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NUR 2407 Exam 3 Study Guide

Pharm Exam 3 Study Guide

1. Digoxin – client teaching, side/adverse effects, normal Digoxin levels and s/s of Digoxin toxicity digoxin (Lenoxin) ❖ For A-fib and CHF – Slows and strengthens the heart. Hold for HR< ➢ Can be PO or IV (IV must be administered slowly – over 5 minutes). - Narrow therapeutic window 0.5 – 2.0 ng/mL digoxin immune Fab (Digibind) is the antidote. Side/Adverse Effects: N/V, loss of appetite, GI symptoms, malaise S/S Dig toxicity: Visual illusions (white, green/yellow halos around objects, confusion, delirium, PVC’s, cardiac dysrhythmias. Client Teaching: Report HA, Visual Disturbances, seeing Halos. How to take pulse and to hold medication is <60. 2. Potassium levels, considerations and precautions related to levels, and when taking with HCTZ or potassium supplements

Normal K+ = 3.5-5.2mEq/L Critical <2.5mEq/ Hypokalemia <3.5 mEq/L Hyperkalemia >5.2mEq/L S/S – Hypokalemia S/S - Hyperkalemia Cardiac Dysrhythmias , twitching, Muscle weakness, lethargy, Fatigue, paresthesia, dyspnea, anorexia, dysrhythmias. Cramping, diarrhea.

Considerations/Precautions: Hold medication if level is too low. Contraindicated with other thiazides or sulfonamides, anuria. When taking with HCTZ or K+ supplements: Monitor K+ levels (K+ loss is the main concern.) Pt. needs to increase K+ intake for prevention of hypokalemia and dysrhythmias. Foods HIGH in K+: Dark leafy greens (Spinach, Kale, etc), Potatoes with skins, Tomatoes, Dried Apricots, Avocados, Bananas, Mushrooms, Orange/Grapefruit juice, beets, K+ based salt substitutes Strawberries Avoid alcohol, increases risk of OrthoHypo

3. ACE Inhibitor: lisinopril (Zestril)-client teaching All end in -pril

❖ Use: Decrease workload of the heart, decrease BP. Often used in concurrence with thiazide diuretics. ❖ Adverse Effects: Hypotension, orthohypo, Persistent dry cough, angioedema, Hyperkalemia in diabetics , renal failure and with potassium-sparing diuretics.

Client Teaching:

Monitor BP following first dose.

Report dry, non-productive cough is continued for long period. Report decreased taste, intake, or weight loss.

Report sore throat or other infections to MD.

Report angioedema, rash, orthostatic hypotension.

Do NOT use alcohol.

NSAIDS decrease efficiency. Avoid foods high in K+ or K+ supplements.

4. Calcium channel blockers (nifedipine) – client teaching

❖ Use: Controls HTN and angina. Dilates coronary arteries , decreases HR, BP. ❖ Adverse Effects: HA (due to Vasodilation), constipation, peripheral edema, rebound Hypotension.

Client Teaching:

Avoid grapefruit juice (increases concentration of meds in blood). Avoid Calcium based Antacids (decreases effects of CCBs).

Avoid caffeine, aspirin, St. John’s Wort, laxatives.

Educate pt on how to properly take pulse, notify MD <50pbm. Change positions slowly.

Maintain good oral hygiene to prevent gingival hyperplasia.

Report any angina.

Wear sunscreen when outside,

5. Nitroglycerin – client teaching, side/adverse effects, contraindications

❖ Use: Reduce angina. Short acting for acute, long acting for severe recurrent episodes.

Side/Adverse Effects: Dizziness, HA (dilation of cerebral vessels), Hypotension, Reflex Tachycardia, flushing, blurred vision

Contraindications: Do not give to pt with hypotension, high intracranial pressure, head trauma, or taking ED medications due to synergistic effect. Client Teaching: Only take 1 SL q 5 min b/c of rapidly dropping BP – up to 3!! Sit down and rest. If not effective, call EMS. Change positions slowly. Do not drink alcohol while taking this med. HA is normal side effect. Keep meds in original dark container due to deactivation and avoid exposure to air or moisture. Transdermal patches should be removed at night (6-12 hours) to prevent tolerance. Avoid aspirin and antihistamines.

