ADVANCED PHARMACOLOGY EXAM BANK 2024-2025, Exams of Nursing

Download ADVANCED PHARMACOLOGY EXAM BANK 2024-2025 and more Exams Nursing in PDF only on Docsity! 1 | P a g e ADVANCED PHARMACOLOGY EXAM BANK 2024-2025 WITH ACTUAL CORRECT QUESTIONS AND VERIFIED DETAILED RATIONALES ANSWERS |FREQUENTLY TESTED QUESTIONS AND SOLUTIONS |ALREADY GRADED A+|NEWEST| GUARANTEED PASS |LATEST UPDATE A female patient has been prescribed aminoglutethimide to treat Cushing syndrome. Before therapy begins a priority nursing action would be to review the patient's A) current lab results, especially complete blood count. B) current body weight and height. C) bilirubin level. D) last menstrual period A) current lab results, especially complete blood count. Cushing's syndrome can sometimes be difficult to diagnose. If someone reports fatigue and weight gain, that doesn't point straight at Cushing's syndrome. Your healthcare provider will have to go through a process of elimination to rule out other conditions, he or she will look at your medical history first and perform a physical examination and then conduct some laboratory tests. Another priority is complete blood cell counts beacuse it is inexpensive and easy to interpret, additional studies may confirm if such tests may be used to rule out Cushing's syndrome among obese children A nurse is caring for a patient in the critical care unit. Phentolamine (Regitine, OraVerse) has been ordered for the management of tissue necrosis caused by extravasation of parenterally administered drugs. Before administering this drug, the nurse will check the patient's chart for indications of__ A) peptic ulcer disease. B) history of acute myocardial infarction. C) diabetes mellitus. D) obesity 2 | P a g e B) history of acute myocardial infarction. Phentolamine (Regitine, OraVerse) is a medication used to manage tissue necrosis caused by extravasation of parenterally administered drugs. Before administering this drug, the nurse needs to check the patient's chart for indications of a history of acute myocardial infarction. Phentolamine is contraindicated in patients with this history or any evidence of coronary artery disease because it can stimulate the heart and increase myocardial oxygen demand, which can be harmful in these patients. The nurse should also be cautious when administering phentolamine to patients with gastric and duodenal ulcers, as the drug has a histamine-like effect. However, obesity and diabetes mellitus should not be a factor in determining the use of phentolamine. A 28-year-old man has been taking sertraline for a few months. On a follow-up visit to the clinic, he reports a change in sexual functioning, dizziness, and insomnia. The most appropriate response by the nurse would be__ A) "How much of the drug are you taking at one time?" B) "Have you stopped taking the drug?" C) "Do you eat a lot of fat in your diet?" D) "How much alcohol do you consume B) "Have you stopped taking the drug?" This is because the symptoms reported by the patient, such as changes in sexual functioning, dizziness, and insomnia, are common side effects of sertraline. It is important to determine if the patient has stopped taking the medication, as abruptly discontinuing sertraline can lead to withdrawal symptoms. By asking this question, the nurse can gather more information about the patient's medication adherence and provide appropriate guidance or interventions. A resident of a long-term care facility receives 12.5 mg metoprolol (Lopressor) at 8 AM and 8 PM daily. Before administering this drug, the nurse should perform and document what assessments? A) Oxygen saturation and respiratory rate B) Heart rate and blood pressure C) Level of consciousness and pain level D) Temperature and respiratory rate B) Heart rate and blood pressure A 59-year-old female patient has been prescribed digoxin. The nurse assigned to the patient will instruct her to avoid which of the following? A) Grapefruit juice B) Protein rich foods C) One glass of red wine per day D) OTC cold remedies D) OTC cold remedies 5 | P a g e A 42-year-old African-American man with congestive heart failure has been prescribed hydralazine-isosorbide. The nurse will closely monitor for which of the following? A) Hypertension B) Hypotension C) Decrease in body temperature D) Increased heart rate B) Hypotension Hydralazine is a vasodilator that relaxes and widens blood vessels, while isosorbide is a nitrate that also dilates blood vessels. These medications work together to reduce the workload on the heart and improve blood flow. However, the vasodilation caused by these medications can lead to a drop in blood pressure After successful treatment for a myocardial infarction, a 69-year-old man has developed a ventricular arrhythmia. His care team has opted for treatment with a Class II antiarrhythmic. The nurse would understand that this patient is likely to be prescribed A) acebutolol. B) lidocaine. C) amiodarone. D) verapamil C) Amiodarone an antiarrhythmic medicine that is classified as a Class II medication and is used to treat a variety of heart rhythm disorders. It does this by intercepting the electrical impulses that are responsible for the irregular beating of the heart a patient has been prescribed aminoglutethimide 250mg PO Q6H to increase to 2g daily over the next several weeks. The nurse should recognize that this patient most likely has a diagnosis of__ A) Cushing syndrome. B) Addison disease. C) diabetes insipidus. D) an autoimmune condition such as asthma A) Cushing syndrome Aminoglutethimide is a medication used in the treatment of Cushing's syndrome by interfering with the production of cortisol in the body. A patient has a diagnosis of Parkinson disease, and the physician will prescribe carbidopa-levodopa. Before drug therapy, the patient should be carefully assessed for the presence of__ A) macular degeneration. 6 | P a g e B) closed-angle glaucoma. C) peptic ulcer disease. D) diabetes mellitus B) closed-angle glaucoma this medicine has the potential to produce a rise in intraocular pressure, which may result in an acute episode of closed-angle glaucoma. This is especially true for individuals who have a history of glaucoma. A normal maintenance dose for digoxin is 0.125 to 0.5 mg/day. In which of the following patients would the nurse most likely administer a lower- than-normal maintenance dose of digoxin? A) A 25-year-old male with congestive heart failure and atrial fibrillation B) A 32-year-old female with cardiomegaly C) A 79-year-old male with cardiomegaly D) A 42-year-old female with a third heart sound C) A 79-year-old male with cardiomegaly In elderly patients with heart failure (in sinus rhythm), a reduced dose should be considered and given In which of the following patients would a nurse expect to experience alterations in drug metabolism? A) A 35-year-old woman with cervical cancer B) A 41-year-old man with kidney stones C) A 50-year-old man with cirrhosis of the liver D) A 62-year-old woman in acute renal failure C) A 50-year-old man with cirrhosis of the liver A patient with class-IV CHF has a medication regimen consisting of metoprolol (Lopressor), enalapril (Vasotec), and furosemide (Lasix). In addition to regularly assessing the patient s heart rate, the nurse should prioritize assessment of the patient's A) intake and output. B) blood pressure. C) cognition. D) exercie tolerance B) blood pressure. A nurse on an acute medical unit has rectally administered a dose of sodium polystyrene sulfonate to a patient. What assessment should the nurse prioritize in the 48 hours following the administration of this drug? 7 | P a g e A) monitoring of serum potassium levels B) stool testing for occult blood C) fluid balance D) hemoglobin, hematocrit, and red blood cells A) monitoring of serum potassium levels This drug is commonly used to treat hyperkalemia by binding to potassium in the intestines and promoting its excretion through the stool A physician has ordered subcutaneous injections of morphine a narcotic Q4 prn for pain for a motor vehicle accident victim. The nurse is aware that there is a high abuse potential for this drug and that it is categorized as a Class II drug Glargine (Lantus) is an insulin analog that essentially has no peak and is administered once a day The NP is examining a 34-year old obese man with a BMI of 35 who complains of almost daily indigestion and heartburn for the past year with a strong acid taste in the mouth about an hour after meals and frequent belching and awakening at night with choking. The history is negative for chronic illnesses and alarm symptoms. A diagnosis of gastroesophageal reflux disease is made. What is the best initial treatment for the patient? Ranitidine (Zantac) 150mg bid Initiate treatment with H2RA in selecting agent, consider clinical efficacy and cost-effectiveness here are some Histamine H2 receptor antagonists: 1. Cimetidine (Tagament) - 400mg twice daily 2. Famotidine (Pepcid) - 20mg twice daily 3. Nizatidone (Axid) - 150mg twice daily 4. Ranitidine (Zantac) - 150mg twice daily A patient comes to the clininc asking for help to quit drinking alcohol. She has a 21-year history of heavy drinking and is worried about developing cirrhosis of the liver. the patient agrees to take disulfiram (Antabuse). The nurse will teach the patient that the combination of alcohol and antabuse will cause which of the following__ nausea Typical adverse reactions to oral calcium-channel blockers include: edema Mr. contreras is a 64-year old patient with T2DM. he has recently been diagnosed with hypertension. which antihypertensive drug is the recommended choice to treat hypertension in patients with diabetes? ACE inhibitor 10 | P a g e Metformin acts by Decreasing hepatic glucose production with minor effects on insulin sensitivity in both liver and peripheral tissues A nurse practitioner is discussing with a patient the efficacy of a drug that his physician has suggested and he begin taking. efficacy of a drug means which of the following How well a drug produces its desired effect The elderly are at high risk of adverse drug reactions due to Age related decrease in renal function A 34 year old male patient is prescribed methimazole (MMI) the nurse practitioner will advise him to report which of the following immediately? Intolerance to cold A patient in need of myocardial infarction prophylaxis has been prescribed sulfinpyrazone for gout. which of the following will the nurse monitor the patient most closely for bleeding A patient with type 1 diabetes has been admitted to the hospital for orthopedic surgery and the care team anticipates some disruptions to the patient's blood glucose levels in the days following surgery. which of the following insulin regiments is most likely to achieve adequate glycemic control? small basal doses twice a day with short acting between meals which medication class is recognized for the treatment of moderate to severe dementia? N-methyl-D-aspartate (NMDA) receptor antagonist. One drug, memantine, is licensed for use in moderate to severe dementia in AD. You are seeing a 65 year old male with a long history of COPD who has recently developed hypertension. which class of antihypertensive agents should the nurse practitioner avoid for this patient? beta-blockers A male patient who is hypertensive takes hydrochlorothiazide for his blood pressure he presents with red, painful swelling of the great toe. In addition to treating gout, you