Question 1

An 80-year-old client is receiving amikacin, an aminoglycoside antibiotic, IVPB every 12 hours. Which data obtained by the nurse is most important to report to the health care provider before hanging the next dose?

Accepted Answer

Serious adverse reactions to aminoglycosides (eg, gentamicin, tobramycin, amikacin) include ototoxicity and nephrotoxicity. Age, renal function, and drug dose affect the occurrence of these adverse reactions. Careful dosing is especially important for older clients. Tinnitus and vertigo are early signs of ototoxicity. The nurse should carefully assess for changes in the client's hearing, balance, and urinary output. (Option A) The blood pressure is low, but the nurse should compare it to previous readings. Blood pressure is not generally affected by IV antibiotics. The client may be taking antibiotics for sepsis. (Option B) The blood urea nitrogen (BUN) is within normal range (6-20 mg/dL [2.1-7.1 mmol/L]), but is at the high end of normal and should continue to be monitored. (Option D) Urine output is adequate (>30 mL/hr) but should be closely monitored. Educational objective: The nurse should closely monitor renal function and assess for any changes in hearing or balance in a client receiving aminoglycoside antibiotics. Ototoxicity and nephrotoxicity are serious adverse reactions related to this type of medication.

Question 2

The nurse receives a new prescription for tamoxifen for a client with breast cancer.  Which information found in the client's medical record would require follow-up with the health care provider?

Accepted Answer

Tamoxifen is a selective estrogen receptor modulator that is prescribed to treat certain types of breast cancer and to prevent breast cancer recurrence. Tamoxifen works by blocking estrogen receptors in certain estrogen-sensitive tissues (eg, breast, vagina), but it also increases affinity for estrogen in some tissues, such as the uterus. In the treatment of breast cancer, tamoxifen inhibits growth of estrogen receptor-positive tumors. Clients typically take tamoxifen for several (eg, 5-10) years after treatment to prevent breast cancer recurrence. Common side effects of tamoxifen therapy, like the effects typically seen in menopause (eg, hot flashes, vaginal dryness, menstrual irregularities), are related to decreased estrogen. Follow-up would be required for clients with symptoms or a history of tamoxifen's most serious side effects, including: Thromboembolic events (eg, deep venous thrombosis, pulmonary embolism, stroke) (Option C) Endometrial cancer (eg, abnormal vaginal bleeding) (Options A, B, and D) Shellfish and peanut allergies, previous smoking history, and history of depression are not contraindications for treatment with tamoxifen. Educational objective: Tamoxifen is a selective estrogen receptor modulator prescribed for the treatment and prevention of estrogen receptor-positive breast cancers. Serious side effects include thromboembolic events (eg, deep venous thrombosis) and endometrial cancer.

Question 3

The nurse is caring for a client taking tamoxifen for breast cancer. Which client statement is most concerning and a priority to report to the health care provider?

Accepted Answer

Selective estrogen receptor modulators (eg, tamoxifen) have differential action in different tissues (mixed agonist/antagonist). In the breast, they block estrogen (antagonist) and are therefore helpful in inhibiting the growth of estrogen-receptive breast cancer cells. However, tamoxifen has estrogen-stimulating (agonist) activity in the uterus, resulting in excessive endometrial proliferation (endometrial hyperplasia). This hyperplasia can eventually lead to cancer. Irregular or excessive menstrual bleeding in premenopausal woman or any bleeding in postmenopausal women can be a sign of endometrial cancer (Option C). Due to its estrogen-agonist actions, tamoxifen also poses a risk for thromboembolic events (eg, stroke, pulmonary embolism, deep vein thrombosis). Clients with breast cancer take tamoxifen for several (5-10) years to prevent recurrence. Therefore, monitoring for life-threatening side effects is very important. (Options A and D) Because tamoxifen blocks estrogen receptors, it can cause symptoms of menopause. Vaginal dryness, hot flashes, and decreased libido (sexual dysfunction) are common and would be discussed after addressing more concerning symptoms. (Option B) Tamoxifen is not associated with significant immunosuppression although it may rarely cause leukopenia. Educational objective: Tamoxifen has mixed agonist and antagonist activity on estrogen receptors in various tissues. It is used for several years in estrogen-responsive breast cancer. However, it is associated with increased risk of endometrial cancer and venous thromboembolism. Menopausal symptoms (eg, vaginal dryness, hot flashes) are the most common side effect.

