. It is given to make the blood and urine more alkaline, therefore promoting urinary excretion of salicylate. (Option D) Syrup of ipecac has been shown to have minimal benefit in treating aspirin overdose; in addition, it is not recommended due to the risk of aspiration pneumonia secondary to induced vomiting. Educational objective: Activated charcoal is used as the initial treatment for aspirin overdose in clients with clinical signs of salicylate toxicity as well as in those who are asymptomatic. Activated charcoal binds with salicylate and therefore inhibits absorption by the small intestine. IV sodium bicarbonate is also used for treating aspirin overdose after treatment with activated charcoal has been initiated.

Question 11

A client is being discharged on enoxaparin therapy following total knee replacement surgery.  Which teaching instruction does the nurse include in the teaching plan?

Accepted Answer

11ecbb05_cc87_4362_b433_89f3294e4b9d_MD0009_00 Enoxaparin (Lovenox) is a low molecular weight heparin (LMWH) that may be prescribed for up to 10-14 days following hip and knee surgery to prevent deep venous thrombosis. Discharge teaching for the client on enoxaparin therapy includes: Pinch an inch of skin upwards and insert the needle at a 90-degree angle into the fold of skin. Continue to hold the skin fold throughout the injection and then remove the needle at a 90-degree angle. Mild pain, bruising, irritation, or redness of the skin at the injection site is common. Do NOT rub the site with the hand. Using an ice cube on the injection site can provide relief (Option B). Avoid taking aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), and herbal supplements (Ginkgo biloba, vitamin E) without health care provider approval as these can increase the risk of bleeding (Option C). Monitor complete blood count to assess for thrombocytopenia. (Option A) Vitamin K-rich foods do not need to be eliminated from the diet during enoxaparin therapy; prothrombin time (PT) and international normalized ratio (INR) are not affected. However, PT and INR are decreased when a vitamin K antagonist (eg, warfarin [Coumadin]) is taken with vitamin K-rich foods. (Option D) Routine coagulation studies (eg, PT, INR, partial thromboplastin time [PTT]) do not need to be monitored in a client who is taking enoxaparin. However, periodic assessment of complete blood count (CBC) is usually required to monitor for hidden bleeding and thrombocytopenia (especially in older clients with renal insufficiency). Educational objective: LMWH (Enoxaparin) requires monitoring of CBC (thrombocytopenia) but not coagulation studies. Administration of unfractionated heparin requires monitoring with PTT, whereas warfarin requires PT/INR monitoring. Clients on these medications should avoid aspirin and NSAIDs.

Question 12

A nurse conducting rounds checks on a client receiving continuous total parenteral nutrition (TPN). The infusion pump is found to be powered down, and TPN is no longer infusing. Which action should the nurse take first?

Accepted Answer

Total parenteral nutrition (TPN) is an IV nutrition solution containing carbohydrates, amino acids, vitamins, minerals, electrolytes, and lipids that is administered to clients who are unable to receive enteral nutrition. TPN is rich in glucose, which supplies caloric energy and stimulates the pancreas to secrete insulin. If TPN is stopped abruptly, the pancreas may continue to secrete increased amounts of insulin in anticipation of glucose metabolism, placing the client at risk for rapid-onset hypoglycemia. Therefore, clients whose TPN infusion has stopped or abruptly slowed should be assessed for signs of hypoglycemia and have blood glucose measured immediately, because hypoglycemia is associated with potentially life-threatening neurologic complications (Option C). (Option A) The nurse must notify the health care provider to obtain appropriate prescriptions for intervention and monitoring. However, the nurse should first ensure the client's safety by assessing for hypoglycemia. (Option B) Obtaining a serum electrolyte panel may be necessary to identify electrolyte abnormalities. However, the nurse must first assess for hypoglycemia because this will occur more rapidly than changes in electrolyte status. (Option D) Removal, identification, and storage of defective equipment are important to prevent future adverse events. However, the nurse should assess and stabilize the client before handling malfunctioning equipment. Educational objective: Total parenteral nutrition (TPN) is a nutritional IV solution that is rich in glucose. Clients whose TPN delivery has stopped abruptly are at risk for severe hypoglycemia due to increased pancreatic insulin production; therefore, the nurse should promptly assess the client for hypoglycemia.