recognize that you may need to: change his thiazide antihypertensive medication A mother brings her 4-year-old child, who is vomiting and has a temperature of 103F into the emergency department. The ED physician orders acetaminophen (Tylenol) for the fever. The best form of Tylenol to give the child considering presentation, would be rectal suppository 11 | P a g e Ms. Simpson has a known history of asthma. she is on theophylline daily. the NP contemplates giving her an antibiotic for her respiratory infection. The NP know that which choice below could elevate theophylline levels? ciprofloxacin To minimize the risk of adverse effects of glucagon when given to an unconscious diabetic patient, as the patient regains consciousness, the nurse should A)administer calcium supplements. B)position the patient in the side-lying position. C)administer carbohydrates. D)monitor for nausea and vomiting. C) administer carbohydrates - it is important to monitor a patient for nausea and vomiting and help him or her into a more comfortable position, it is most important to administer supplemental carbohydrates as soon as the patient becomes conscious. Administering supplemental carbohydrates serves to restore liver glycogen and prevent secondary hypoglycemia. Calcium supplements are not necessary in this situation. A patient who is a steroid-dependent asthmatic is started on a beclomethasone inhaler. which should be part of patient education? rinses the mouth well after each use A nurse practitioner is providing care for a patient who suffered extensive burns to his extremitiews during a recent industrial accident. topical lidocaine gel has been ordered to be applied to the surfaces of all his burns in order to achieve adequate pain control. When considering this order the nurse practitioner should be aware that there is a risk of systemic absorption of the lidocaine through the patients traumatized skin During a clinic visit, a patient complains of having frequent muscle cramps in her legs. the nurses assessment reveals that the patient has been taking over the counter laxatives for the past 7 years. the nurse informed the patient that prolonged use of laxatives May cause nutrient deficiencies Autonomic drugs have little effect when administered orally Wwhich can elevate theophylline levels Concomittant treatment with cimetidine (Tagamet) 12 | P a g e What information would the nurse practitioner include in teaching a patient about the treatment of vitamin B12 deficiency following a total gastrectomy? The patient will receive monthly cyanocobalamin injections for life after being given daily weekly injections for the first month A patient on valproic acid may experience which of the following symptoms? nausea, vomiting, stomach pain, diarrhea; dizziness, drowsiness, weakness; headache; tremors, problems with walking or coordination; blurred vision, double vision; hair loss; or changes in appetite, weight gain. The nurse practitioner is following up on a patient who is experiencing acute asthma problems. albuterol (Proventil) by metered-dose inhaler (MDI) has been ordered as treatment. which patient response would indicate to the family nurse practitioner that the patient understands how to take the medication? "I will take 1 puff of the medication and then wait a minute before taking the second puff" Which effect does the nurse practitioner expect may occur when using cholinergic agonists? Effects include slowed heart rate and decreased myocardial contractility, vasodilation, bronchoconstriction and increased bronchial mucus secretion, increased GI activity and secretions, increased bladder tone, relaxation of GI and bladder sphincters, and pupil constriction. The NP knowns that lithium levels should be measured while patients are on lithium therapy. The NP also recognizes that lithium has a low therapeutic index and toxicity can occur at doses close to therapeutic levels Mr. Penny age 67 was diagnosed with chronic angina several months ago and has been unable to experience adequate relief of his symptoms. as a result, his physician has prescribed ranolazine (Ranexa). Which of the following statements is true regarding the use of ranolazine for the treatment of this patient's angina Mr. Penny requires concurrent treatment with a beta blocker, nitrate, or calcium channel blocker A primary therapy for patients with mild ulcerative colitis is mesalamine (Pentasa) The nurse practitioner has prescribed elemental iron 6mg/kg/day in three divided doses for a toddler diagnosed with iron-deficiency anemia. what instructions would the family nurse practitioner include for the parents use a straw so it doesn't stain teeth The family nurse practitioner prescribed Losartan 50mg PO daily for a hypertensive patient. this medication promotes vasodilation by blocking the action of angiotensin II 15 | P a g e Susie is a 40 year old female with Type 2 Diabetes. She reports that over the last several days, she has been having some hypoglycemic episodes and feels it is related to medication. Her medication list is as follows: A) Victoza (liraglutide) 1.8 mg SC daily B) Metformin 500mg p.o. Twice a Day C) Glyburide 5 mg p.o. Twice a day D) Lisinopril 10mg p.o. dailo C) Glyburide is a type of medication known as a sulfonylurea, which can cause hypoglycemia (low blood sugar) as a side effect. The Nurse Practitioner is teaching a patient about the role of medications in the treatment of asthma. Which statement by the patient would require further teaching? "I will take my medication on an empty stomach, Avoiding allergens and environmental triggers, Modifying home environment, Wearing mask while exercising in cold weather, Early treatment of respiratory infections, Adherence to medication regimens 60-year-old male presents to your office with a history of seizure disorder. The patient states that he has been taking valproic acid. Which of the following is a known potential adverse effect of valproic acid? Pancreatitis Which of the following is a contraindication for antimuscarinic drugs? angle-closure glaucoma, myasthenia gravis, paralytic ileus, pyloric stenosis, and prostatic enlargement. A 66-year-old woman has a complex medical history that includes poorly-controlled type 1 diabetes, renal failure as a result of diabetic nephropathy and chronic heart failure (CHF). Her care provider has recently added spironolactone (Aldactone) to the woman's medication regimen. The nurse should consequently assess for signs and symptoms of hyperkalemia. Which antihypertensive agent is associated with hair growth? Minoxidil A 65-year-old male presents with a history of worsening urinary urgency, frequency, and hesitancy. He also tells you that he has to "push really hard" to urinate and that his urine dribbles a little after he is done urinating. What medication should be avoided? ipratropium inhaler What is associated with chronic overtreatment with levothyroxine (Synthroid)? Tachycardia 16 | P a g e A patient is recovering from an acute episode of thrombophlebitis and is being treated with warfarin (Coumadin) 5 mg PO daily. In reviewing medication information, the Nurse Practitioner would include what information in their teaching? Do not take a multivitamin supplement What is a serious side effect of ibuprofen in the older adult patient? Impairment of renal function The NP is examining a 34-year-old obese man with a body mass index (BMI) of 35 who complains of almost daily indigestion and heartburn for the past year with a strong acid taste in the mouth about an hour after meals, and frequent belching and awakening at night with choking. The history is negative for chronic illnesses and alarm symptoms. A diagnosis of gastroesophageal reflux disease (GERD) is made. What is the best initial treatment for the patient? Omeprazole (Prilosec) 20 mg every morning 30 minutes before breakfast. A patient with a history of bronchial asthma is seen in the clinic for increased episodes of difficulty breathing. He has been taking theophylline 100 mg PO tid. He is 40 years old and obese with an 16-pack- year history of cigarette smoking and excessive intake of coffee daily. He eats a low-carbohydrate, high- protein diet. Which identified factors decrease the therapeutic effects of the theophylline? Smoking history and diet A Nurse Practitioner is caring for a patient who is diabetic and has been diagnosed with hypertension. An angiotensin-converting enzyme inhibitor, captopril, has been prescribed for her. Which of the following should the Nurse Practitioner assess before beginning drug therapy? Serum potassium levels What drug class will decrease the facial flushing that occurs with niacin? NSAIDS Which of the following conditions is a contraindication for pioglitazone (Actos). Severe congestive heart failure A patient in need of myocardial infarction prophylaxis has been prescribed sulfinpyrazone for gout. Which of the following will the nurse monitor the patient most closely for? Bleeding Which can elevate theophylline levels? 17 | P a g e Concomitant treatment with cimetidine (Tagamet). A 39 y/o female is diagnosed with Graves disease. She also has a small goiter. Her symptoms are not deemed to be severe and propylthiouracil is prescribed. Where is the most serious potential adverse effect of this medication? Agranulocytosis The Family nurse practitioner prescribed losartan 50 mg PO daily for a hypertensive patient. This medication promotes vasodilation by: Blocking the action of angiotensin II A clinic Nurse Practitioner is planning care for a 68-year-old man who has been on omeprazole (Prilosec) therapy for heartburn for some time. Regarding the patient's safety, which of the following would be a priority nursing action? A) Teach the patient to take omeprazole 1 hour before meals B) Emphasize that the drug should not be crushed or chewed C) Coordinate bone density testing for the patient D) Monitor the patient for the development of diarrhea C) Coordinate bone density testing for the patient A nurse is caring for a postsurgical patient who has small torturous veins and had a difficlut IV insertion. the patient isnow recieving medications on a regular basis. what is the best nursing intervention to minimize the adverse effects of this drug therapy? A) monitor the patient's bleeding time B) check the patients blood glucose levels C) record baseline vital signs D) Monitor the IV site for redness, swelling, or pain D) monitor the iv site for redness, swelling, or pain A patient is in the clinic after 6 weeks of taking riluzozle (Rilutek) for a recent diagnosis of amyotrophic lateral sclerosis. The nurse will prioritize assessment for which of the following? A) weight gain B) constipation C) increased energy D) dizziness D) dizziness Which of the following patients demonstrates the clearest indication for treatment with prednisone? 