Question 4

A client in the intensive care unit is receiving IV vancomycin and gentamicin.  The nurse should monitor for which potential complication with the administration of these medications?

Accepted Answer

Vancomycin and aminoglycosides (eg, gentamicin, amikacin, tobramycin) are strong antibiotics that can cause nephrotoxicity and ototoxicity. The client receiving these medications simultaneously would be at an even higher risk for these adverse reactions. The nurse should monitor the client's renal function by assessing blood urea nitrogen (BUN) and creatinine levels and measuring urinary output. Increased levels of BUN and creatinine may indicate kidney damage. The health care provider should be notified before continuing these medications. (Option A) Blood in the nasogastric tube could be a complication of peptic ulcer disease and the use of nonsteroidal anti-inflammatory drugs and corticosteroids. (Option B) A decrease in the RBC count may be evidence of bone marrow suppression that can occur with use of certain cancer drugs (eg, methotrexate). (Option D) Muscle cramping can occur occasionally with use of gentamicin but is not an indication to stop the infusion. Muscle aching and cramping that may signify a complication occur with the use of statins (eg, atorvastatin, rosuvastatin) and fibrates (eg, gemfibrozil, fenofibrate). Educational objective: The nurse should recognize that the risk of nephrotoxicity and ototoxicity is potentiated when vancomycin and aminoglycosides (eg, gentamicin) are administered together. Kidney and hearing functions should be closely monitored in these clients.

Question 5

The nurse develops a teaching plan for a client prescribed isoniazid, rifampin, ethambutol, and pyrazinamide to treat active tuberculosis (TB). Which of the following instructions associated with the adverse effects of rifampin is most important for the nurse to include?

Accepted Answer

Active TB is treated with combination drug therapy. Isoniazid causes hepatotoxicity and peripheral neuropathy. Rifampin (Rifadin) also causes hepatotoxicity. Therefore, baseline liver function tests should be obtained. Clients should be advised to watch for signs and symptoms of hepatotoxicity (eg, jaundice, anorexia). Ethambutol causes ocular toxicity, and clients will need frequent eye examinations. A teaching plan for a client prescribed rifampin includes these additional instructions: Rifampin changes the color of body fluids (eg, urine, sweat) due to its body-wide distribution. Tears can turn red, making contact lenses appear discolored. Client should wear eyeglasses instead of soft contact lenseswhile taking this medication. Women should use nonhormonal birth control methods while taking this drug as it can decrease the effectiveness of oral contraceptives. (Option A) Red urine is an expected finding with rifampin use; clients should not be concerned. (Option B) Clients should be advised to not consume alcohol and drugs that can increase the risk for hepatotoxicity (eg, acetaminophen) during long-term use of this drug. (Option D) The effectiveness of treatment for active TB is determined by 3 negative sputum cultures and chest x-ray. If the entire course of therapy (6-9 months) is not completed, reinfection, spread to others, and development of resistant strains of TB bacteria can result. Educational objective: Common potential side effects of rifampin include hepatotoxicity, red-orange discoloration of body fluids, and increased metabolism of some drugs (eg, oral contraceptives, hypoglycemics, warfarin).

Question 6

The health care provider prescribes amoxicillin/clavulanate (liquid) twice a day for a child with acute sinusitis. What instructions are most important for the parents? Select all that apply.

Accepted Answer

Amoxicillin/clavulanate belongs to aminopenicillin group and is often used to treat respiratory infections. Instructions for parents about amoxicillin include: The medication may be taken with or without food as food does not affect absorption The most common side effects of this medication are nausea, vomiting, and diarrhea. If nausea or diarrhea develops, the medicine may be administered with food to decrease the gastrointestinal side effects (Option A). Shake the liquid well prior to administration. Administer at evenly spaced intervals throughout the day to maintain therapeutic blood levels (Option D). Ensure that the child receives the full course of therapy; do not discontinue the medication if the child is feeling better or symptoms have resolved (Option B). (Option C) Rash, itching, dyspnea, or facial/laryngeal edema may indicate an allergic reaction, and the medication should be discontinued. (Option E) Pediatric liquid medications are often dispensed with a measuring device designed to administer the exact dose prescribed. The following calibrated devices may be included: dropper, oral syringe, plastic measuring cup, or measuring spoon. Educational objective: Amoxicillin/clavulanate in liquid form should be shaken well prior to administration; the correct dose is administered using a calibrated measuring device. It is taken with or without food, at evenly spaced intervals, and until all the medication is consumed. If nausea or diarrhea develops, the medication may be administered with food.