Question 13

The nurse is caring for a client with cirrhosis who has hepatic encephalopathy. The client is prescribed lactulose. Which assessment by the nurse will most likely indicate that the medication has achieved the desired therapeutic effect?

Accepted Answer

Hepatic encephalopathy in cirrhosis results from higher serum ammonia levels that cause neurotoxic effects, including mental confusion. Oral lactulose is given to reduce the ammonia by trapping it in the gut and then expelling it with a laxative effect. Improved mental status implies reduction of ammonia levels. (Option A) Clients with cirrhosis typically have hypokalemia due to hyperaldosteronism (as aldosterone is not metabolized by the damaged liver). Hypokalemia can also result from diuretics used to treat the fluid retention and ascites. Lactulose is not intended to treat this pathology. (Option C) Lactulose is a laxative. In cirrhosis, constipation (which allows more ammonia to be absorbed) and hard stool (which irritates hemorrhoids) are to be avoided. However, the main purpose of lactulose is expelling the ammonia, with resulting benefits. (Option D) Abdominal distension (ascites) in cirrhosis is treated with diuretics (eg, furosemide, spironolactone) and paracentesis. Lactulose does not influence this pathology or symptom. Educational objective: Lactulose is a laxative used to trap and expel ammonia in clients with cirrhosis who have hepatic encephalopathy. Elevated ammonia levels cause mental confusion.

Question 14

The nurse reinforces teaching to a female client about taking misoprostol to prevent stomach ulcers. Which statement by the client would prompt further instruction?

Accepted Answer

Misoprostol (Cytotec) is a synthetic prostaglandin that protects against gastric ulcers by reducing stomach acid and promoting mucus production and cell regeneration. It is often prescribed to prevent gastric ulcers in clients receiving long-term nonsteroidal anti-inflammatory drug (NSAID) therapy. Antacids, especially those that contain magnesium (eg, Gaviscon), can increase the adverse effects of misoprostol (eg, diarrhea, dehydration). If clients require therapy with antacids, they should choose one that does not contain magnesium (eg, calcium carbonate [Tums]) and contact the health care provider if adverse effects occur (Option D). (Option A) Taking misoprostol with food can help decrease gastrointestinal side effects (eg, abdominal pain, cramping, diarrhea). (Option B) Misoprostol is also used for labor induction and is classified as a pregnancy category X drug. Women of childbearing age must be educated on using reliable birth control and the possible sensation of uterine cramping while taking misoprostol. Clients who suspect they are pregnant must stop taking the medication and contact their health care provider immediately. (Option C) The client can continue taking ibuprofen (an NSAID) with misoprostol because misoprostol is designed to reduce side effects of ibuprofen. Educational objective: Misoprostol prevents gastric ulcers in clients receiving long-term nonsteroidal anti-inflammatory drug therapy. It should not be taken with antacids but can be taken with food to reduce gastrointestinal upset. Women of childbearing age should be educated on using reliable birth control methods as misoprostol can induce labor.

Question 15

In which scenarios should the nurse hold the prescribed medication and question its administration? Select all that apply.

