final exam

Antiemetics

Select Prototype Medications

Serotonin antagonists:
  - Ondansetron
  -

Expected Pharmacological Action

  • Antiemetics prevent emesis (vomiting) by:
      - Blocking serotonin receptors in the chemoreceptor trigger zone (CTZ).
      - Antagonizing serotonin receptors on afferent vagal neurons from the upper GI tract to the CTZ.

Therapeutic Uses

  • Prevents emesis related to:
      - Chemotherapy
      - Radiation therapy
      - Postoperative recovery.

  • Off-label uses:
      - Treatment of nausea and vomiting related to pregnancy.
      - Childhood viral gastritis.

  • Administration routes:
      - PO (by mouth)
      - IM (intramuscular)
      - IV (intravenous)

Nursing Actions

  • For Ondansetron:
      - Monitor for headache, diarrhea, dizziness.
      - Treat headaches with non-opioid analgesics.
      - Monitor stool patterns.
      - Be aware of prolonged QT interval which can lead to torsades de pointes (serious dysrhythmia).
      - Monitor ECG in clients with cardiac disorders/out with other QT-prolonging medications.
      - Use cautiously in clients with electrolyte abnormalities.

Warnings, Contraindications/Precautions

  • Pregnancy:
      - Safety not established for ondansetron, metoclopramide, scopolamine.

  • Lactation:
      - Avoid chronic use of promethazine during pregnancy; safety for ondansetron, metoclopramide, scopolamine not established.

  • Specific Contraindications:
      - Ondansetron contraindicated in long QT syndrome clients.
      - Use cautiously for clients with urinary retention/obstruction, asthma, and narrow-angle glaucoma: dopamine antagonists, antihistamines, and anticholinergic antiemetics.

Nursing Administration

  • Antiemetics prevent or treat nausea and vomiting from various causes.

  • Nursing assessments can help identify underlying factors related to the use of appropriate medication.

  • For chemotherapy-induced nausea and vomiting (CINV), administer antiemetics prior to chemotherapy as this is more effective than treating nausea after its onset.

  • Combining three antiemetics is more effective than using a single antiemetic.

Ondansetron Administration

  • Administer IV 1 hour before chemotherapy or PO 1 hour before anesthesia to prevent nausea and vomiting.

  • For clients receiving radiation, administer PO three times daily.

Iron Preparations

Select Prototype Medications

  • Oral:
      - Ferrous sulfate

Expected Pharmacological Action

  • Iron preparations provide iron needed for RBC development and oxygen transport.

  • Iron demand increases during growth (children, pregnancy) or RBC high demand (post blood loss).

  • Since iron is poorly absorbed, large amounts must be ingested to increase hemoglobin (Hgb) and hematocrit (Hct) levels.

Therapeutic Uses

  • Used to treat and prevent iron-deficiency anemia.

Types of Iron Preparations

  • Ferumoxytol: Limited to clients with chronic kidney disease, requires only two doses over 3–8 days.

  • SFGC (Sucrose-Formed Gluconate Complex): Used for long-term hemodialysis clients along with erythropoietin.

  • Iron Sucrose: Used for chronic kidney disease clients on erythropoietin and those not on dialysis.

Complications

  • GI distress (nausea, constipation, heartburn).

Nursing Actions

  • Administer medication with food if intolerable, although this greatly reduces absorption.

  • Monitor the client's bowel patterns and intervene accordingly.

Client Education

  • Stools may turn black or dark green while taking an iron preparation; this resolves with continued use.

  • For liquid form:
      - Dilute with water or juice.
      - Drink with a straw.
      - Rinse mouth after swallowing to prevent teeth staining.

IM Injections

  • Administer deep IM using Z-track technique to avoid staining skin and other tissues.
      - Avoid this route if possible due to risk of complications.

Anaphylaxis

  • Risk with parenteral iron dextran, triggered by dextran, not iron; minimal risk with other forms (SFGC, iron sucrose).
      - IV route is safer than IM.

Nursing Actions

  • Administer test dose and observe closely; administer only slow infusion.

  • Be prepared with life-support equipment and epinephrine.

Hypotension

  • Can progress to circulatory collapse with parenteral administration.

Nursing Actions

  • Monitor vital signs during parenteral iron administration.