Question 7

A client with active pulmonary tuberculosis is prescribed 4-drug therapy with ethambutol.  The community health nurse instructs the client to notify the health care provider immediately if which adverse effect associated with ethambutol occurs?

Accepted Answer

Ethambutol (Myambutol) is used in combination with other antitubercular drugs (eg, isoniazid, rifampin, pyrazinamide) to treat active tuberculosis. The client must have baseline and periodic eye examinations during therapy as optic neuritis is a potentially reversible adverse effect. The client is instructed to report signs of decreased visual acuity and loss of color (red-green) discrimination. (Options B and D) Dark-colored urine and yellow skin can indicate the presence of hepatotoxicity, which is associated with many drugs used to treat tuberculosis (eg, isoniazid, pyrazinamide, rifampin). However, hepatotoxicity is not common with ethambutol. (Option C) Difficulty hearing (tinnitus, subjective hearing loss) is an adverse reaction to streptomycin. Streptomycin, an aminoglycoside antibiotic, is a second-line drug sometimes used to treat multi-drug-resistant tuberculosis, with ototoxic and nephrotoxic adverse effects. Educational objective: Clients taking ethambutol must have baseline and periodic eye examinations during therapy as optic neuritis is a potentially reversible adverse effect.

Question 8

A client with fibromyalgia refuses to take the prescribed drug duloxetine. When the nurse asks, why, the client responds, "Because I'm not depressed!" What is the nurse's most appropriate response?

Accepted Answer

11ecbb05_cc8d_36d4_b433_837f95f3eb5f_MD0009_00 Fibromyalgia (FM) results from abnormal central nervous system pain transmission and processing. It is characterized by chronic, bilateral musculoskeletal axial pain (above and below the waist), multiple tender points, fatigue, and sleep/cognitive disturbances. Duloxetine (Cymbalta) is a serotonin-norepinephrine reuptake inhibitor that has both antidepressant and pain-relieving effects. It is used to relieve chronic pain that interferes with normal sleep patterns in clients with FM. With the restoration of normal sleep patterns, fatigue often improves as well (Option B). Other effective drugs to treat the chronic pain associated with FM include pregabalin and amitriptyline (Elavil), an older tricyclic antidepressant drug. (Option A) Although depression often accompanies chronic pain, duloxetine can be prescribed specifically to treat the chronic pain associated with FM. (Option C) Duloxetine is prescribed for major depressive disorder and to relieve pain associated with diabetic neuropathy and FM. It is not given to relieve the adverse effects of other drugs. (Option D) A client has the right to refuse any drug. However, the nurse should first explain the purpose of the drug to the client before notifying the HCP. Educational objective: Medications such as duloxetine, pregabalin, and amitriptyline have neuropathic pain-relieving effects. They are commonly used for treating pain associated with diabetic neuropathy and FM. Duloxetine is particularly effective for treating both depression and pain.

Question 9

A client has nausea, abdominal cramping, and persistent mucus-like, watery diarrhea that is positive for Clostridium difficile.  The nurse anticipates the client will be prescribed which medication to treat this condition?

Accepted Answer

C difficile is often associated with antibiotic therapy but can also be a nosocomial hospital-acquired infection. Antibiotics, especially broad-spectrum, reduce normal bacteria in the body. This allows other bacteria, such as C difficile, to take over and cause a superinfection. It grows in the intestinal tract and causes antibiotic-associated diarrhea. Metronidazole (Flagyl) is an anti-infective drug commonly used to treat C difficile. For severe C difficile infection, oral vancomycin may be used; intravenous vancomycin is ineffective. (Option A) Ceftriaxone (Rocephin) is a cephalosporin antibiotic; its use could cause C difficile infection. (Option B) Fluconazole (Diflucan) is a broad-spectrum antifungal agent; it is not indicated to treat C difficile. (Option D) Pantoprazole (Protonix) is a proton pump inhibitor agent; its use has been associated with development of C difficile infection. Educational objective: Antibiotics reduce normal bacteria in the body, allowing other bacteria or fungi, such as C difficile, to take over. C difficile is a toxin-producing microorganism that grows in the intestinal tract and causes antibiotic-associated diarrhea. Metronidazole (Flagyl) and oral vancomycin are commonly used to treat this condition.