6. Beta-blockers atenolol (Tenormin), metoprolol (Lopressor, Toprol-XL) – nursing considerations, side effects ❖ Use: Decreases HR and BP. Treats heart failure and dysrhythmia due to HTN and angina.

Side/Adverse Effects: Based on inhibition of fight-or-flight response

Decreased HR. Hypotension Bronchoconstriction fatigue and activity intolerance as HR is less responsive with exertion insomnia ED Pulmonary edema mental status changes increased liver enzymes drug induced lupus syndrome Nursing Considerations:

Monitor BP, hold if HR <60 or SBP <90, Monitor ECG, Pulse while adjusting dose and periodically during therapy Monitor prescription refills Lab work BUN, serum lipoprotein, K+, triglyceride, uric acid levels May increase blood glucose level Contraindicated in respiratory pt. Counteracts with antihistamines and antacids that contain aluminum. S/S of Overdose:

Bradycardia, severe drowsiness/fainting/dizziness, dyspnea, bluish fingernails/palms, seizures. NOTIFY MD STAT!!

7. Alpha-adrenergic blocker – client teaching (prazosin (Minipress)

❖ Use: Decreases BP via vasodilation. ❖ Also decreases LDL, increases HDL ❖ Can also be used to treat BPH: benign prostatic hypotension. Advantage over ACE inhibitors – DOES NOT CAUSE COUGH

Client Teaching:

WATCH FOR ORTHOSTATIC HYPOTENSION (change positions slowly).

Weigh self at least twice weekly and educate how to assess feet and ankles for fluid retention.

Avoid driving due to dizziness/drowsiness.

Monitor nasal congestion. Monitor OTC meds taken in combination with prazosin (NSAIDS, cough/cold/allergy meds).

Notify MD if erections last longer the 4 hours, females if pregnancy is planned.

8. Heparin – lovenox (Enoxaparin), fragmin (Dalteparin), innohep (Tinzaparin) use, client teaching, normal PTT for client not on/on heparin, nursing considerations, antidote ❖ Use: Inhibits blood clotting by inactivating thrombin and several other procoagulant enzymes by inhibiting the aggregation of platelets in the veins. DOES NOT dissolve clots.

Antidote for heparin is Protamine Sulfate

Normal PTT for client not on/on heparin:

NOT on heparin: 25-35 seconds

ON heparin: 70-120 seconds Nursing Considerations:

Heparin dose should be double checked before administration.

Do not use in pt with active bleed, bleeding disorders, severe HTN, recent trauma, or intracranial hemorrhage. Client Teaching:

How to give SubQ shot (rotation of sites, area, report soreness/redness, etc)

May bruise/bleed more at injury. Use electric shaver, don’t blow nose hard, careful when clipping finger/toe nails, etc... )

Report tarry/black stool, blood/pink urine, dizziness, lightheadedness, fainting, severe HA, etc.

9. Coumadin – warfarin (Coumadin) use, client teaching, normal PT/INR for client not on/on warfarin, nursing considerations, antidote

❖ Use: Prevention CVA, TIA, MI, DVT, PE, prosthetic heart valves, indwelling central catheters. Anticoagulant.

Antidote is Vitamin K (INR>5.5, via IV; must be administered slowly)

Normal PT/INR for pt not on/on warfarin:

NOT on warfarin 0.8-1.

ON warfarin 2-

Client Teaching: Avoid foods high in Vitamin K (asparagus, broccoli, cabbage, cauliflower, kale, green tea, gingko, garlic, ginger)

Avoid Cranberry Juice and alcohol Avoid IM injections and activities with potential injuries.