20 | P a g e dental hygiene, it is important for the nurse to assess the patient's overall health and any potential side effects or complications that may arise from taking the medication. Dental hygiene practices can have an impact on a person's overall health, so it is important for the nurse to inquire about this aspect of their self-care routine during a follow-up visit. A nurse notes new drug orders for a patient who is already getting several medications. Which of the following is the most important consideration when preparing to administer the new drugs? A) How the patient will feel about new medications added to her drug therapy B) Possible drug-drug interactions that might occur C) Any special nursing considerations that the nurse must be aware of D) If generic preparations of the drugs can be used B) Possible drug-drug interactions that might occur A nurse is discussing with a patient the efficacy of a drug that his physician has suggested, and he begin taking. Efficacy of a drug means which of the following? A) The amount of the drug that must be given to produce a particular response B) How well a drug produces its desired effect C) A drug's strength of attraction for a receptor site D) A drug's ability to stimulate its receptor B) How well a drug produces its desired effect A nurse is conducting a medication resolution of a new resident of a care facility and notes that the woman has been taking neostigmine. The nurse should recognize that the woman may have a history of what health problem? A) Alzheimer disease B) Parkinson disease C) Myasthenia gravis D) Multiple sclerosis C) Myasthenia gravis A 77-year-old man's chronic heart failure is being treated with a regimen of quinapril (Accupril) and furosemide (Lasix). Which of the following assessment findings would suggest that the loop diuretic is contributing to a therapeutic effect? A) The man's glomerular filtration rate and creatinine levels are within reference ranges. B) The man's heart rate is between 60 and 70 beats per minute with a regular rhythm. C) The man's potassium and sodium levels remain with reference ranges. D) The man's chest sounds are clear and his ankle edema is lessened D) The man's chest sounds are clear and his ankle edema is lessened 21 | P a g e A nurse explains to a patient that nitroglycerin patches should be applied in the morning and removed in the evening. This medication schedule reduces the potential for__ A) adverse effects. B) nitrate dependence. C) nitrate tolerance D) toxic effects C) nitrate tolerance A nurse who provides care on a busy medical unit of a large hospital is constantly faced with new drugs on patients' medication administration records. What strategy should the nurse employ to foster up-to- date information about the nursing management of new or uncommon drugs? A) Focus on learning about a prototype drug that is characteristic of a larger drug class B) Identify similarities between new drugs and older drugs that are commonly used on the unit C) Commit time and energy during each shift to learning about new drugs D) Liaise with pharmacists and pharmacy technicians who work at the hospital A) Focus on learning about a prototype drug that is characteristic of a larger drug class A prototype drug is one individual pharmaceuticals drug, a group of chemicals that has chemical structures, action mechanism, and mode of action, in pharmacology and pharmaceuticals. A drug prototype is a well-understood drug model compared to other drugs in its class. Users can predict the actions and adverse effects of other drugs from the same class by learning the characteristics of a prototype drug. A 58-year-old man is admitted to the emergency department. A diagnosis of severe digoxin toxicity is made. Bradycardia is present, and an electrocardiogram (ECG) confirms toxicity. The nurse will administer which of the following drugs? A) Furosemide B) Digoxin immune fab C) Captopril D) Dopamine B) Digoxin immune fab A hospital patient's physician has prescribed quetiapine (Seroquel) to be administered at bedtime. Being unfamiliar with the medication, the nurse has looked it up in a nursing drug manual and noted that the drug is an antipsychotic that is indicated for the treatment of schizophrenia and bipolar disorder. The patient has no psychiatric history, and upon questioning, the physician states that it is being prescribed to help the patient fall asleep at night. How should the nurse best understand this practice? A) This off-label use of the drug is prohibited by federal laws and professional practice standards. 22 | P a g e B) This is an appropriate use of the drug, provided it is supported by the literature. C) This is acceptable if the patient has failed to respond adequately to conventional sleep aids. D) This is a practice that may negate the physician's and nurse's liability insurance B) This is an appropriate use of the drug, provided it is supported by the literature. A 4-year-old child is brought to the emergency department by her mother. The mother reports that the child has been vomiting, and the nurse notes that the child's face is flushed and she is diaphoretic. The mother thinks that the child may have swallowed carbachol drops. A diagnosis of cholinergic poisoning is made. Which of the following drugs would be administered? A) Acetylcholine B) Atropine C) Cevimeline D) Nicotine A) Acetylcholine The treatment for cholinergic poisoning is aggressive supportive care, plus targeted therapy for cholinergic toxicity which is ATROPINE followed by an available oxime such as pralidoxime. A nurse is providing discharge instructions to a patient who will be taking fludrocortisone at home. The nurse will encourage the patient to eat a diet that is__ A) low in sodium and potassium. B) low in sodium, high in potassium. C) high in iron. D) low in proteins B) low in sodium, high in potassium. Salt retention. Side effects of having more salts in our body. When there is high salt present in our body, this will cause elevation of the blood pressure and as well as it has something to do with heart failure. Decreased potassium level. Potassium is inversely proportional to sodium. Common complications of potassium includes cardiac activities. A nurse is developing a care plan for a patient who has multiple sclerosis. An expected outcome for the patient who is receiving glatiramer would be a decrease in A) chest pain. B) fatigue. C) breathing difficulties. D) heart palpitations 25 | P a g e C) Hypotension D) Decreased salivation B) Hypertension Hypertension is defined as the condition of high blood pressure in the body of an individual. This can occur as a result of retention of enormous amount of urine in the body. As such, the person is likely to display symptoms such as leg swellings and damaging of the kidney affecting its efficiency. Urinary retention is because of some kind of blockage in the urinary tract. Thus this condition can medically be dealt with by the application of Bethanechol which aids in easing the urination process which is affected by the processes of birth, surgery and other medical processes and prescriptions. A 12-year-old child who has been taking sertraline for the past 2 weeks has returned to the clinic to be seen. It will be critical for the nurse to assess for A) onset of suicidal ideation. B) weight loss. C) feelings of grandiosity. D) decreased sleep A) onset of suicidal ideation. Sertraline is an antidepressant medication commonly used to treat depression, anxiety disorders, and other mental health conditions. While it is generally safe and effective, it can increase the risk of suicidal thoughts and behavior, especially in children and adolescents. Therefore, the nurse should monitor the child for any signs of suicidal ideation, such as talking about death or self-harm, withdrawing from social activities, or showing sudden changes in mood or behavior. A 30-year-old woman is taking phenelzine (Nardil) 30mg PO tid. The nurse knows that at that dosage, the patient will need to be carefully monitored for A) dizziness. B) diarrhea. C) increased secretions. D) facial flushing. A) dizziness. A patient has been admitted to the intensive care unit following a myocardial infarction. His nurse is preparing to administer his ordered medications when she notices that one drug ordered is used for treating seizure disorders. The nurse does not find a history of seizures in the patient's record. The most appropriate action for the nurse is to__ A) ask the charge nurse if she knows why the drug has been ordered. B) look up the drug to see if there are other conditions that the drug could be prescribed for. 26 | P a g e C) question the physician about the prescribed medication. D) call the pharmacist and inquire about therapeutic uses of the drug. C) question the physician about the prescribed medication. A nurse is aware of the high incidence and prevalence of major depression in the population. Which of the following individuals possesses the clearest risk factors for depression? A) A man who has a history of intravenous drug use and multiple hospital admissions for subsequent infections B) A woman whose father had a long history of depression before he committed suicide C) A man who is experiencing significant lifestyle changes after losing his job D) A woman who has recently begun treatment for idiopathic seizure activity B) A woman whose father had a long history of depression before he committed suicide The nurse has been assigned a 49-year-old patient who has acute colitis, and the nurse just completed gathering data concerning core drug knowledge and core patient variables. To implement nursing management of drug therapy for this patient, the nurse will then__ A) evaluate the outcome of the drug therapy. B) devise strategies to maximize the therapeutic effects of the drug. C) implement planned nursing actions. D) assess for data that will indicate interactions between core drug knowledge and core patient variables. B) devise strategies to maximize the therapeutic effects of the drug. A nurse has been caring for a 49-year-old man who was hospitalized with recurrent ventricular fibrillation and received IV amiodarone. The man is now scheduled to be discharged on oral amiodarone, and the nurse has just completed discharge instructions. Which of the following statements made by the patient indicates that further instruction is necessary? A) "I will notify my physician if I develop a cough and have difficulty breathing." B) "I am going on a cruise next week and plan to just lie in the sun all day and relax." C) "I plan to see my ophthalmologist in 2 weeks." D) "It is important for me to have my thyroid gland checked regularly B) "I am going on a cruise next week and plan to just lie in the sun all day and relax." - photosensitive drug A 73-year-old man was diagnosed with Parkinson disease earlier this year and has begun taking carbidopa-levodopa four times daily in an effort to control the signs and symptoms of the disease. The nurse should recognize that this therapeutic effect is achieved by influencing the__ A) uptake of acetylcholine. B) dopamine receptors in the brain. 