Question 10

The nurse reviews the medication administration records and laboratory results for assigned clients.  Which medication requires that the health care provider be notified before administration?

Accepted Answer

Clopidogrel (Plavix) is a platelet aggregation inhibitor used to prevent blood clot formation in clients with recent myocardial infarction, acute coronary syndrome, cardiac stents, stroke, or peripheral vascular disease. Because it can cause thrombocytopenia and increase the risk for bleeding, the nurse should notify the health care provider (HCP) of the low platelet count (normal: 150,000-400,000/mm³ [150-400 × 10⁹/L]) before administering clopidogrel. (Option A) Calcium acetate (PhosLo) is used to control hyperphosphatemia in clients with end-stage kidney disease by binding to phosphate in the intestines and excreting it in the stool. Because the phosphate level is high (normal adult: 2.4-4.4 mg/dL [0.78-1.42 mmol/L]), it is not necessary to notify the HCP. (Option C) Magnesium sulfate is used to correct hypomagnesemia and treat torsades de pointes and seizures associated with eclampsia. Because the magnesium level is low (normal adult: 1.5-2.5 mEq/L [0.75-1.25 mmol/L]), it is not necessary to notify the HCP. (Option D) Metformin (Glucophage) is a first-line drug for the control of blood sugar in clients with type 2 diabetes mellitus. Glycosylated hemoglobin (A_1C) measures the total hemoglobin that has glucose attached to it, expressed as a percentage. Glucose remains attached to the red blood cell for the life of the cell (about 120 days) and reflects glycemic control over an extended period. The recommended A_1C level for a client with diabetes is <7%. Although the A_1C level is elevated, the medication would be administered regardless of the result (unless the client is hypoglycemic), so it is not necessary to notify the HCP. Educational objective: Clopidogrel (Plavix) can cause thrombocytopenia (platelet count <150,000/mm³ [150 × 10⁹/L]) and increase a client's risk for bleeding.

Question 11

A client with ulcerative colitis is prescribed the drug sulfasalazine. Which information should the nurse discuss with the client concerning this drug? Select all that apply.

Accepted Answer

Sulfasalazine (Azulfidine) is a sulfonamide (salicylate and sulfa antibiotic) and nonbiologic disease-modifying antirheumatic drug (DMARD) used for mild to moderate chronic inflammatory rheumatoid arthritis (RA) and inflammatory bowel disease (eg, ulcerative colitis). It inhibits the production of prostaglandin, a mediator in the body's inflammatory response. Most "sulfa" medications (eg, trimethoprim, sulfamethoxazole) share common side effects, including: Crystalluria causing kidney injury - client should drink 8 glasses of water daily to maintain adequate urine output (eg, 1200-1500 mL/day) Photosensitivity and risk for sunburn - client should avoid sun exposure and apply sunscreen Folic acid deficiency (megaloblastic anemia and stomatitis) - client should eat folate-rich foods and take 1 mg/day folic acid supplement Rarely life-threatening agranulocytosis (leukopenia) - client should be monitored for complete blood count at the start of therapy and report fever or sore throat immediately Stevens-Johnson syndrome - client should stop the medicine if rash develops (Option B) Ulcerative colitis is characterized by bloody diarrhea, and the medication is taken to reduce this effect. (Option C) Urine and skin can turn an orange-yellow color but will return to normal when the drug is discontinued. This is an expected finding. Educational objective: Sulfasalazine (Azulfidine) is used for mild to moderate chronic inflammatory RA and inflammatory bowel disease. Important adverse effects include crystalluria with kidney injury, yellow-orange skin and urine discoloration, folic acid deficiency, and photosensitivity.

Question 12

The clinic nurse is preparing to administer an allergy immunotherapy injection to a client recently initiated on the therapy. Which statement by the client indicates a need for further teaching?