Use a soft toothbrush, do not floss, use electric razor.

Report S.S of bleeding/bruising

Do not take aspirin or NSAIDS, St. John’s wort Advise the importance of having labs done.

Nursing Considerations:

Monitor PT/INR levels frequently

Assess for bleeding Monitor all new prescriptions closely (Antibiotics may alter)

Contraindicated for pt with peptic ulcer or GI bleed

Signs of Anticoagulation toxicity:

Blood in urine, stool, vomit, bleeding gums, excessive bruising.

10. Lidocaine – indications for use

Use: Ventricular Arrhythmias, topical/mucosal/infiltration anesthetic

11. Diuretics – types/examples, timing of dosing, client teaching

LOOP: Examples: furosemide (Lasix), bumetanide (Bumex) MOST POTENT High risk for dehydration and hypokalemia. Prevents Na+ reabsorption in the loop of Henle which causes rapid/large diuresis and loss of K+ and small amounts of NA and Mg. Reserved for serious HTN or heart failure (decreases preload) NOT used for maintenance. THIAZIDE: Example: Hydrochlorothiazide (HCTZ) Increases excretion of Na and water by inhibiting Na reabsorption in distal tubule. Most common maintenance diuretic. Used to tx of edema, HF, HTN Monitor K+ loss POTASSIUM-SPARING: Example: spironolactone (Aldactone) Weakest of all diuretics Does not block reabsorption of Na. Used when pt is at risk for hypokalemia but need to monitor for hypokalemia. Timing of Dosing: Give Diuretics in the morning to prevent nocturia Client Teaching: Eat foods High in K+. Monitor weight, notify MD if more than 3lb. gin in 1 day. Avoid alcohol Avoid exercise in hot weather. Monitor for rash, muscle weakness, cramps, nausea, dizziness, tingling in extremities. Diabetic pt. monitor blood glucose levels closely.

12. Lipitor – atorvastatin (Lipitor) client teaching, side/adverse effects

❖ Use: Reduce LDLs, increase HDLs

Side/Adverse Effects:

Abdominal cramps, constipation, diarrhea, flatus, heartburn, increased liver enzymes, Rhabdomyolysis (breakdown of muscles leading to renal failure (muscle pain, fever, dark reddish urine). Antineurotic edema.

Client Teaching: Advise pt med should be taken in conjunction with diet restrictions, exercise, and to stop smoking.

Notify MD immediately of muscle weakness, pain or tenderness, instruct importance of follow up appointments to monitor drugs effectiveness. Avoid grapefruit juice.

Administer with food to decrease GI upset.

Take in evening. Optimize biosynthesis.

13. IV atropine – atropine (Atro-Pen) indication for use, what to monitor for, nursing considerations ❖ Use: Sinus Bradycardia, Heart Block, Reversal of Muscarinic effects of Anticholinesterase Agents (an Anticholinergic) or Poisoning. Increases Heart Rate. Monitor For:

Tachycardia, Urinary Retention, (Can’t see, can’t pee, can’t spit, can’t shit).

Assess VS and ECG frequently during IV therapy.

Report any significant changes in HR or BP. Report any increased Ventricular ectopy or Angina to MD.

Monitor I&O.

Assess for abdominal distention, listen for bowel sounds for constipation.

Nursing Considerations: Increase fluids if constipation occurs.

Contraindicated for glaucoma

Notify MD of any significant changes in VS.

Respiratory

14. Steroids – client teaching, side/adverse effects, potential effects on CHF, directions specific to inhalers (beclomethasone (QVAR))

❖ Use: to decrease inflammation of the airway. Tx of asthma, not for rescue. Side/Adverse Effects:

Sore throat, hoarseness, coughing, dry mouth, pharyngeal and laryngeal fungal infections, HA, adrenal suppression (increased dose and long term therapy only), decrease bone mineral density, rhinitis, sinusitis.