27 | P a g e C) synthesis of epinephrine. D) sensitivity of beta-2 receptors. B) dopamine receptors in the brain. Levodopa is the precursor to dopamine. Most commonly, clinicians use levodopa as a dopamine replacement agent for the treatment of Parkinson's disease. It is most effectively used to control bradykinetic symptoms that are apparent in Parkinson's disease. Levodopa is typically prescribed to a patient with Parkinson's disease once symptoms become more difficult to control with other anti- Parkinsonism drugs. The drug can also be used for postencephalitic Parkinsonism and symptomatic Parkinsonism due to carbon monoxide intoxication. A patient is admitted to the emergency department with severe chest pain. The emergency department physician orders intravenous nitroglycerin 5 mcg/min, titrate dose by 5 mcg/min every 3 to 5 minutes per infusion pump as needed. Before administering the nitroglycerin, the nurse should prioritize which of the following assessments? A) Blood pressure B) Urinary output C) Heart rate D) Blood urea nitrogen (BUN) A) Blood pressure A patient has been prescribed several drugs and fluids to be given intravenously. Before the nurse starts the intravenous administration, a priority assessment of the patient will be to note the__ A) heart rate. B) body weight and height. C) blood pressure. D) skin surrounding the potential IV site. D) skin surrounding the potential IV site. Which of the following patients would a nurse determine to be at the greatest risk for quinidine toxicity? A) A 30-year-old pregnant woman B) A 44-year-old man diagnosed with cardiac insufficiency C) A 50-year-old woman with myasthenia gravis D) A 55-year-old man diagnosed with complete heart block D) A 55-year-old man diagnosed with complete heart block Quinidine is contraindicated in patients with complete AV block, severe intraventricular conduction defects, left bundle-branch block, or ventricular ectopy. Quinidine is contraindicated in patients with digitalis-induced AV conduction disorders A nurse is assigned to a patient who is taking lithium. Which of the following drug serum levels would indicate that the patient is at risk for adverse effects of the drug? 30 | P a g e adverse drug effects and risks associated with prednisone treatment? A) Avoid OTC antacids for the duration of treatment B) Advocate for intravenous, rather than oral, administration C) Teach the patient strategies for dealing with headaches D) carefully assess the patient for infections D) carefully assess the patient for infections Steroid drugs, such as prednisone, work by lowering the activity of the immune system. The immune system is your body's defense system. Steroids work by slowing your body's response to disease or injury. Prednisone can help lower certain immune-related symptoms, including inflammation and swelling A nurse is performing an admission assessment of an elderly patient who is being admitted to a medical ward from the emergency department. Which of the following is an open-ended assessment question? A) "Have you ever had a bad response to a drug that you've taken?" B) "Does anyone in your immediate family have a history of drug allergies?" C) "Are you comfortable with receiving needles?" D) "What kind of reactions have you had to medications?" D) "What kind of reactions have you had to medications?" In order to promote therapeutic drug effects, the nurse should always encourage patients to A) take their medication with meals. B) take their medication at the prescribed times. C) increase medication dosages if necessary. D) use alternative therapy to increase the effects of their medications B) take their medication at the prescribed times. Frequent episodes of exercise-related chest pain have caused a 79-year-old woman to use her prescribed nitroglycerin spray several times in recent weeks. This patient's age will have what effect on her use of nitroglycerin? A) The woman may experience paradoxical vasoconstriction when taking nitroglycerin. B) Decreased saliva production will inhibit the absorption of the drug in her mucosa. C) The woman will need to allow more time between doses in order to facilitate absorption. D) The woman will be more susceptible to hypotension than a younger patient D) The woman will be more susceptible to hypotension than a younger patient Mild hypotension is occasionally related with nitrate treatment, but significant adverse effects are infrequent. There have been cases where nitroglycerin delivery resulted in life-threatening hypotension and bradycardia. Hypotension is a nitroglycerin adverse effect. Hypotension of varying degrees is usually caused by a decrease in venous return and, to some extent, arteriolar resistance. Because of the hypotension, the vasomotor center is stimulated by baroreceptor- 31 | P a g e mediated reflex activation. As a result, vascular tone and heart rate rise, assisting in blood pressure support. A 47-year-old woman has been diagnosed with open angle glaucoma. Pilocarpine drops are prescribed. The nurse's assessment reveals that the patient has worn soft contact lenses for 15 years. The nurse will instruct the patient to A) apply the contact lenses and wait 5 minutes before applying the drops. B) remove the contact lenses before applying the drops. C) apply the drops directly on the contact lenses. D) stop wearing the contact lenses during the pilocarpine therapy B) remove the contact lenses before applying the drops. A nurse who provides care on an acute medicine unit has frequently recommended the use of nicotine replacement gum for patients who express a willingness to quit smoking during their admission or following their discharge. For which of the following patients would nicotine gum be contraindicated? A) A patient who received treatment for kidney failure due to an overdose of acetaminophen B) A patient whose pulmonary embolism was treated with a heparin infusion C) A patient with a history of angina who experienced a non-ST wave myocardial infarction D) A patient whose stage III pressure ulcer required intravenous antibiotics and a vacuum dressing C) A patient with a history of angina who experienced a non-ST wave myocardial infarction It is contraindicated in patients with life threatening arrhythmias or worsening angina pectoris. It was also found that nicotine gum aggravates regional myocardial hypoperfusion in patients with known coronary artery disease. A patient calls the clinic and reports that he is having chest pain. The patient states that "I'm scared that I am going to die and I've been pacing up and down my driveway." After calming the patient, the initial instruction by the nurse would be to__ A) ask the patient to call 911 and wait outside for the ambulance to arrive. B) ask the patient to place a nitroglycerin tablet under his tongue immediately. C) have the patient take his pulse for 1 minute. D) have the patient go into his house and sit or lie down D) have the patient go into his house and sit or lie down The initial instruction by the nurse would be for the patient to go inside the house and sit or lie down before taking nitroglycerin medicine to prevent dizziness or fainting. If the person has nitroglycerin drugs in his house, the nurse should then inform him to put the tablet under his tongue and that he can take another tablet in 5 minutes and an additional one in 10 minutes if the pain has not reduced. However, if the pain still persists after the third tablet, the patient should call 911 because he may be experiencing a myocardial infarction. Constipation is a major problem in patients with amyotrophic lateral sclerosis (ALS). The nurse will educate the patient and family to__ 32 | P a g e A) choose a laxative at the local drug store. B) use prune juice only. C) consult their physician before purchasing a laxative. D) walk at least 500 yards a day C) consult their physician before purchasing a laxative. Constipation is a common problem in patients with amyotrophic lateral sclerosis (ALS). The nurse will educate the patient and family on the best ways to manage and prevent constipation. One of the main recommendations is to consult their physician before purchasing a laxative as some may not be suitable for the patient's condition. A nurse has been assigned to care for a 52-year-old attorney who has hypertension and peptic ulcer disease. Before administering his medications, the nurse must complete an initial assessment. Core patient variables will be obtained from which of the following? (Select all that apply.) A) The patient's interview B) The patient's medical history C) The patient's medical record D) The patient's physical examination E) The patient's health insurer A) The patient's interview B) The patient's medical history C) The patient's medical record D) The patient's physical examination A 59-year-old woman has long-standing diagnoses of type 1 diabetes and hypertension and has recently been diagnosed with glaucoma. Her ophthalmologist has prescribed pilocarpine (Akarpine), which will achieve its intended therapeutic effect by which of the following means? A) By blocking receptors of acetylcholine B) By increasing synthesis of acetylcholine C) By directly stimulating cholinergic receptors D) By stimulating nicotinicN receptors C) By directly stimulating cholinergic receptors Pilocarpine is a muscarinic receptor agonist which acts on the cholinergic receptor thereby stimulating contraction of iris sphincter muscle in the eyes in order to produce miosis thereby relieving pupillary block and opening anterior chamber angle. A woman in her twenties has been accompanied to her primary care provider by her mother, who states that her daughter has been experiencing increasingly severe episodes of irritable grandiose behavior. The care provider has consequently begun a treatment regimen that includes pharmacological therapies. This patient is most likely experiencing which of the following mood disorders? A) Bipolar disorder 35 | P a g e A) A 47-year-old female with hypertension B) A 52-year-old male with adult-onset diabetes C) A 17-year-old female with symptoms of an upper respiratory infection D) A 62-year-old male with gout A) A 47-year-old female with hypertension Phenylephrine causes vasoconstriction in the arteries by directly activating alpha-1 adrenergic receptors. The blood flows with a lot of pressure due to the smaller vessel diameter. Which of the following would be an expected outcome in a patient who has been given atropine during a medical emergency? A) Reduction of severe hypertension B) Increased level of consciousness C) Restoration of normal sinus rhythm D) Resolution of respiratory acidosis C) Restoration of normal sinus rhythm A 53-year-old man has been treated for severe asthma for several years with prednisone. Recently, his physician initiated alternate day therapy for him. The patient tells the nurse that he would rather take the medication every day to prevent confusion. Which of the following would be the best response by the nurse? A) "This schedule will be more convenient for you." B) "This schedule will enable you to lose weight." C) "This schedule will decrease the cost of your medication." D) "This schedule allows rest periods so that adverse effects are decreased but the anti-inflammatory effects continue D) "This schedule allows rest periods so that adverse effects are decreased but the anti-inflammatory effects continue" A middle-aged male patient has received a diagnosis of amyotrophic lateral sclerosis (ALS) and has begun treatment with riluzole (Rilutek). The patient's nurse should recognize what goal of this treatment regimen? A) Restoration of normal motor nerve function B) Maintenance of normal mobility and activities of daily living C) Delaying of tracheostomy or mechanical ventilation D) Relief of neuropathic pain C) Delaying of tracheostomy or mechanical ventilation A patient has been prescribed an oral drug that is known to have a high first-pass effect. Which of the following measures has the potential to increase the amount of the free drug that is available to body cells? 