Accepted Answer

Allergy immunotherapy injections (allergy shots) trigger an increase in the body's production of specific immunoglobulins to reduce the client's allergy symptoms when exposed to specific allergens (eg, pollen, cat dander, dust mite). Small doses of the allergen(s) are injected subcutaneously on a client-specific schedule. Rarely, allergy shots may induce an immediate and potentially fatal anaphylactic reaction. The client must remain at the facility for 30 minutes after an injection so the nurse can monitor for severe systemic reactions (eg, respiratory failure, tongue and throat swelling) (Option A). (Option B) For the first few months, allergy shots are typically given every week, with a dose increase at every injection until the target maintenance dose is reached. The maintenance dose is then given every few weeks for 3-5 years. (Option C) Although rare, the client may have a mild, systemic allergic reaction (eg, hives, itching, facial swelling, mild asthma) up to 24 hours after an allergy shot. The occurrence of any systemic reaction should be reported to the health care provider as the next dose increase may need to be delayed. (Option D) It is common to have a localized reaction to an allergy shot. The nurse should reinforce teaching that some redness and swelling at the injection site is expected and not life-threatening. Educational objective: A client receiving an allergy shot is at risk for anaphylaxis immediately after the injection, so the client must remain at the facility and be monitored for 30 minutes after the injection.

Question 13

A client with latent tuberculosis has been taking oral isoniazid (INH) 300 mg daily for 2 months. The client tells the nurse that for the past week she has had numbness, a burning sensation, and tingling in her hands and feet. Additional intake of which of the following would mostlikely have prevented this?

Accepted Answer

INH interferes with the action of vitamin B₆ (pyridoxine), resulting in peripheral neuropathy; it manifests as ataxia and paresthesia. Individuals who are most predisposed to becoming neurotoxic from taking INH include older adults, those who are malnourished, diabetic clients, pregnant or breastfeeding clients, alcoholics, children, those with liver or renal disease, and HIV-positive individuals. To prevent these complications, a vitamin B₆ supplement at a dose of 25-50 mg/day is recommended for those at high risk. (Option A) Folic acid deficiency does not cause peripheral neuropathy. It is associated with macrocytic anemia and neural tube defects in children. (Option C) Vitamin B₁₂ deficiency can cause peripheral neuropathy; however, it is not seen with INH therapy. (Option D) Vitamin D deficiency causes osteomalacia but not peripheral neuropathy. Educational objective: High-risk clients on isoniazid therapy for treatment of tuberculosis may experience neurological side effects due to a decrease in the body's ability to utilize vitamin B₆ (pyridoxine). A vitamin B supplement will prevent these effects.

Question 14

A student nurse is caring for a client with iron deficiency anemia who is newly prescribed ferrous sulfate.  Which action by the student nurse requires the supervising nurse to intervene?

Accepted Answer

Ferrous sulfate is an oral iron supplement prescribed to prevent or treat iron deficiency anemia, which occurs when the body lacks sufficient iron, an essential mineral in the formation of new RBCs. Low iron levels may result from malabsorption, insufficient intake, increased requirements (eg, pregnancy), or blood loss. The nurse should avoid administering calcium supplements or antacids with or within 1 hour of ferrous sulfate because calcium decreases iron absorption (Option D). (Option A) Taking an iron supplement increases the client's risk for constipation. Instructing the client to increase fluid intake during therapy may help prevent hard stools. (Options B and C) Taking an iron supplement with vitamin C (eg, orange juice) further enhances duodenal acidity and increases absorption. An acid-rich environment enhances iron absorption, so oral supplements should be taken 1 hour before or 2 hours after meals. Educational objective: Ferrous sulfate is an oral iron supplement prescribed to prevent or treat iron deficiency anemia. The nurse should administer the medication 1 hour before or 2 hours after meals because it is best absorbed in an acidic environment. Antacids or calcium supplements decrease absorption of iron if administered with or within 1 hour of ferrous sulfate.

Question 15

The nurse cares for a client following a percutaneous coronary intervention via the right groin. The client received an IV infusion of abciximab during the procedure. Which actions should the nurse implement? Select all that apply.