Fatal Iron Toxicity in Children

  • Can occur from overdose (2–10 g) of iron.

Nursing Actions

  • Monitor for manifestations such as severe GI symptoms, shock, acidosis, liver, and heart failure.

  • Use chelating agent deferoxamine parenterally to treat toxicity.

  • Gastric lavage can help remove iron from the stomach.

  • Avoid concurrent oral and parenteral iron administration.

Contraindications/Precautions

Warnings

  • Pregnancy:
      - Ferrous sulfate and oral iron dextran are safe; parenteral safety not established.

  • Lactation:
      - Same as pregnancy.

  • Contraindicated for clients with previous hypersensitivity to iron, anemias not from iron deficiency.

  • Caution with clients having peptic ulcer disease, regional enteritis, ulcerative colitis, and severe liver disease.

Interactions

  • Concurrent administration of antacids or tetracyclines reduces iron absorption.

Nursing Actions

  • Avoid antacids within 1 hour after iron administration.

  • Space iron administration 1 to 2 hours apart from tetracycline.

  • Vitamin C increases absorption but does so with GI side effects.

Client Education

  • Avoid caffeine and dairy during medication intake as they reduce iron absorption.

Nursing Administration

Client Education

  • Take iron on an empty stomach (1 hour before meals) for better absorption.

  • If GI side effects occur, take with food although absorption might be affected.

  • Space doses evenly throughout the day for optimal RBC production.

  • For liquid iron:
      - Dilute and drink through a straw to avoid teeth staining.

Folic Acid

Select Prototype Medication

  • Folic Acid

Expected Pharmacological Action

  • Essential for DNA production and erythropoiesis (RBC, WBC, platelets).

Therapeutic Uses

  • Treatment of megaloblastic anemia due to folic acid deficiency.

  • Prevention of neural tube defects in early pregnancies; important for all women of childbearing age.

  • Treatment of malabsorption syndromes (sprue).

  • Supplement for alcohol use disorder (due to poor dietary intake of folic acid, and liver injury).

Contraindications/Precautions

Warnings

  • Pregnancy: Safe

  • Lactation: Use cautiously.

  • Avoid indiscriminate use due to risk of masking vitamin B12 deficiency symptoms.

Interactions

  • Folate levels reduced by methotrexate and sulfonamides.

Nursing Actions

  • Avoid concurrent use with these medications.

  • Folic acid can decrease phenytoin blood levels due to increased metabolism; monitor blood levels.

Nursing Administration & Care

Nursing Care

  • Assess for symptoms of megaloblastic anemia (pallor, easy fatigue, palpitations, paresthesia).

  • Obtain and monitor baseline folic acid, Hgb, Hct levels, RBC, and reticulocyte counts periodically.

Client Education

  • Increase intake of food sources high in folic acid (liver, leafy greens, citrus fruits, dried peas and beans).

  • Monitor risk factors for folic acid therapy need (heavy alcohol use, childbearing age).

Nursing Evaluation of Medication Effectiveness

  • Effectiveness indicated by:
      - Folate levels within reference range.
      - Return to expected RBC, reticulocyte count, Hgb, and Hct levels.
      - Absence of anemia findings (no pallor, dyspnea, or easy fatigue).
      - No neural tube defects in newborns.

Potassium Supplements

Select Prototype Medication

  • Potassium Chloride

Expected Pharmacological Action

  • Essential for nerve impulses conduction, maintaining acid/base balance, and electrical excitability of muscle.

Therapeutic Uses

  • Treat hypokalemia (potassium < 3.5 mEq/L).

  • Address potassium loss via diuretics (e.g., furosemide).

  • Correct potassium loss from prolonged vomiting, diarrhea, excessive laxative use, or GI fistula.

Complications

  • GI ulceration and distress (nausea, vomiting, diarrhea, abdominal discomfort, esophagitis).

Nursing Actions

  • Administer with meals or 8 oz of water to minimize GI complications and prevent ulceration.
      - Important: Do not dissolve the tablet in the mouth to prevent ulceration.

Hyperkalemia

  • Rare with oral administration.

Nursing Actions

  • Monitor IV potassium clients for hyperkalemia manifestations (bradycardia, changes in ECG, etc.).