36 | P a g e A) Giving the drug with food in order to delay absorption B) Administering the drug in small, frequent doses C) Limiting the patient's protein intake and encouraging fluids D) Administering the drug intravenously rather than orally D) Administering the drug intravenously rather than orally A patient has been receiving regular doses of an agonist for 2 weeks. Which of the following should the nurse anticipate? A) The drug will decrease in effectiveness B) The drug will increase in effectiveness C) There will be a steady state with no anticipated changes D) The drug will cause excessive therapeutic effects even when administered in small doses. A) The drug will decrease in effectiveness A drug or substance that attaches to a receptor within a cell or on its surface and generates the same activity as the substance that ordinarily binds to the receptor is known as an agonist. When your body develops a tolerance to a medicine, it indicates that the medication, at its present level, is no longer as effective as it once was. It could signify that your body has grown accustomed to the medicine and you are no longer getting the same advantages or effects. After seeking care for tremors that have become increasingly severe in recent months, a 71-year-old man has been diagnosed with Parkinson disease and will soon begin treatment with carbidopa- levodopa. Which of the following statements indicates that the patient has an accurate understanding of his new medication? A) "I'll have to learn how to modify each dose of carbidopa-levodopa based on how bad my symptoms are that day." B) "I've read that carbidopa-levodopa is quite short-acting so I'll have to take it several times a day." C) "I'll make sure to stop taking my other medications so that my carbidopa-levodopa doesn't interact with them." D) "I've heard that it can take up to a year for carbidopa-levodopa to cure someone of Parkinson disease B) "I've read that carbidopa-levodopa is quite short-acting so I'll have to take it several times a day." A nurse is caring for a patient who is taking metoprolol (Lopressor). Which of the following statements would indicate that teaching by the nurse concerning the beta-adrenergic antagonist has been effective? A) "I may have a very dry mouth while taking this drug." B) "I should never stop taking this drug abruptly." C) "I can stop walking a mile a day." D) "Since I am taking this drug, I no longer need to worry about my diet B) "I should never stop taking this drug abruptly." 37 | P a g e A female patient has been taking prednisone for her asthma for 1 month. The nurse will teach her to gradually decrease her dose of prednisone to avoid A) hypokalemia. B) gastrointestinal problems. C) adrenal insufficiency. D) menstrual irregularities C) adrenal insufficiency. A 21-year-old man experienced massive trauma and blood loss during a motorcycle accident and has been started on a dopamine infusion upon his arrival at the hospital. In light of this drug treatment, what assessment should the care team prioritize? A) Respiratory assessment B) Arterial blood gases C) Monitoring of intracranial pressure D) Cardiac monitoring D) Cardiac monitoring A 58-year-old woman was diagnosed with myasthenia gravis many years ago and has been on a regimen of neostigmine (Prostigmin), a reversible cholinesterase inhibitor. In light of the patient's drug regimen, a nurse can conclude that the pathophysiology of myasthenia gravis involves__ A) excessive synthesis and release of acetylcholine at neuromuscular junctions. B) a lack of functional cholinergic receptors at neuromuscular junctions. C) an inherent susceptibility to cholinergic crisis. D) deficient reuptake of acetylcholine B) a lack of functional cholinergic receptors at neuromuscular junctions Insufficient amounts of ACh prevent normal muscle contraction and cause muscle weakness. Botulinum toxin prevents ACh from being released into the synaptic cleft. With no ACh binding to its receptors at the motor end-plate, no action potential is produced, and muscle contraction cannot occur. The binding of acetylcholine to its receptor activates the muscle and causes a muscle contraction. In myasthenia gravis, antibodies (immune proteins produced by the body's immune system) block, alter, or destroy the receptors for acetylcholine at the neuromuscular junction, which prevents the muscle from contracting. A nurse has been assigned to a 52-year-old woman who has been hospitalized and has a diagnosis of Parkinson disease. The patient has been taking carbidopa-levodopa for about 1 year. The patient states that she has been having "more side effects from her drugs lately" and the nurse observes that the client appears to be lethargic and have a decreased attention span. Which of the following would be an appropriate nursing diagnosis based on the statement of the patient and the observations of the nurse? 40 | P a g e Efficacy is the relationship between receptor occupancy and the ability to initiate a response at the molecular, cellular, tissue or system level. In other words, efficacy refers to how well an action is took after the drug is bound to a receptor Affinity Affinity is how well a drug can bind to a receptor (Fast/strong binding = higher affinity) Benzodiazepine MOA Act on GABA which is a major inhibitory NTM in the CNS; Effects are produced by interacting with a protein complex with in the neuronal membrane GABA which has a high 'affinity' for benzo's specifically; Inhibition of polysynaptic afferent pathways resulting in skeletal muscle relaxation; It decreases the spread of seizure activity due to an increased pre-synaptic inhibition of the CNS Benzodiazepine uses/indications Similar actions however different doses/concentrations/combinations produce different actions thus have different uses Anxiety/panic disorders skeletal muscle relaxation seizures sedation for procedures (due to relaxation and amnesic properties) Benzodiazepines adverse effects Most derived through CNS actions; Ataxia, dizziness, drowsiness/sedation, blurred vision, hypnosis, weakness, fatigue More severe: hypersensitivity, mental depression, hypotension, paradoxical stimulation, rebound seizures Benzo pharmacokinetics Widely distributed throughout the body accumulate in lipid rich areas (CNS and adipose tissue) the more lipophilic the agent the faster it is absorbed Onset 30 min- 1 hr lasting 4-6 hours, peak at 1-2 hours IV Admin: onset 1-5 min, peak immediately, last 15-20 min metabolized by the liver and excreted in urine Beta blocker (BB) MOA Interrupts the nerve impulses across the neurons by antagonizing the receptors with in the cardiac cells resulting in blockade of the beta 1 receptors'; -B1 blockade results in reduction of heart rate (chronotropic), rate of conduction through the AV node (dromotropic), and force of contraction (inotropic) This in turn decreases the oxygen demand on the myocytes, reduction in BP from the reduced HR and inotropic actions 41 | P a g e Hypoglycemia can occur with beta blockade because β2-adrenoceptors normally stimulate glycogen breakdown (glycogenolysis) in the liver and pancreatic release of the hormone glucagon, which work together to increase plasma glucose Beta blocker Therapeutic uses Useful in angina, HTN, cardiac dysrhythmias, MI, HF, Hyperthyroidism, migraines, pheochromocytoma, Glaucoma In angina/MI: reduction of oxygen demand HTN: B1 blockade as well as suppressed renin release via B1 blockade in the kidneys shows a marked decrease in PVR which results in improved stroke volume Beta Blocker Adverse effects B1 blockade: bradycardia resulting in reduced CO and precipitating HF, AV heart block, Rebound cardiac Excitability B2 effects incl: bronchoconstriction, and Inhibition of glycogenolysis resulting in hypoglycemia Beta blocker Pharacokinetics Highly lipid soluble Absorption usually rapid/complete 50% 1st pass metabolism peak concentrations approx. 1.5-2 hours, onset about 4-5 hrs liver metabolized, renal excretion as a metabolite Beta blocker interactions Calcium channel blockers: Negative Ino/dromo/chronotropic effects anti-arrhythmics: may enhance their effects leading to unwated outcomes Nitrates: may potentiate hypotensive effects MAO inhibitors: may increase reduction of sympathetic activity thus the inability to respond to Fight/flight mechanism resulting in reduced BP/HR overall Digitalis: Can potentiate suppressed AV conduction Calcium Channel Blockers (CCB) MOA inhibition of calcium movement in smooth and cardiac muscle tissue by selectively antagonizing calcium influx movment across the cellular membrane responsible for smooth/cardiac muscle conduction velocity: produces relaxation of coronary smooth muscles, dilation of coronary arteries; reduced dromotropic effects of the sa/av node and reduced automaticity Effects peripherally result in vasodilation through smooth muscle relaxation Different agents have different effects on different receptors within the transmembrane calcium channels Non specific effects in blood coagulation by inhibiting platelet aggregation in the clotting cascade 42 | P a g e CCB indications Hypertension, angina, dysrhythmias CCB Adverse effects Peripheral edema, flushing, palpitations, headache Pulmonary edema, rebound tachycardia, bradycardia, skin rash CCB drug interactions BB and other antiarrhythmics can potentiate their effects increased concentrations of theophyliine and digoxin may occur Non-depolarizing Neuromuscular Blocker MOA Prevent Ach from activating Nicotinic 'm' receptors on skeletal muscle, causing relaxation and flaccidity (does not cause depolarization at the neuromuscular endplate) Competes with Ach for biding with Nm receptors, blocking Ach thus preventing stimulation causing the muscle to no longer be engaged and relax; effect lasts until there is insufficient amount available to overtake the Ach (muscles paralyze at different times: Levator muscles of the eyelids first, than limbs, abdomen, and lastly the glottis diaphragm and intercostal) Non-depolarizing Neuromuscular Blocker indications To facilitate muscular relaxation for general procedures requiring its purose such as to facilitate ETI, Mechanical ventilation, Surgery Non-depolarizing Neuromuscular Blocker Adverse effects Hypotension: is due to release of histamine from mast cells and partial blockade of Nn receptors in the ANS by suppressing sympathetic tone to peripheral vasculature Myasthenia gravis: condition characterized by an overall decreased number of Nm receptors thus a Nm blocking agent given in this subset could produce a more profound, rapid, and prolonged effect Non-depolarizing Neuromuscular blocking agent drug interactions Hypokalemia can enhance effects Hyperkalemia can reduce effects Aminoglycoside antibiotics (gentamycin, vancamyacin), tetracycline, non PCN antibiotics: can intensive the response to Nm blockade Cholinesterase inhibitors: Decrease the effectiveness effectively reversing the Nm blockade due to an increased degredation of Ach @ the neuromuscular junction 45 | P a g e pts who are on stimulants (caffeine) or theophylline may require larger doses as these drugs counter the effects of adenosine Amiodarone HCL (codarone) class III vw anti-arrhythmic: MOA Amiodarone slows conduction rate and prolongs the refractory period of the SA and AV nodes - and prolongs phase 3 of the cardiac action potential, the repolarization phase where there is normally decreased calcium permeability and increased potassium permeability. It has numerous other effects, however, including actions that are similar to those of antiarrhythmic classes Ia, II, and IV. It also inhibits adrenergic stimulation and decreases peripheral vascular resistance- causing some vasodilation Amiodarone HCL (codarone) class III vw anti-arrhythmic: Indications