Accepted Answer

Glycoprotein (GP) IIb/IIIa receptor inhibitors (eg, abciximab, eptifibatide, tirofiban) are used as platelet inhibitors to prevent the occlusion of treated coronary arteries during percutaneous coronary intervention procedures and prevent acute ischemic complications. GP IIb/IIIa receptor inhibitors can cause serious bleeding. The nurse should closely monitor the client for any bleeding at the groin puncture site after the percutaneous coronary intervention (Option A). The nurse should check the client's baseline complete blood count (eg, hemoglobin, platelet count). Some clients may develop serious thrombocytopenia within a few hours, further increasing the bleeding risk (Option B). Hypotension, tachycardia, changes in heart rhythm, blood in the urine, abdominal/back pain, mental status changes, and black tarry stools may also indicate internal bleeding and should be monitored carefully when GP IIb/IIIa receptor inhibitors are administered (Options D and E). (Option C) During and after the infusion of GP IIb/IIIa receptor inhibitors, no traumatic procedures (initiation of IV sites, intramuscular injections) should be performed unless absolutely necessary due to the risk of bleeding. Educational objective: Glycoprotein IIb/IIIa receptor inhibitors (eg, abciximab, eptifibatide, tirofiban) inhibit platelet aggregation and increase bleeding risk. Serious thrombocytopenia can occur within few hours, further increasing bleeding risk. After administration, the nurse should monitor the client's blood counts, blood pressure, and heart rate and rhythm, as well as watch for signs of bleeding.

Question 16

A client is prescribed long-term pharmacologic therapy with hydroxychloroquine to treat systemic lupus erythematosus.  Which intervention related to the drug's adverse effects should the nurse include in the teaching plan?

Accepted Answer

Hydroxychloroquine (Plaquenil) is an antimalarial drug, but it is more commonly prescribed to reduce fatigue and treat the skin and arthritic (eg, joint inflammation, pain) manifestations of systemic lupus erythematosus (SLE). Hydroxychloroquine can also help to reduce lupus exacerbations in clients with inactive to mild disease, but several months can pass before its therapeutic effects become apparent. Although rare, serious adverse drug reactions such as retinal toxicity and visual disturbances can occur with hydroxychloroquine. Therefore, clients are instructed to undergo regular ophthalmologic examination every 6-12 months (Option A). (Option B) Hydroxychloroquine should be taken with food to decrease gastrointestinal upset (common side effect). (Option C) Some clients with severe SLE are prescribed long-term corticosteroid (prednisone) therapy to prevent organ damage and are at risk for adverse reactions, such as accelerated osteoporosis. Osteoporosis is not an adverse reaction of hydroxychloroquine, and vitamin D and calcium supplementation is not required. (Option D) There are no effects of hydroxychloroquine that would require wearing a MedicAlert bracelet. Educational objective: Hydroxychloroquine (Plaquenil) is used to treat the skin and arthritic manifestations of SLE. Taking the medication with food can help alleviate gastrointestinal upset. Serious adverse drug reactions include retinopathy and visual disturbances; therefore, regular ophthalmologic examination every 6-12 months is required.

Question 17

The nurse provides teaching about methotrexate to a client with rheumatoid arthritis. It is most important to address which topic regarding this drug?

Accepted Answer

Methotrexate (Rheumatrex) is classified as a folate antimetabolite, antineoplastic, immunosuppressant drug used to treat various malignancies and as a nonbiologic disease-modifying antirheumatic drug (DMARD) used to treat rheumatoid arthritis and psoriasis. Methotrexate can cause bone marrow suppression resulting in anemia, leukopenia, and thrombocytopenia. Leukopenia and its immunosuppressant effects can increase susceptibility to infection. Clients should be educated about obtaining routine killed (inactivated) vaccines (eg, influenza, pneumococcal) and avoiding crowds and persons with known infections. Live vaccines (eg, herpes zoster) are contraindicated in clients receiving immunosuppressants, such as methotrexate. Alcohol should be avoided in clients taking methotrexate as it is hepatotoxic and drinking alcohol increases the client's risk for hepatotoxicity. (Option A) Regular eye examinations every 6 months are indicated for clients prescribed the nonbiological DMARD antimalarial hydroxychloroquine (Plaquenil) as it can cause retinal damage. Ethambutol, used to treat tuberculosis, also requires frequent eye examinations. (Options B and D) Photosensitivity (common with tetracycline, thiazide diuretics, and sulfonamides) and nephrotoxicity (common with aminoglycosides, vancomycin, and nonsteroidal anti-inflammatory drugs) can occur, but immunosuppression is more likely and potentially fatal. Educational objective: Methotrexate is a nonbiologic disease-modifying antirheumatic drug used to treat rheumatoid arthritis. The major adverse effects associated with its use include bone marrow suppression, hepatotoxicity, and gastrointestinal irritation.