Potential effects on CHF:

Use with caution for pt with hx of CHF due to fluid overload. Monitor lungs for crackles.

Directions specific to inhalers:

Prime inhaler. Press down to make sure you will get a full spray. Spray about 4 times. If you have a spacer: place spacer on end of inhaler, press down to allow medication into spacer, breathe all air out of lungs, place mouth around other end of spacer and breathe in deeply, hold breath for about 10 seconds and breathe out.

If NO spacer: hold inhaler about an inch from mouth, blow all the air out of your lungs, spray inhaler and breath in as you spray, hold breath for about 10 seconds and then breathe out.

Rinse mouth when done. Clean mouth piece on inhaler.

15. albuterol (an adrenergic inhaler) – indication for use, mechanism of action, client teaching

❖ Use: Short acting rescue inhaler. Tx of acute asthma attacks, bronchospasms, and prevention of exercise induced asthma. Action:

Beta2 Selective Adrenergic Agonist. Binds to the beta2 Adrenergic receptors in airway smooth muscle, relaxes airway smooth muscle with subsequent bronchodilation.

Client Teaching:

Rescue inhaler should be followed up with maintenance meds.

Take as directed, do not exceed recommended dose Notify MD if SOB is not relieved by med or if accompanied by diaphoresis, dizziness, chest pain or palpitations.

Prime inhaler before first use and discard after 200 sprays.

Advise pt that albuterol may cause an unusual or bad taste or rinse mouth after use.

Use albuterol first if taking other inhalant medications.

16. ipratropium (Atrovent) (an anticholinergic) – side effects, client teaching

❖ Use: Adjunctive management of bronchospasm caused by asthma.

Side/Adverse Effects: Dizziness, HA, blurred vision, sore throat, cough, nervousness, increased HR, dryness, Anticholinergic effects, fatigue, palpitations, urinary retention.

Client Teaching: Instruct on proper use of inhaler, rinse mouth after use,

Perform good oral hygiene.

Chew sugarless gum or candy to minimize dry mouth.

Do not exceed 12 doses in 24 hours.

Notify MD if symptoms are not relieved within 30 minutes after admin of med. Explain importance of pulmonary function tests prior to and during therapy.

Avoid spraying in eyes.

Notify MD if cough, nervousness, HA, dizziness, nausea, or GI upset occurs.

Limit fluids and void before administration due to urine retention.

17. salmeterol (Serevent) – indications for use, timing of dosing, client teaching

❖ Use: To prevent bronchospasm in pt who are not controlled on long term asthma control medication. Prevention of exercise induced bronchospasm, maintenance tx to prevent spasm in COPD including bronchitis and emphysema. Timing of Dosing:

Follows rescue inhaler

Client Teaching:

Do not use this med to treat acute symptoms. Do not use additional salmeterol to prevent exercise induced bronchospasm.

Notify MD if difficulty breathing persists after admin of med.

Mouth piece should be kept dry, do not wash.

Instruct pt to not blow into device and hold it in a level horizontal position. Consult MD before stopping or reducing therapy.

18. montelukast (Singulair) – indications for use, directions for use, client teaching

❖ Uses: Decreases inflammation component of asthma/allergies. o Decreases exercise induces bronchospasm. o Preventative or maintenance (NOT FOR RESCUE). o Management of seasonal rhinitis. o Prevention of exercise induced bronchoconstriction in pt 6 years + Directions for use:

Client Teaching:

Administer in the evening, regardless of presence of symptoms, due to drowsiness.

Use at least 2 hours before exercise even if not experiencing any symptoms.

Do not stop therapy without consult of MD. Do not stop or reduce other asthma medicines, may continue med during acute exacerbation of asthma attack but this med will not provide relief for acute attacks so keep a rapid acting therapy with you at all times.

Monitor for emergence of anxiety, agitation, panic attacks, insomnia, irritability, hostility, mania, or worsening of depression and suicidal ideation.