VF/Pulseless VT unresponsive to CPR and shock therapy Hemodynamically stable monomorphic VT Polymorphic VT with a normal QT interval Stable irregular narrow complex tachycardia (AF < 48 hrs) Stable regular Narrow complex tachycardia (unresponsive to adenosine/instances where adenosine is contraindicated) Amiodarone HCL (codarone) class III vw anti-arrhythmic: Dose Cardiac arrest: 300 mg IVP diluted in 20 ml NS/D5W; repeated at 150 mg in 3-5 min Recurrent life threating ventricular arrhythmias Rapid Infusion: 150 mg/10 min (15 mg/min) q 10 min prn Slow infusion: 360 mg IV over 6 hrs (1 mg/min) Peds: VF/VT pulseless: 5 mg/kg IVP max of 300 mg, repeat twice Ventricular tachyarrhythmias: 5 mg/kg IV over 20-60 min repeated prn max of 15 mg/kg or 2.2 g Amiodarone HCL (codarone) class III vw anti-arrhythmic: Contraindications Av block, 2/3rd degree without a pacemaker Bradycardia resulting in syncope as it may cause atropine resistant bradycardia Sinus node impairment Cardiogenic shock sensitivity to amiodarone or iodine thyroid disease Other drugs that cause a prolonged QT (procainamide) and stop infusion if QT widens by 50% of baseline or if hypotension results 46 | P a g e Acetylsalicylic acid/ASA (aspirin, bufferin, Novasen) Salicylate, antiplatelet, antipyretic, anti-inflammatory: MOA Anti-platelet: at low doses impedes clotting by inhibiting enzyme CoX-1 and prostaglandin synthesis which prevents formation of platelet aggregating substance Thromboxone A2 (this is irreversible and can prolong bleeding time) All mechanisms are related to inhibition of CoX-1 and prostaglandin acting non specifically on the hypothalamus/platelets/ sites of injury Acetylsalicylic acid/ASA (aspirin, bufferin, Novasen) Salicylate, antiplatelet, antipyretic, anti-inflammatory: Indications Acute coronary syndromes Acetylsalicylic acid/ASA (aspirin, bufferin, Novasen) Salicylate, antiplatelet, antipyretic, anti-inflammatory: Dose 160-325 mg Po as soon as possible (even if pt states they have taken their own) Acetylsalicylic acid/ASA (aspirin, bufferin, Novasen) Salicylate, antiplatelet, antipyretic, anti-inflammatory: contraindications HSN to ASA or other NSAIDs Active GI bleeding Acetylsalicylic acid/ASA (aspirin, bufferin, Novasen) Salicylate, antiplatelet, antipyretic, anti-inflammatory: Cautions Active ulcer disease ashmatics Bleeding disorders Impaired renal/hepatic functions Never given to children/adolescents with viral infections as it may precipitate reye's syndrome Atropine Anticholinergic: MOA Blocking the effects of acetylcholine (parasympathetic tone) on the SA and AV nodes thereby increasing the SA and AV conduction velocity resulting in increased HR Blocks the actions of parasympathetic nervous system and glands via the Ach receptor blockade producing reduced secretions on bronchial, salivary, and sweat glands Atropine Anticholinergic: Indications -Temporizing measure while awaiting a TCP for pt with symptomatic bradycardia, conduction block, sinus arrest -reversal of neuromuscular blockade prior to admin of anticholinesterases (neostigmine) to -counter their cholinergic effects 47 | P a g e -Organophosphate poisoning -MFI with Ketamine: decreasing bronchial secretions due to the cholinergic effects of ketamine Atropine Anticholinergic: Dose Symptomatic Bradycardia: 0.5 mg q 3-5 min prn max of 3 mg total MFI w/ ketamine: 0.01 mg/kg IVP to 0.5 mg once Organophosphate poisioning: 2 mg IVP q 5 prn Peds: 0.2 mg/kg IV max single dose 0.5 mg max total dose 1.0 mg OP poisoning: 0.05 mg/kg IVP prn q 5 min ** Note: smaller doses may precipitate paradoxical bradycardia (<0.5mg adult, <0.1mg ped)** Atropine Anticholinergic: contraindications HSN Glaucoma Tachycardia Atropine Anticholinergic: Notes Do not delay external pacing in pt with signs of poor perfusion S/S of atropine (anti-cholinergic) overdose: midriasis agitation dry skin fever flushed (blind as a bat, mad as a hatter, dry as a bone, hot as a hare, red as a beet respectively) Tx requires neostigmine CaCl (calcium chloride) Electolyte: MOA Needed for maintenance of nervous, muscular, skeletal systems and enzyme reactions and normal cardiac contractility as well as blood coagulation Affects secretory activity of the endocrine and exocrine glands 50 | P a g e Angioedema disorientation dizziness rash urticarial GI bleeding thrombocytopenia nephrotoxicity hepatotoxicity Dexamethasone (decadron) Glucocorticoid: MOA -Stimulates synthesis of enzymes needed to decrease inflammatory response -reduces inflammation by suppressing the synthesis of inflammatory mediators, infiltration of phagocytes, release of lysosomal enzymes and proliferation of lymphocytes -Crosses the placental barrier and promotes fetal lung maturation by increasing the production of surfactant Dexamethasone (decadron) Glucocorticoid: Indications Anaphylaxis bronchospasm croup Prevention of hyaline membrane disease in premature infants (24-34 wks) Dexamethasone (decadron) Glucocorticoid: Dose varies 8-10 mg IV/IM/PO premature delivery: 5 mg IVP/IMtid 24-48 hrs prior to delivery Peds: 0.6 mg/kg (typically 2-4 mg) IV/IM/PO max of 16 mg/day Dexamethasone (decadron) Glucocorticoid: Contraindications Systemic fungal infections live viral vaccines hsn to drug or components Magnesium sulfate (MgSO4) mineral/electrolyte: MOA Replaces magnesium and maintains magnesium levels Interferes with the release of Ach at the myoneural junction 51 | P a g e Has a tocolytic effect of the vascular smooth muscle system by Suppressing automaticity in depolarized cells having two effects: ◦interferes with calcium uptake in bronchial smooth muscle ◦interferes with acetylcholine release Magnesium sulfate (MgSO4) mineral/electrolyte: Indications Refractory VF/VT with suspected hypomagnesemia (hx of alcoholism, malnutrition, protracted diarrhea) Life threatening ventricular arrhythmias due to digitalis toxicity Torsades Control of seizures in PIH (eclampsia) Adjunctive therapy in severe bronchospasm Hypomagnesemia Magnesium sulfate (MgSO4) mineral/electrolyte: Dose Can vary CA/Torsades/Bronchospasm 2 g in 50 ml over 5-10 min In cardiac arrest 2 g in 10 ml SIVP Eclampsia (seizures in pregnancy) loading dose of 4-5 g in 250 ml over 20 min or if no IV obtainable 10 g IM maintenance infusion of 2 g/hr (2g in 1000 ml over 60 min) Peds: for all 25-50 mg/kg IV over 10-30 min For cardiac arrest 25-50 mg/kg in 10 ml SIVP Magnesium sulfate (MgSO4) mineral/electrolyte: Contraindications Myocardial damaged pts heart blocks coma Pregnant women in actively progressing labor Magnesium sulfate (MgSO4) mineral/electrolyte: Notes Can cause flushing/sweating and higher doses can cause hypotension or with rapid administration Use caution if pt has renal failure 52 | P a g e Dimenhydrinate (gravol) Anti-emetic, antivertigo, antihistamine: MOA Inhibits nausea and vomiting by centrally depressing sensitivity to the labyrinth apparatus that relays stimuli to the chemoreceptor trigger zone and stimulates the vomiting center of the brain; It also has some mild antagonism of muscarinic acetylcholine receptors in both the central and autonomic nervous system, which inhibits various signal transduction pathways Dimenhydrinate (gravol) Anti-emetic, antivertigo, antihistamine: Indications Nausea, vomiting, dizziness assoc with motion sickness/vertigo Meniere's disease Dimenhydrinate (gravol) Anti-emetic, antivertigo, antihistamine: Dose Varies 25-50 mg SIVP 50-100 mg IM Peds: 1.25 mg/kg IM to a max of 300 mg/day Dimenhydrinate (gravol) Anti-emetic, antivertigo, antihistamine: Contraindications HSN to drug or benzyl alcohol Any condition made worse by anti-cholinergic effects newborns Diphenhydramine HCl (Benadryl) Anti-histamine, antivertigo, anti-emetic, anti-dyskinetic, sedative): MOA Antihistamine: competes for H1 receptor sites on smooth muscle of the bronchi, GI tract, uterus, and large vessels; by binding to these cellular receptors, it prevents access of histamine and suppresses histamine induced allergic symptoms (however they do not stop the RELEASE of H1) Centrally acting anti-muscarinic actions of h1 blockade are responsible for the responsible for anti- vertigo/antiemesis Antidyskinetic: Alleviates extraparmydal symptoms such as akathesia (RLS) as a result of using anti- dompaminergic medications Diphenhydramine HCl (Benadryl) Anti-histamine, antivertigo, anti-emetic, anti-dyskinetic, sedative): Indications Allergic reaction/anaphylaxis Dyskinesia from anti-psychotic/anti-emetic agents 55 | P a g e enoxaparin sodium (lovenox) Low molecular weight heparin Contra-indications Hypersensitivity to heparin or pork products Active major bleeding Acute or sub-acute bacterial endocarditis Heparin or LMWH induced thrombocytopenia Suspected or known intracranial bleeding or spinal epidural hemorrhage IV administration in patients >75 yrs of age ephedrine adrenergic; vasopressor MOA Ephedrine is both a direct and indirect acting sympathomimetic that stimulates alpha and beta adrenergic receptors. Release of norepinephrine from its storage sites is one of its indirect effects. In therapeutic doses, ephedrine relaxes bronchial smooth muscles and produces cardiac stimulation with increased systolic and diastolic blood pressure when norepinephrine stores aren't depleted. Ephederine Adrenergic, vasopressor Indications To correct hypotensive states (i.e. sepsis, spinal trauma, head injury, anaphylaxis) Note: Ephedrine can be given as a "bridge drug" (due to it short half life) until an inotropic / vasopressor infusion is started to maintain an adequate BP. Ephederine Adrenergic, vasopressor Dose Need to ask: What is the likelihood of Ischemic Heart Disease? Low - 10 mg SIVP Moderate - 7.5 mg SIVP High - 5.0 mg SIVP Give every 3-5 minutes until max dose of 50 mg or the desired effect is accomplished; duration of drug is approximately 15 min Ephederine Adrenergic, vasopressor Contraindications Hypersensitivity to drug or other sympathomimetics In pts with porphyria Severe CAD Any pt taking MAO inhibitors 56 | P a g e Epinepherine (adrenalin) Adrenergic agonist/sympathomimetic MOA Directly stimulates the alpha and beta-adrenergic receptors in the sympathetic nervous system. Bronchodilation: Relaxes bronchial smooth muscle (beta2 receptors) and inhibits histamine release. CV and vasopressor : produces positive chronotropic and inotropic effects (beta1 receptors); increasing cardiac output, myocardial oxygen consumption and force of contraction. Vasodilation (beta2 receptors) and vasoconstriction (alpha receptors). Epinepherine (adrenalin) Adrenergic agonist/sympathomimetic Indications Cardiac Arrest - V-fib, Pulseless V-Tach, Asystole, PEA Epinephrine infusion may be used for patients with symptomatic bradycardia, particularly if associated with hypotension, for whom atropine may be inappropriate or after atropine fails Vasopressor infusions may be administered after ROSC to support cardiac output, especially blood flow to the heart and brain. Used to treat severe hypotension (e.g., systolic blood pressure < 70 mm Hg) Anaphylaxis Severe asthma with an allergenic component Beta Blocker overdose Epinepherine (adrenalin) Adrenergic agonist/sympathomimetic Dosing (may vary) Cardiac Arrest: IV Dosage: 1 mg (1:10,000) q 3-5 minutes Endotracheal: 2 - 2.5 mg (1:1000) diluted to 10 mL N/S Anaphylaxis: IV epinephrine 0.05 to 0.1mg (5% to 10% of the epinephrine dose used routinely in cardiac arrest) has been used successfully in patients with anaphylactic shock --- careful