  • Severe hyperkalemia treatment: Calcium salt, glucose and insulin, sodium bicarbonate, sodium polystyrene sulfonate, peritoneal or hemodialysis.

Contraindications/Precautions

  • Contraindicated for severe kidney disease or hypoaldosteronism.

Interactions

  • Increased hyperkalemia risk with potassium-sparing diuretics (e.g., spironolactone) and ACE inhibitors (e.g., lisinopril).

Nursing Actions

  • Avoid concurrent use with these medications.

  • Absorption may be decreased by oxalates in spinach/rhubarb and phytates in bran/whole grains.

Nursing Administration

Oral Formulations

  • Mix powdered formulations in at least 90–240 mL of cold water or juice; drink slowly.

  • Effervescent tablets should be dissolved in 90–240 mL of cold water.

Client Education

  • Administer potassium chloride with meals or at least 8 oz of water to prevent GI adverse effects.

  • Do not crush or chew extended-release tablets; notify the provider if swallowing is difficult.

Magnesium Sulfate

Select Prototype Medication

  • Parenteral: Magnesium Sulfate

Expected Pharmacological Action

  • Activates many intracellular enzymes, binds mRNA to ribosomes, regulates muscle contractility and blood coagulation.

Therapeutic Uses

  • Magnesium supplements for clients with hypomagnesemia (magnesium < 1.3 mEq/L).

  • Oral magnesium for low magnesium levels and laxative use.

  • Parenteral magnesium for severe hypomagnesemia; IV for stopping preterm labor/anticonvulsant during labor.

Complications

  • Muscle weakness, flaccid paralysis, painful contractions, suppression of AV conduction, respiratory depression.

Nursing Actions

  • Monitor cardiac and neuromuscular status cautiously during IV administration.

  • Monitor blood magnesium levels.

  • Do not administer with neuromuscular-blocking agents to avoid respiratory issues.

  • Have calcium gluconate on hand to reverse magnesium effects.

Contraindications/Precautions

Warnings

  • Pregnancy: Avoid administering magnesium sulfate within 2 hours of delivery.

  • Lactation: Present in breast milk; monitor for toxicity.

  • Contraindicated for clients with AV block, rectal bleeding, nausea, vomiting, and abdominal pain.

  • Use carefully in renal/cardiac disease patients.

Interactions

  • Magnesium sulfate reduces absorption of tetracyclines and digoxin; monitor therapeutic effects.

Nursing Administration

Nursing Care

  • Monitor blood magnesium, calcium, phosphorus levels, blood pressure, heart rate, and respiratory rate during IV administration.

  • Assess for depressed/absent reflexes as signs of toxicity; always have calcium gluconate ready.

Client Education

  • Educate on dietary magnesium sources (whole grain cereals, nuts, legumes, green leafy vegetables, bananas).

Hormonal Contraceptives

Estrogen-Progestin Combinations

  • Combination oral contraceptives (OCs) contain estrogen and progestin.

  • Progestin-only OCs are known as mini-pills.

  • Combination OCs can be:
      - Monophasic: The dosage remains constant throughout the cycle.
      - Biphasic, Triphasic, Quadriphasic: The estrogen/progestin ratios are adjusted within the cycle to mimic normal menstrual cycles.

Select Prototype Medications

  • Combination OCs:
      - Ethinyl estradiol and norethindrone
      - Ethinyl estradiol and drospirenone

  • Progestin-only OC:
      - Norethindrone

  • Transdermal Patch:
      - Ethinyl estradiol and norelgestromin

  • Vaginal Contraceptive Ring:
      - Ethinyl estradiol and etonogestrel

  • Parenteral:
      - Depot medroxyprogesterone acetate (IM and subcutaneous use)

  • Etonogestrel Implants

  • Hormonal IUD

Expected Pharmacological Action

  • Oral contraceptives prevent conception by:
      - Inhibiting ovulation
      - Thickening cervical mucus
      - Altering the endometrial lining to reduce fertilization chances.

Therapeutic Uses

  • Prevention of pregnancy

  • Treating:
      - Premenstrual Dysphoric Disorder (PDD)
      - Acne
      - Fibrocystic breast disease
      - Leiomyomas (to manage discomfort/bleeding)
      - Reducing menstrual blood loss to help iron deficiency anemia
      - Alleviating dysmenorrhea by reducing menstrual cramping
      - Protection against endometrial and ovarian cancers.