19. guaifenesin (Robitussin) with dextromethorphan or codeine – indications for use

❖ Use: Anti-tussive, guaifenesin (Mucinex). Indications for use:

Systemic relief of coughs caused by minor upper respiratory tract infections. Most effective for chronic nonproductive cough.

Dextromethorphan is a common ingredient in nonprescription cough and cold preparations. This suppresses the cough reflex by a direct effect on the cough center in the medulla. It is related to opioids structurally but has no analgesic properties.

20. theophylline (Theo-24) – side/adverse effects, client teaching

❖ NARROW THERAPEUTIC WINDOW

❖ Use: Long-term control of reversible airway obstruction caused by asthma or COPD.

Side/Adverse Effects: Seizures, anxiety, HA, arrhythmias, tachycardia, N/V, angina, palpitations, insomnia.

Rarely used due to AE of dysrhythmias (tachycardia), convulsions, cardiorespiratory collapse.

Client Teaching:

Levels must be monitored frequently to prevent adverse reaction.

Only take prescribed dose at the prescribed time. Encourage pt to drink 2,000 milliliters/day minimum to decrease the viscosity of the airway secretions.

Advise pt to notify MD of OTC cough/cold/breathing preparations as some may increase side effects and cause arrhythmias. Discourage smoking.

Advise pt to not eat charcoal broiled foods daily or anything containing foods/drinks (colas, chocolate, coffee). Notify MD if prescribed dose fails to produce desired results or symptoms worsen.

21. Sequences of inhaler use

Prime inhaler. Press down to make sure you will get a full spray. Spray about 4 times.

If you have a spacer: place spacer on end of inhaler, press down to allow medication into spacer, breathe all air out of lungs, place mouth around other end of spacer and breathe in deeply, hold breath for about 10 seconds and breathe out.

If NO spacer: hold inhaler about an inch from mouth, blow all the air out of your lungs, spray inhaler and breath in as you spray, hold breath for about 10 seconds and then breathe out. Rinse mouth when done.

Clean mouth piece on inhaler.

GI

22. metoclopramide (Reglan) – indications for use, mechanism of action

❖ Uses: Antiemetic. Prevention of chemotherapy-induced emesis. Tx of postsurgical and diabetic gastric stasis. Facilitation of small bowel intubation in radiographic procedures. Management of GERD. Tx and prevention of postoperative N/V when nasogastric suctioning is undesirable.

Mechanism of Action: Blocks dopamine receptors in chemoreceptor trigger zone of the CNS.

Stimulates motility of the upper GI tract and accelerates gastric emptying.

23. promethazine (Phenergan) – side effects/adverse effects with prolonged use

Side/Adverse Effects with Prolonged use: Can cause involuntary movements. NMS (Neuroleptic Malignant Syndrome), confusion, disorientation, sedation, blurred vision, tinnitus, EPS (Extrapyramidal Reactions).

24. ondansetron (Zofran) – use, client teaching, nursing considerations, pregnancy teaching

❖ Use: Serotonin blocker. ❖ Prevention of N/V. ❖ N/V associated with chemo/radiation therapy, post-op N/V. Client Teaching:

Take as directed. Notify MD if symptoms of irregular heartbeat, serotonin Syndrome, or involuntary movements of the face, eyes or limbs occur

Nursing Considerations: Assess for N/V, abdominal distention, bowel sounds prior to and after admin, assess for EPS (shuffling walk, facial grimacing, rigidity, trembling of hands).

Monitor ECG in pt with heart failure, Brady arrhythmias or other medications they may take that can prolong QT interval. Monitor for S/S of Serotonin Syndrome.

Pregnancy Teaching:

Category B

Use cautiously in OB, lactation.

Pedi: Safety is not established.

25. atropine (Lomotil) – side/adverse effects, precautions, contraindications, nursing considerations, know what conditions it may make worse

❖ Use: Decrease GI and Respiratory secretions. Side/Adverse Effects:

Slows GI motility, Increased intraocular pressure

Dizziness, confusion, drowsiness, HA, constipation, dry mouth, N/V. blurred vision.