titration of a continuous infusion of IV epinephrine 5 - 15 mcg/min, based on severity of reaction and in addition to crystalloid infusion, may be considered in treatment of anaphylactic shock. Severe Asthma: IM epinephrine (concentration 1:1000) 3 doses of approximately 0.3 mg administered at 20-minute intervals 57 | P a g e IV dose: 0.1 mg of 1:10000 (approx 1 ml) prn Symptomatic Bradycardia with Hypotension: 2 - 10 mcg/minute infusion; Mix 1 mg of Epinephrine (1:1000) in 100 ml of N/S (10 ug/ml) Post Resuscitation Care to support cardiac output: Start infusion at 0.1 - 0.5 mcg/kg/min infusion (titrate to desired effect Epinepherine (adrenalin) Adrenergic agonist/sympathomimetic Dosing PEDSQ (may vary) Bradycardia/Arrest: Standard Dose: 0.01 mg/kg IVP (1:10,000; 0.1ml/kg); maximum dose 1 mg IV/IO Endotracheal: 0.1 mg/kg (1:1000; 0.1ml/kg); maximum dose 2.5 mg ETT Anaphylaxis: 0.01 mg/kg 1:1000 IM/SQ max 0.3 mg q 15 prn 0.01 mg/kg 1:10000 IVP (do not exceed 1.0 mg) q 3- 5 min Infusion: 0.1 mcg/kg/min IV/IO; Mix 1 mg of epinephrine (1:1000) in 250 ml of N/S (4mcg/ml) Post Resuscitation Care to support cardiac output: 0.1 - 1.0 mcg/kg/min IV infusion (< 0.3 mcg/kg/min generally produce B-adrenergic actions; higher dose infusion of > 0.3 mcg/kg/min cause a-adrenergic vasoconstriction. Croup: 3 ml 1:1000 nebulized prn Epinepherine (adrenalin) Adrenergic agonist/sympathomimetic Contraindications none in emergency setting Epinepherine (adrenalin) Adrenergic agonist/sympathomimetic Notes/Precautions High dose epi can be effective in the setting of beta/calcium channel blocker overdose titrate to effect on all infusions as responses are variable adequate hydration is necessary as epinepherine can dry bronchial secretions and thus making it difficult to dislodge 60 | P a g e Reverse respiratory depression and sedative effects of benzodiazepines Management of suspected pure benzodiazepine overdose Flumazenil (romazicon) bezodiazepine antagonist Dose First dose: 0.2 mg IV over 15 seconds. If no adequate response, give second dose Second dose: 0.3 mg IV over 30 seconds. If no adequate response, give third dose Third dose: 0.5 mg IV over 30 seconds. If no adequate response, repeat once every minute until adequate response or total of 3 mg is given Flumazenil (romazicon) bezodiazepine antagonist Contraindications Do not use in suspected tricyclic (TCAs) overdose Do not use in seizure-prone patients Do not use in unknown drug overdose or mixed drug overdose with drugs known to cause seizures (eg, TCAs, cocaine, amphetamines, etc.) Note: effects may not outlast beznos thus continuous monitoring of ventilatory status Furosemide (lasix) Loop diuretic MOA Diuretic: Inhibits sodium and chloride reabsorption in the proximal part of the ascending loop of Henle and distal renal tubule, promoting excretion of sodium, water, chloride and potassium. Hyperkalemia: Non-potassium (K+) sparing diuretic; potassium (K+) excreted from the body in the urine. Furosemide (lasix) Loop diuretic Acute pulmonary edema (BP >90 mmHg without S&S of shock) Hyperkalemia (Adult only) Furosemide (lasix) Loop diuretic 61 | P a g e Dose 0.5-1.0 mg/kg SIVP over 1 to 2 minutes (Hyperkalemia: start at 1.0mg/kg) If no response in 15-20 minutes double dose up to total of 2 mg/kg SIVP over 1 to 2 minutes Peds: 1 mg/kg SIVP/IM max single dose of 20 mg Furosemide (lasix) Loop diuretic Contraindications/notes Complete renal shutdown (anuria except acute) Hypokalemia Severe hypovolemia, hypotension, dehydration Watch for signs of electrolyte depletion & monitor ECG Monitor for signs of ototoxicity (rapid administration Consider urinary catheterization in long transports Glucagon (glucagen) Anti-hypoglycemic MOA Stimulates hepatic production of glucose from glycogen stores (glycogenolysis). Has an inotropic myocardial effect that stimulates cyclic AMP in cardiac tissue via non alpha, non beta receptors. Relaxes the musculature of the GI tract Glucagon (glucagen) Anti-hypoglycemic Indications Hypoglycemia (when IV access cannot be established). Administration of glucagon may be helpful for severe cardiovascular instability associated with betablocker toxicity that is refractory to standard measures, including vasopressors Glucagon (glucagen) Anti-hypoglycemic Dose Adult - Hypoglycemia: 1 mg SC / IM / IV, q 15-20 minutes prn 62 | P a g e Beta Blocker toxicity: 3 mg slow IVP; followed by an IV infusion of 3 mg/hr Pediatric - Hypoglycemia: 0.025 mg/kg SC / IM / IV / IO may repeat in 25 minutes if needed. Beta Blocker toxicity: 0.05-0.1 mg/kg, up to 1 mg SIVP Glucagon (glucagen) Anti-hypoglycemic Contraindications Hypersensitivity (beef or pork proteins as glucagon derived from beef or pork pancreas) Pheochromocytoma Notes: Administration to comatose patient (with normal liver glycogen stores) usually produces a return to consciousness within 20 minutes. Hepatic stores of glycogen are necessary for glucagon to exert an antihypoglycemic effect. Therefore glucagon may be ineffective on patients who are malnourished i.e. alcoholism Lowers serum potassium levels Do not mix with saline - use sterile water Haloperidol (haldol) Antipsychotic/antidopaminergic MOA Antipsychotic : strong postsynaptic blockade of CNS dopamine receptors, thereby inhibiting dopaminemediated effects, thereby inhibiting dopamine-mediated effects. Has many central and peripheral effects; has weak peripheral anticholinergic and antiemetic effects, produces both alpha and ganglionic blockade, and counteracts histamine and serotonin mediated activity. Haloperidol (haldol) Antipsychotic/antidopaminergic Indications Acute psychotic episodes Tourette's syndrome 65 | P a g e Ketamine Hcl (ketalar) Dissociative anesthetic Indications MFI with systolic < 90mmHg or associated bronchospasm Induction of general anesthesia for short procedures not requiring skeletal muscle relaxation. Maintain sedation post advanced airway management Managment of severe pain refractory to other treatments Note: some studies are showing effective sedation in EDS and other uses for hyperactive or violent patients Ketamine Hcl (ketalar) Dissociative anesthetic Dose Adult/Pediatric - ( *dilute with an equal volume of NS, D5W, or sterile water) MFI: 1-2mg/kg IVP prn; titrate to desired Maintain sedation / Procedural sedation: 0.5-2mg/kg IVP prn; titrate to desired effect Pain managment: 0.2-0.5 mg/kg prn Ketamine Hcl (ketalar) Dissociative anesthetic All are relative: Increased intracranial pressure (ICP) Severe hypertension Aneurysms Acute Heart Failure, angina and MI with an elevated BP Note: Ketamine produces short acting amnesia without muscular relaxation. Increases heart rate and blood pressure that makes it favorable for those patients that are hypotensive, not due to hypovolemia. Ketamine has limited or no respiratory depression, it also has B2 agonist and antihistamine properties, making it the drug of choice for induction of bronchospasm patients. Ketorolac (toradol) NSAID analgesic MOA Inhibits COX -1 and COX-2 and causes reversible inhibition. Powerful analgesic with minimum antiinflammatory actions, suppresses prostaglandin synthesis. 66 | P a g e Ketorolac (toradol) NSAID analgesic Indications Short term pain managment Colic pain related to renal/cholelethiasis Menstrual pain Ketorolac (toradol) NSAID analgesic Contraindications active peptic ulcer disease history of recent GI bleeding and advanced renal impairment confirmed or suspected intracranial bleeding use prior to major surgery hypersensitivity to drug and other NSAIDs use during labor and delivery concurrent use with other NSAIDs pediatric Preoperative pain post CABG surgery Asthma (current or severe bronchospasm) Labetelol Hcl (trandate) Alpha/beta adrenergic blocker, anti-hypertensive MOA Antihypertensive: Inhibits catecholamine access to both beta and postsynaptic alpha-adrenergic receptor sites. (May also have a vasodilating effect). tends to have stronger peripheral actions than central beta actions Labetelol Hcl (trandate) Alpha/beta adrenergic blocker, anti-hypertensive Indications Severe hypertension and hypertensive emergencies Arterial hypertension in acute Ischemic stroke patients who are potential candidates for acute reperfusion therapy with a blood pressure level of Systolic >185 mmHg or diastolic >110 mmHg Considerations for use in PIH in hypertensive crisis with fetal compromise noted Labetelol Hcl (trandate) Alpha/beta adrenergic blocker, anti-hypertensive Dose 67 | P a g e 20 mg SIVP initially; may repeat 40 - 80 mg SIVP q 10 min to maximum dose of 300 mg A reasonable target is to lower blood pressure by 15% - 20% Labetelol Hcl (trandate) Alpha/beta adrenergic blocker, anti-hypertensive Contraindications Conditions associated with severe or prolonged hypotension Overt cardiac failure 2nd or 3rd degree AV block Severe bradycardia Cardiogenic shock Asthma Lidocaine (xylocaine) Anesthetic, anti-arrhythmic, sodium channel blocker MOA Ventricular antiarrhythmic : One of the oldest antiarrhythmics. Suppresses automaticity and shortens the effective refractory period and action potential of the His-Purkinje fibers and suppresses spontaneous ventricular depolarization during diastole. Unlike quinidine and procainamide, lidocaine doesn't significantly alter hemodynamics when given in usual doses. It seems to act preferentially on diseased or ischemic myocardial tissue; exerting its effects on the conduction system, it inhibits reentry mechanisms and halts ventricular arrhythmias. Local anesthetic : acts to block initiation and conduction of nerve impulses by decreasing the permeability of the nerve cell membrane to sodium ions. Lidocaine (xylocaine) Anesthetic, anti-arrhythmic, sodium channel blocker Indications Lidocaine may be considered, if amiodarone is not available, in cardiac arrest (VF/VT) unresponsive to shock delivery, CPR, and a vasopressor. Hemodynamically stable monomorphic VT Local anesthesia for local procedures (sutures, excisions) Lidocaine (xylocaine) Anesthetic, anti-arrhythmic, sodium channel blocker Contraindications: Ventricular escape rhythms, Idioventricular rhythms 70 | P a g e Metoclopramide (maxeran) Anti-emetic, anti-dopaminergic, GI-stimulant Indications Anti-emetic - useful in chemotherapy, GERD induced NV, gastritis without diarrhea. End stage cancerous pt Anti-emetic of choice in palliative care Metoclopramide (maxeran) Anti-emetic, anti-dopaminergic, GI-stimulant Contraindications Hypersensitivity Presence of GI hemorrhage, obstruction, or perforation Pheochromocytoma History of seizure disorder Patients receiving drugs likely to cause extrapyramidal reactions Caution: Hypertension Depression Parkinson's disease Metoprolol tartrate (lopressor) Beta blocker, anti-hypertensive MOA Acute MI : exact mechanism by which metoprolol decreases mortality after AMI is unknown. Metoprolol reduces heart rate, systolic blood pressure and cardiac output via non selective beta blockade of the adrenergic receptors on the myocardium Metoprolol tartrate (lopressor) Beta blocker, anti-hypertensive Indications PO dose for patients with acute myocardial infarction (AMI) and no contraindications within the first 24 hrs of hospitalization Stable, narrow-complex tachycardias if rhythm remains uncontrolled or unconverted by adenosine or vagal maneuvers or if SVT is recurrent Control ventricular rate in patients with atrial fibrillation or atrial flutter Certain forms of polymorphic VT (associated with acute ischemia, familial