Accepted Answer

Heparin is a natural anticoagulant. Its risk is heparin-induced thrombocytopenia (HIT), also known as heparin-associated thrombocytopenia. Normal platelet range is 150,000-400,000/mm³ (150-400 x 10⁹/L). A mild lowering of platelets may occur and resolve spontaneously around the 4th day of administration. The danger is type II HIT, a more severe form in which there is an acute drop in the number of platelets (more than 50% from baseline), which requires discontinuing heparin (Option A). Angiotensin-converting enzyme (ACE) inhibitors such as lisinopril are teratogenic. Lisinopril can cause embryonic/fetal developmental abnormalities (cardiovascular and central nervous system) if taken during pregnancy, especially during the first 13 weeks of gestation. During the 2nd and 3rd trimesters, ACE inhibitors interfere with fetal renal hemodynamics, resulting in low fetal urine output (oligohydramnios) and fetal growth restriction (Option B). Nitroglycerine causes vasodilation and can lower blood pressure. Systolic blood pressure should be >90 mm Hg to ensure renal perfusion (Option C). (Option D) Gingival hyperplasia or hypertrophy is a known side effect of phenytoin (Dilantin) and is not a reason to stop the drug. Vigorous dental hygiene beginning within 10 days of initiation of phenytoin therapy can help control it. Signs and symptoms that require discontinuation include toxic levels or phenytoin hypersensitivity syndrome (fever, skin rash, and lymphadenopathy). (Option E) Warfarin (Coumadin) is used to prolong clotting so that the desired result is a "therapeutic" range rather than the client's "normal" control value when not on the drug. Therapeutic range is considered roughly 1.5-2.5 times the control (International Normalized Ratio [INR] of 2-3), but up to 3-4 times the control (INR of 2.5-3.5) in high-risk situations such as an artificial heart valve. Educational objective: Heparin should be held when there is significant thrombocytopenia. Angiotensin-converting enzyme inhibitors are not administered to pregnant women, and nitrates are not administered when a client is hypotensive. Prothrombin time/International Normalized Ratio is expected to be 1.5-2.5 (up to 4) times the control value when therapeutic effects are reached. Gingival hyperplasia is a side effect of phenytoin (Dilantin) administration and is not a reason to stop the drug.

Question 16

The nurse is preparing to administer a scheduled dose of metoclopramide IV to a client with diabetic gastroparesis.  Which clinical finding causes the nurse to question the prescription?

Accepted Answer

11ecbb05_cc81_c520_b433_fb0c59e20fbd_MD0009_00 Metoclopramide is a commonly used antiemetic medication that treats nausea, vomiting, and gastroparesis by increasing gastrointestinal motility and promoting stomach emptying. With extended use and/or high doses, metoclopramide may lead to the development of tardive dyskinesia (TD), a movement disorder that is characterized by uncontrollable motions (eg, sucking/smacking lip motions) and is often irreversible (Option D). uncontrollable motions The movement alterations of TD may impact a client's essential activities of daily living (eg, eating, dressing) and overall quality of life. The nurse should question the administration of a medication associated with TD in clients experiencing movement alterations. (Option A) Metoclopramide increases gastrointestinal motility, which may result in diarrhea in some clients. This symptom is reversible and usually easily managed. (Option B) Burping is not a typical side effect associated with metoclopramide. (Option C) Headache is a common adverse effect of metoclopramide that typically improves spontaneously. Educational objective: Clients receiving metoclopramide at high doses and/or for extended periods are at risk for developing tardive dyskinesia (TD), an often irreversible movement disorder. The nurse should question a prescription for metoclopramide if symptoms of TD (eg, uncontrollable lip smacking, hand wringing, rocking) are present.

Question 17

Which herbal supplements pose an increased risk for bleeding in surgical clients and should be discontinued prior to major surgery? Select all that apply.

Accepted Answer

11ecbb05_cc88_06b3_b433_a98d60eecfc2_MD0009_00 Clients are often aware of the need to discontinue prescription medications such as aspirin and anticoagulants prior to elective surgery, but they may not know that some herbal supplements can increase bleeding risk. The nurse should question the client specifically about the use of herbal supplements. Herbal supplements that can increase risk for bleeding include: Gingko biloba Garlic Ginseng Ginger Feverfew (Option A) Black cohosh is used for treatment of menopausal symptoms. The main side effect is liver injury. (Option E) Hawthorn extract is used to control hypertension and mild to moderate heart failure. Hawthorn use does not increase the risk of bleeding. Educational objective: Use of herbal supplements such as ginkgo biloba, garlic, ginseng, ginger, and feverfew should be reported to the health care provider before surgery as they may increase the risk of bleeding.