Question 18

The nurse administers IV vancomycin to a client with a methicillin-resistant Staphylococcus aureus infection. Which nursing actions are most appropriate? Select all that apply.

Accepted Answer

When administering IV vancomycin, the nurse should assess for and work to prevent possible complications by performing the following: Draw the prescribed trough level prior to administration. Therapeutic vancomycin levels range from 10-20 mg/L (6.9-13.8 µmol/L) for hemodynamically stable clients. Adverse effects of vancomycin toxicity include nephrotoxicity (eg, elevated creatinine levels) and ototoxicity (eg, hearing loss, vertigo, tinnitus). Infuse medication over at least 60 minutes (≤10 mg/min). Faster rates increase the likelihood of complications (Option C). Monitor blood pressure during the infusion. Hypotension is a possible adverse effect (Option D) Assess for hypersensitivity. Red man syndrome is a nonallergic histamine reaction characterized by sudden onset of severe hypotension, flushing, and/or maculopapular rash of the face, neck, chest, and upper extremities (Option B). Monitor for anaphylaxis (eg, rash, pruritus, laryngeal edema, wheezing). Observe IV site every 30 minutes for pain, redness, or swelling. Vancomycin is a vesicant and may cause thrombophlebitis or, if extravasation occurs, tissue necrosis. Administration using a central venous catheter is preferred; however, a peripheral IV may be used for short-term therapy (Option E). (Option A) Assessment of deep tendon reflexes is appropriate with magnesium sulfate administration. Manifestations of hypermagnesemia include lethargy, nausea, vomiting, and decreased deep tendon reflexes. Educational objective: Nursing care of clients receiving IV vancomycin includes drawing prescribed trough levels before drug administration, infusing the drug over at least 60 minutes, monitoring the client during administration (eg, blood pressure, respiratory status, signs of hypersensitivity/anaphylaxis), and assessing the IV site during and after administration.

Question 19

The nurse is reinforcing education to a client with a venous thromboembolism who is prescribed rivaroxaban.  Which statement by the client indicates the medication teaching has been effective?

Accepted Answer

Factor Xa inhibitors (eg, rivaroxaban [Xarelto], edoxaban, apixaban) are anticoagulants used to prevent and treat venous thromboembolism. Factor Xa inhibitors are being prescribed more frequently than other oral anticoagulants (eg, warfarin), as they have a lower risk of bleeding and require less ongoing monitoring (eg, PT/INR). Clients prescribed rivaroxaban should be educated to avoid taking over-the-counter medications or supplements that increase bleeding risk, such as NSAIDs (eg, aspirin), garlic, and ginger. The combined effects of rivaroxaban and other anticoagulants may greatly increase the risk of uncontrolled bleeding (eg, epidural, intracranial, gastrointestinal) and hemorrhage (Option C). (Option A) Unlike warfarin, factor Xa inhibitors are not affected by vitamin K, which is found in many green, leafy vegetables (eg, spinach, kale). (Option B) Anticoagulants, particularly factor Xa inhibitors, increase the risk for spontaneous intracranial bleeding or formation of epidural hematomas. Clients taking factor Xa inhibitors should be instructed to immediately contact their health care provider for symptoms of neurological impairment (eg, extremity weakness, altered sensation, numbness). (Option D) Routine monitoring of clotting times (eg, PT/INR, PTT) is unnecessary for clients prescribed factor Xa inhibitors. Educational objective: The nurse should instruct clients receiving factor Xa inhibitors (eg, rivaroxaban, edoxaban, apixaban), which are anticoagulants, to avoid taking additional medications or supplements with anticoagulant effects (eg, NSAIDs, garlic, ginger). The combined anticoagulant effects increase the risk for uncontrolled bleeding and hemorrhage.

Question 20

The nurse is preparing to administer IV cefazolin to a client with cellulitis. The client's allergies are listed as amoxicillin, ciprofloxacin, and sulfa drugs. What should the nurse do first?