long QT syndrome, 71 | P a g e catecholaminergic) Hypertensive crisis in the event of no other agent available for control of Blood pressure Metoprolol tartrate (lopressor) Beta blocker, anti-hypertensive Contraindications/notes Hypersensitivity CHF - severe LV failure Heart block (greater than 1st degree or 1st degree with PRI > 0.24 secs) Bradycardia < 60 bpm Cardiogenic shock Systolic blood pressure < 100 mmHg IV calcium channel blocker within 30 minutes Precautions: Bronchial asthma Impaired hepatic function Impaired respiratory function Diabetes Heart failure Midazolam (versed) Benzodiazepine MOA Sedative and anesthetic : Exact mechanism unknown. As with other benzodiazepines, depresses the CNS of the brain. Potentiates the effect of GABA (gamma-aminobutyric acid) - an inhibitory neurotransmitter. Anticonvulsant : Suppresses the spread of seizure activity due to enhanced pre-synaptic inhibition. Amnesic : Exact mechanism unknown Midazolam (versed) Benzodiazepine Indications Seizures / Status epilepticus Conscious sedation (cardioversion/pacing/fracture realignment/severely anxious or agitated patients) Maintenance of sedation for intubated and mechanically ventilated patients Medication facilitated intubation (MFI) 72 | P a g e Midazolam (versed) Benzodiazepine Contraindications Hypersensitivity Acute narrow angle glaucoma Acute alcohol intoxication Although caution should be used when administering midazolam to a patient who is hypotensive it can be given safely in small doses. The main concern appears to be in those patients who are hypovolemic and when given fast IVP and in larger doses. For these reasons administer midazolam slowly and at a dose not greater than 2.5 mg in patients with hypotension. Morphine Sulfate (statex, Ms contin) Opioid Analgesic MOA Principle opium alkaloid, the standard for opiate agonist analgesic activity. Binds to opiate receptors in the CNS, altering the response to, and perception of, pain. Produces generalized CNS depression. Morphine Sulfate (statex, Ms contin) Opioid Analgesic Indications Pain control - moderate to severe STEMI when chest discomfort is unresponsive to nitrates Acute Cardiogenic pulmonary edema (if blood pressure is adequate) UA/NSTEMI - Use with caution Morphine Sulfate (statex, Ms contin) Opioid Analgesic Contraindications/cautions Hypersensitivity Presence of MAO inhibitors, tricyclics, or phenothiazides within 14 days (greatly reduce dosage) Hypotension Precautions: Use with caution in RV infarction Use with caution in UA/NSTEMI chest pain because of an association with increased mortality Use cautiously in elderly or debilitated patients or those patients with impaired renal or hepatic function. Use cautiously in breast feeding patients 75 | P a g e Produces a positive inotropic response of the heart (beta1 receptors). (weak) Norepinephrine bitartrate (levophed) Alpha adrenergic agonist, vasopressor (sympathomimetic) Indications Hypotension (< 70mmHg) refractory to other adrenergic agonists (sympathomimetics) and not related to hypovolemia. Neurogenic shock Vasopressor infusions may be administered after ROSC to support cardiac output, especially blood flow to the heart and brain. Norepinephrine bitartrate (levophed) Alpha adrenergic agonist, vasopressor (sympathomimetic) Contraindications/cautions Contraindications: Mesenteric or peripheral vascular thrombosis Profound hypoxia, hypercapnia, or hypotension from blood volume deficit. Precautions: Do not mix with alkaline solutions as it can be deactivated (e.g. sodium bicarbonate). If given with Beta blockers a markedly elevated BP can occur Extravasation causes tissue necrosis Ondansetron (zofran) seratonin receptor antagonist, anti-emetic MOA is a highly specific and selective serotonin 5-HT3 receptor antagonist, with low affinity for dopamine receptors. The 5-HT3 receptors are present both peripherally on vagal nerve terminals and centrally in the chemoreceptor trigger zone Serotonin is released by the enterochromaffin cells of the small intestine in response to chemotherapeutic agents and may stimulate vagal afferents (via 5-HT3 receptors) to initiate the vomiting reflex. It is thought that ondansetron's antiemetic action is mediated mostly via antagonism of vagal afferents with a minor contribution from antagonism of central receptors Ondansetron (zofran) seratonin receptor antagonist, anti-emetic Indications 76 | P a g e Prevention of nausea and vomiting (i.e. head injury, spinal injury, AAA, open eye injury) Prevention of nausea and vomiting associated with initial and repeat courses of emetogenic cancer chemotherapy, including high dose cisplatin Prevention of radiation induced nausea and vomiting Prevention of post operative nausea and vomiting Prophylaxis and treatment of nausea and vomiting Ondansetron (zofran) seratonin receptor antagonist, anti-emetic Contraindications/cautions Hypersensitivity to drug Prolonged QT (relative) Precautions: Ondansetron is not effective in preventing motion-induced nausea and vomiting. Patients with hepatic failure oxytocin (syntocin, pintocin) Oxytocic, exogenous hormone MOA Increases the sodium permeability of the uterine myofibrils, indirectly stimulating the contraction of uterine smooth muscle (this response mimics labor contractions). Stimulates mammary gland smooth muscle, facilitating lactation oxytocin (syntocin, pintocin) Oxytocic, exogenous hormone Indications Postpartum hemorrhage (PPH) Use in management of 3rd stage of labor (after delivery of anterior shoulder) oxytocin (syntocin, pintocin) Oxytocic, exogenous hormone Contraindications/notes Contraindications: Hypersensitivity Prior to delivery of anterior shoulder Multiple births (until all delivered) Placenta previa and other obstetrical emergencies Severe toxemia 77 | P a g e Precautions: Uterine surgeries (e.g. cesarean section) Cardiac arrhythmias may result if given as an IV bolus. Pancuronium Bromide (pavulon) Non-deploarizing NM blocking agent MOA Skeletal muscle relaxant : Prevents neuromuscular transmission by blocking the effect of acetylcholine (ACh) at the myoneural junction, thus blocking depolarization. May increase heart rate through direct blocking effect on the acetylcholine (ACh) receptors of the heart. Pancuronium Bromide (pavulon) Non-deploarizing NM blocking agent Indications Medication Facilitated Intubation (MFI) after administration of sedation/analgesia (When succinycholine is contraindicated and sedation/analgesia is not enough to facilitate intubation AND rescue airway available) Post intubation to facilitate airway control & maintain muscle relaxation Pancuronium Bromide (pavulon) Non-deploarizing NM blocking agent Contraindications/cautions Contraindications: Hypersensitivity to drug or components (bromide). A difficult intubation in a patient who is presently self ventilating adequately and ventilation may be difficult once paralyzed. Precautions: Has no sedative/analgesic properties. Can produce hypotension. Can increase intracranial pressure (in patients with head injury- use vecuronium). Pentaspan (pentastarch) Plasma volume expander MOA The colloidal properties of pentastarch render it useful as a plasma volume expander. I.V. infusion of pentastarch results in expansion of the plasma volume in excess of the volume infused (replace blood 80 | P a g e dAtypical V-Tach (Torsades de Pointes) TCA antidepressant induced dysrhythmia 2nd or 3rd degree AV block Patients with preexisting QT prolongation Myasthenia gravis SLE - Lupus Pre-exitation with preexisting QT prolongation Procainamide Hcl (pronestyl) Class 1a anti-arrhythmic Notes Discontinue if one of the following occurs: 1) Hypotension ensues 2) The QRS widens by 50% of original width 3) Dysrhythmia is suppressed 4) Total of 17 mg/kg is administered 5) If cardiac or renal dysfunction is present, reduce maximum total dose to 12 mg/kg and maintenance infusion to 1 to 2 mg/min 6) Proarrhythmic, especially in the setting of AMI, hypokalemia, or hypomagnesemia 7) May induce hypotension in patients with impaired LV function Propofol (diprivan) General anesthetic, sedative-hypnotic MOA Anesthetic actio n: produces a dose-dependant CNS depression similar to benzodiazepines and barbiturates (can be used to maintain anesthesia through careful titration of the infusion rate). through potentiation of GABA receptor activity, thereby slowing the channel-closing time, and also acting as a sodium channel blocker Propofol (diprivan) General anesthetic, sedative-hypnotic Indications Induction and maintenance of general anesthesia in mechanically ventilated patients Procedural sedation Propofol (diprivan) General anesthetic, sedative-hypnotic Contraindications/cautions/notes 81 | P a g e Contraindications: Hypovolemia and shock Hypersensitivity to drug or emulsion (egg phospholipids, soybean oil etc) Increased ICP or impaired cerebral perfusion due to decreased systemic arterial pressure and subsequent cerebral perfusion pressure. Pregnancy Precautions: Hypotension can occur do to vasodilation. Propofol is highly lipid soluble (nearly insoluble in water) and the reason it is administered in a lipid emulsion. This leads to rapid transfer across the blood brain barrier Rocoronium Bromide (zemuron) Non-depolarizing NM blocking agent MOA Skeletal muscle relaxant : Prevents neuromuscular transmission by blocking the effect of acetylcholine (ACh) at the myoneural junction, thus blocking depolarization. Acetylcholinesterase inhibitors, such as neostigmine, antagonize this action. Rocoronium Bromide (zemuron) Non-depolarizing NM blocking agent Indications Medication Facilitated Intubation (MFI) after administration of sedation/analgesia (When succinycholine is contraindicated and sedation/analgesia is not enough to facilitate intubation AND rescue airway available) Post intubation to facilitate airway control & maintain muscle relaxation Rocoronium Bromide (zemuron) Non-depolarizing NM blocking agent Contraindications Contraindications: hypersensitivity to drug or components A difficult intubation in a patient who is presently self ventilating adequately and ventilation may be difficult once paralyzed Sodium Bicarbonate Alkalinizing agent 82 | P a g e MOA Alkalinizing ag ent : dissociates to provide bicarbonate ions needed to buffer hydrogen ions. Sodium Bicarbonate Alkalinizing agent Indications Patients with documented preexisting metabolic acidosis i.e.; diabetic ketoacidosis, Overdoses of tricyclic antidepressant and cocaine overdose (with QRS wider than 0.12 seconds), aspirin overdose, Phenobarbital overdose Known preexisting Hyperkalemia Cardiac arrest in special situations; such as pre-existing metabolic acidosis Sodium Bicarbonate Alkalinizing agent Contraindications/cautions Respiratory acidosis Early in cardiac arrest (unless a specific reason to administer) Respiratory and metabolic alkalosis Hypocalcemia Precautions: May inactivate catecholamines in solution (ie epinephrine) Flush well following administration, as it will cause precipitate if mixed with calcium salts (i.e. calcium chloride) Succinylcholine (anectine) Depolarizing NM blocking agent MOA Skeletal muscle relaxant: Similar to acetylcholine (Ach), it produces depolarization at the myoneural junction. It has a high affinity for Ach receptor sites and is resistant to acetylcholinesterase, thus producing a more prolonged depolarization. Possesses histamine-releasing properties. Succinylcholine (anectine) Depolarizing NM blocking agent indications