Complications

Thromboembolic Events

  • Risks include myocardial infarction (MI), pulmonary embolism, thrombophlebitis, stroke; less likely with progestin-only OCs.

Client Education

  • Advise against smoking.

  • Report warmth, edema, tenderness, or pain in lower legs, chest pain, shortness of breath, severe headache.

Hypertension
Client Education

  • Monitor and report high blood pressure and vision changes.

Breakthrough or Irregular Uterine Bleeding
Client Education

  • Track the duration and frequency of breakthrough bleeding.

  • Evaluate for pregnancy if 2 or more menstrual periods are missed.

Breast Cancer
Nursing Actions

  • Avoid use with clients having or suspected to have breast cancer.

Hyperglycemia
Nursing Actions

  • Monitor glucose levels in diabetic clients; adjust antihyperglycemics as needed.

Hyperkalemia
Nursing Actions

  • Do not use combination OCs with drospirenone in clients at risk for hyperkalemia (renal/adrenal insufficiency).

Contraindications/Precautions

Warnings

  • Pregnancy: Contraindicated for hormonal contraceptives; progestin-only is safe.

  • Lactation: Combination OCs contraindicated; progestin-only is safe.

  • Reproductive Health: Notify provider if pregnancy is planned or suspected.

  • Contraindicated for clients who are:
      - Smokers older than 35 years
      - Have a history of thrombophlebitis/cardiovascular events
      - Have suspected/known breast cancer
      - Have liver conditions
      - Experience abnormal vaginal bleeding

  • Use cautiously:
      - Hypertension
      - Diabetes mellitus
      - Gallbladder disease
      - Uterine leiomyoma
      - Seizures
      - Migraine headaches.

Interactions

  • Effectiveness may decrease with carbamazepine, phenobarbital, ritonavir, rifampin, St. John's wort.

  • Some sources suggest that antibiotics may decrease oral contraceptive effectiveness.

Nursing Actions

  • Suggest secondary birth control method during antibiotic therapy for clients using hormonal contraceptives.

  • Oral contraceptives can decrease effects of:
      - Warfarin
      - Oral hypoglycemics.

Nursing Actions

  • Monitor INR, PT, and glucose levels; provider may adjust dosages as necessary; monitor for breakthrough bleeding.

  • Oral contraceptives can increase effects of:
      - Theophylline
      - Imipramine
      - Tricyclic antidepressants
      - Chlordiazepoxide
      - Diazepam

Nursing Actions

  • Monitor for toxicity signs; provider may need to decrease dosage.

Nursing Administration

  • Nurses/administering personnel of childbearing age should avoid direct handling of hormonal medications to minimize reproductive system effects.

  • Rule out pregnancy before starting therapy.

Dosing

  • Most combination OCs administered cyclically in a 28-day regimen; extended-cycle OCs taken longer than 28 days.

  • Typical cycle: 84 days with 4 days of withdrawal bleeding.

  • For IM/subcutaneous contraception, administer under conditions indicating the patient is not pregnant (6 weeks postpartum if breastfeeding exclusively or within first 5 days postpartum if not).

Client Education

  • Quit smoking.

  • Report abdominal pain, chest pain, severe headaches, vision problems, or severe leg pain/swelling.

  • Take pills daily at the same time.

  • Traditional 28-day regimen: Take for 21 days, followed by 7 days of no medication (placebo if using inert pills).

  • For missed pills in first week: Take one pill as soon as possible; use backup contraception for 7 days.

  • For missed pills in second or third week: Take one pill as soon as possible, continue with active pills, skip placebo, and start the next pack.

  • For transdermal patches: Apply to the lower abdomen, upper arm, torso, or buttock; place a new patch weekly for 3 weeks, omit during the fourth week.

  • For vaginal rings: Insert and keep for 3 weeks, then remove for the fourth week. If out for more than 3 hours, use backup contraception for the next 7 days.

  • For contraceptive implants: Insert under the skin in the inner upper arm and change every 3 years.

  • IUDs replaced according to type (between 3–10 years, depending on the device type).