Accepted Answer

Clients with an allergy to penicillin antibiotics (eg, amoxicillin, ampicillin) can possibly experience a cross-sensitivity reaction to cephalosporin antibiotics (eg, cefazolin, cephalexin, ceftriaxone), because the drug molecules are structurally similar. The nurse should obtain more information about this client's reported allergies, as reactions range from mild to severe. In particular, the nurse must first assess the type of reaction the client had to amoxicillin (Option C). The nurse should then clarify the prescription with the health care provider (HCP) prior to administration. If this client's reaction to amoxicillin was a rash or other mild reaction that was not life-threatening, the HCP may decide that cephalosporin can be safely administered. However, cephalosporins are contraindicated for a client with a history of anaphylactic reactions to penicillin, and a different antibiotic should be prescribed. (Option A) The nurse should hold the medication until more is known about the client's reaction to amoxicillin. (Option B) The nurse must first obtain more information about the reaction so the HCP can make an informed decision about whether the cephalosporin antibiotic can be administered or should be changed. (Option D) The nurse must first obtain more information about the type of allergic reaction before notifying the pharmacy. Educational objective: A client with a penicillin allergy may experience a cross-sensitivity reaction to cephalosporin antibiotics (eg, cefazolin, cephalexin, ceftriaxone). Cephalosporins can typically be administered safely to clients with a history of mild allergic reaction (eg, rash), but are contraindicated in clients with a history of penicillin anaphylaxis.

Exam 8: Pharmacology

An 80-year-old client is receiving amikacin, an aminoglycoside antibiotic, IVPB every 12 hours. Which data obtained by the nurse is most important to report to the health care provider before hanging the next dose?

The nurse receives a new prescription for tamoxifen for a client with breast cancer. Which information found in the client's medical record would require follow-up with the health care provider?

The nurse is caring for a client taking tamoxifen for breast cancer. Which client statement is most concerning and a priority to report to the health care provider?

A client in the intensive care unit is receiving IV vancomycin and gentamicin. The nurse should monitor for which potential complication with the administration of these medications?

The nurse develops a teaching plan for a client prescribed isoniazid, rifampin, ethambutol, and pyrazinamide to treat active tuberculosis (TB) . Which of the following instructions associated with the adverse effects of rifampin is most important for the nurse to include?

The health care provider prescribes amoxicillin/clavulanate (liquid) twice a day for a child with acute sinusitis. What instructions are most important for the parents? Select all that apply.

A client with active pulmonary tuberculosis is prescribed 4-drug therapy with ethambutol. The community health nurse instructs the client to notify the health care provider immediately if which adverse effect associated with ethambutol occurs?

A client with fibromyalgia refuses to take the prescribed drug duloxetine. When the nurse asks, why, the client responds, "Because I'm not depressed!" What is the nurse's most appropriate response?

A client has nausea, abdominal cramping, and persistent mucus-like, watery diarrhea that is positive for Clostridium difficile. The nurse anticipates the client will be prescribed which medication to treat this condition?

The nurse reviews the medication administration records and laboratory results for assigned clients. Which medication requires that the health care provider be notified before administration?

A client with ulcerative colitis is prescribed the drug sulfasalazine. Which information should the nurse discuss with the client concerning this drug? Select all that apply.

The clinic nurse is preparing to administer an allergy immunotherapy injection to a client recently initiated on the therapy. Which statement by the client indicates a need for further teaching?

A student nurse is caring for a client with iron deficiency anemia who is newly prescribed ferrous sulfate. Which action by the student nurse requires the supervising nurse to intervene?

The nurse cares for a client following a percutaneous coronary intervention via the right groin. The client received an IV infusion of abciximab during the procedure. Which actions should the nurse implement? Select all that apply.

A client is prescribed long-term pharmacologic therapy with hydroxychloroquine to treat systemic lupus erythematosus. Which intervention related to the drug's adverse effects should the nurse include in the teaching plan?

The nurse provides teaching about methotrexate to a client with rheumatoid arthritis. It is most important to address which topic regarding this drug?

The nurse administers IV vancomycin to a client with a methicillin-resistant Staphylococcus aureus infection. Which nursing actions are most appropriate? Select all that apply.

The nurse is reinforcing education to a client with a venous thromboembolism who is prescribed rivaroxaban. Which statement by the client indicates the medication teaching has been effective?

The nurse is preparing to administer IV cefazolin to a client with cellulitis. The client's allergies are listed as amoxicillin, ciprofloxacin, and sulfa drugs. What should the nurse do first?