Question 18

A client with obesity has just started taking orlistat.  Which statement by the client indicates a need for further teaching?

Accepted Answer

Orlistat is a lipase inhibitor that prevents the breakdown and absorption of fats from the intestine. This medication is prescribed to clients with obesity who have difficulty losing weight or a comorbidity that makes weight loss therapeutically essential (eg, diabetes, heart disease). Orlistat should always be used with diet modification and an exercise regimen. Because orlistat blocks the absorption of fats, it also interferes with fat-soluble vitamin uptake. Clients should offset this effect by taking a multivitamin that contains vitamins A, D, E, and K. To be most effective, multivitamins should be taken >2 hours after taking orlistat (Option A). (Option B) Clients may experience fecal incontinence, flatulence, oily stools, and oily spotting because unabsorbed fat is eliminated through defecation. (Option C) A low-fat diet is an essential component of weight loss when a lipase inhibitor has been prescribed. (Option D) The nurse should teach the client to take orlistat with, or within 1 hour of, meals that contain fat. If the client selects foods that do not contain fat, the dose may be skipped. Educational objective: Orlistat, a lipase inhibitor, prevents the absorption of fat from the gastrointestinal tract and is used with diet (eg, low-fat) and exercise to promote weight loss. Because orlistat blocks the absorption of fats, it also interferes with the uptake of fat-soluble vitamins. Clients should take a daily multivitamin with vitamins A, D, E, and K >2 hours after taking orlistat to prevent nutrient deficiencies.

Question 19

A nurse is observing a nursing student reinforce teaching to a client on how to take sucralfate.  Which statement made by the student would require intervention by the nurse?

Accepted Answer

Sucralfate is an oral medication that forms a protective layer in the gastrointestinal mucosa, which provides a physical barrier against stomach acids and enzymes. It does not neutralize or reduce acid production but is prescribed to treat and prevent both stomach and duodenal ulcers. Sucralfate is generally prescribed 1 hour before meals and at bedtime and, for effective results, is taken on an empty stomach with a glass of water. Sucralfate forms a better protective layer at a low pH level. Therefore, antacids or other acid-reducing medications (eg, proton pump inhibitors, H2 blockers) should be avoided within 30 minutes of taking sucralfate to prevent altered absorption (Option B). (Option A) Sucralfate should be taken 1 hour before meals to protect the stomach. (Option C) Sucralfate binds with many medications (eg, digoxin, warfarin, phenytoin), reducing their bioavailability and effectiveness. Therefore, all other medications are generally taken ≥1-2 hours before or after taking sucralfate. (Option D) Constipation is a common side effect of sucralfate. Educational objective: Sucralfate should be taken on an empty stomach with a glass of water because it forms a better protective layer at a low pH level. Therefore, acid-reducing agents (eg, antacids, proton pump inhibitors, H2 blockers) should be avoided within 30 minutes of taking sucralfate, and all other medications should be taken ≥1-2 hours before or after sucralfate.

Question 20

The nurse is caring for a client with an inflammatory bowel disease exacerbation. The client is prescribed sulfasalazine. Which finding would require a priority follow-up by the nurse?