Precautions/ Contraindications:

Severe Liver disease, infectious diarrhea, diarrhea associated with C-diff, dehydrated pt, glaucoma, known alcohol intolerance, pt physically dependent on opioids, inflammatory bowel disease, pregnancy, lactation, children under 12.

Nursing Considerations:

Assess for frequency and consistency of stools and bowel sounds prior to and throughout therapy.

Assess fluid and electrolyte balance.

Check skin turgor for dehydration.

Monitor liver function tests. Know what conditions it may make worse:

GLAUCOMA

26. MOM – side/adverse effects, precautions, nursing considerations

Side/Adverse Effects: Diarrhea, flushing, sweating Precautions: Use cautiously in any degree of renal insufficiency, heart block, active labor or within 2 hours of delivery, hypocalcemia, hypomagnesemia. Nursing Considerations:

Assess for abdominal distention, presence of bowel sounds, usual pattern of bowel function. Assess color, consistency and amount of stool produced.

MOM RUINS ENTERIC COATING ON BISACODYL

27. Management of hyperacidity and constipation in clients with renal failure – best choices for treatment

Fiber supplement, bulk forming. Example; MiraLax

28. pantoprazole (Protonix), omeprazole (Prilosec) PPI (proton pump inhibitors) – indications for use, mechanism of action, client teaching , timing of dosing

❖ Use: Blocks acid production. Indications for Use:

Erosive esophagitis associated with GERD.

Maintenance of healing of erosive esophagitis.

Pathologic gastric hypersecretory conditions. Mechanism of Action:

Binds to an enzyme in the presence of acidic gastric pH. Preventing the final transport of hydrogen ions into the gastric lumen. Client Teaching:

Do NOT crush.

May cause diarrhea.

May enhance other medication, contact MD to get approval. Take before meals.

Avoid alcohol, products containing NSAIDS and foods that may cause increase of GI upset.

Notify MD of onset of black/tarry stools, rash, diarrhea, abdominal cramping, fever.

Timing of Dosing:

Take before breakfast on empty stomach.

**29. OTC antacids and laxatives/stool softeners - client teaching, mechanism of action

30. sucralfate (Carafate) – client teaching, timing of dosing**

❖ Use: Forms viscous covering to coat and protect ulcers. Does not inhibit acid production.

Client Teaching:

Take 30-60 minutes before meals.

If given through NG tube, must be dissolved, not crushed.

Advise pt to take therapy for 4-8 weeks even if feeling better to ensure ulcer healing. Increase fluid intake, dietary bulk, exercise may prevent drug induced constipation.

Explain importance of routine exams to monitor progress. Assess for abdominal pain and frank or occult blood in the stool.

Math – one calculation question involving a bottle of powder that was reconstituted, and how much to give for the ordered dose and concentration available after reconstituted.

Practice Question 1:

The physician orders cefazolin sodium 0.5g IM every 8 hours. The nurse has to reconstitute from a powder. The vial contains 1g with directions “add 2.5 mL sterile water and shake.” Provides a volume of 3 mL (333mg/mL). How many mL of medication will the nurse administer?

Practice Question 2:

The provider has ordered Rocephin 0.5g IM every 8 hours. The nurse has to reconstitute from a powder, a vial containing 1 g with directions to “add 2.3 mL sterile water and shake to create a 1,000 mg in 2.6 mL solution.” How many mL of medication should the nurse administer?

Practice Question 3: The physician orders cefazolin sodium 0.25g IM every 8 hours. The nurse has to reconstitute from a powder. The vial contains 1g with directions “add 2.5mL sterile water and rotate.” This provides a volume of 3 mL (330mg/mL). How many ML of medication will the nurse administer?

Answers to practice questions:

1. 1.5mL

2. 1.3mL
3. 0.75ml