Accepted Answer

Sulfasalazine (Azulfidine) contains sulfapyridine and aspirin (5-ASA) and is used as a topical gastrointestinal anti-inflammatory and immunomodulatory agent in inflammatory bowel disease (IBD). When the 5-ASA is combined with the sulfa preparation, the drug does not become absorbed until it reaches the colon. Dehydration is a risk with IBD as the client can have up to 20 diarrheal stools a day. The client usually does not feel thirsty until after there is a fluid volume deficit. Sulfa can crystallize in the kidney if the client is dehydrated. Normal urine specific gravity is 1.003-1.030. Elevated specific gravity can indicate concentrated urine and be a sign of dehydration (Option D). (Option A) Due to the inflammatory nature of IBD, erythrocyte sedimentation rate, C-reactive protein, and white blood cells can be elevated. This is an expected finding during an exacerbation. (Option B) Mild to moderate anemia (normal hemoglobin 13.2-17.3 g/dL [132-173 g/L] for males, 11.7-15.5 g/dL [117-155 g/L] for females) is common with most chronic inflammatory conditions (eg, rheumatoid arthritis, IBD) as the body cannot use the available iron in bone marrow with active inflammation. In addition, IBD exacerbation usually includes bloody stools, resulting in blood loss iron deficiency anemia. This needs follow-up but is not a priority. (Option C) Yellow-orange discoloration of the client's skin and urine is an expected side effect from the drug. Educational objective: Dehydration is a concern with sulfasalazine and most other "sulfa" medications due to the risk of crystal formation in the kidney. It is also a potential complication of inflammatory bowel disease.

Exam 8: Pharmacology

The nurse is caring for a client who had surgery yesterday. When administering omeprazole, the client asks "What is that for? I don't take it at home." Which reply by the nurse is most appropriate?

The nurse is caring for a client who started receiving chemotherapy 10 days ago. Today, the health care provider prescribes filgrastim. Which of the following is an expected outcome of this medication?

A client is receiving chemotherapy for acute myeloid leukemia. The health care provider prescribes allopurinol to prevent tumor lysis syndrome (TLS) . Which laboratory value indicates a therapeutic response to the medication?

The clinic nurse reviews the medical record of a client who was prescribed etanercept, a tumor necrosis factor (TNF) inhibitor. Which test result is most important for the nurse to check before initiating this treatment?

A child with cystic fibrosis is to receive a dose of pancrelipase at 12:00 PM. The client states that he is not hungry and will eat his lunch in an hour. Which action is appropriate for the nurse to take?

The nurse is reviewing prescriptions for the assigned clients. Which prescription should the nurse question?

A client has been on long-term therapy with esomeprazole. What is essential for the nurse to ask the client?

The emergency department nurse prepares a male client for surgery. The client was admitted with a traumatic open fracture of the femur, hematocrit of 36% (0.36) , and hemoglobin of 12 g/dL (120 g/L) . Which prescription should the nurse validate with the health care provider before administration?

The nurse is caring for a client diagnosed with endometrial cancer who is receiving brachytherapy. Which interventions should the nurse implement while caring for this client? Select all that apply.

A client is being discharged on enoxaparin therapy following total knee replacement surgery. Which teaching instruction does the nurse include in the teaching plan?

A nurse conducting rounds checks on a client receiving continuous total parenteral nutrition (TPN) . The infusion pump is found to be powered down, and TPN is no longer infusing. Which action should the nurse take first?

The nurse is caring for a client with cirrhosis who has hepatic encephalopathy. The client is prescribed lactulose. Which assessment by the nurse will most likely indicate that the medication has achieved the desired therapeutic effect?

The nurse reinforces teaching to a female client about taking misoprostol to prevent stomach ulcers. Which statement by the client would prompt further instruction?

In which scenarios should the nurse hold the prescribed medication and question its administration? Select all that apply.

The nurse is preparing to administer a scheduled dose of metoclopramide IV to a client with diabetic gastroparesis. Which clinical finding causes the nurse to question the prescription?

Which herbal supplements pose an increased risk for bleeding in surgical clients and should be discontinued prior to major surgery? Select all that apply.

A client with obesity has just started taking orlistat. Which statement by the client indicates a need for further teaching?

A nurse is observing a nursing student reinforce teaching to a client on how to take sucralfate. Which statement made by the student would require intervention by the nurse?

The nurse is caring for a client with an inflammatory bowel disease exacerbation. The client is prescribed sulfasalazine. Which finding would require a priority follow-up by the nurse?