ATI Pharmacology Exam

1) Sucralfate (mucosal protectant) —> forms a protective barrier over ulcers

2) Gentamicin, Cefazolin, Furosemide 

3) Zolpidem —> short-term treatment of insomnia

4) Fentanyl, Morphine

5) Diazepam toxicity = respiratory depressetion and hypotension —> flumazenil —> reverse effects 

6) levothyroxine (thyroid hormone) —> used to treat clients who have hypothyroidism with adverse effects including nervousness, irritability, diaphoresis, tachycardia, and laboratory findings of decreased thyroid stimulating hormone and elevated thyroid hormone levels (T3/T4) 

7) Beclomethasone (glucocorticoid inhalers)  —> rinse your mouth to prevent oroppharengeal candidiasis and hoarseness, albuterol inhalers 

8) Gentamicin (amino glycoside) —> nephrotoxicity adverse affect, acetaminophen

9) heparin —> subcutaneous injection at least 2 inches away from the umbilicus 

10) Fluphenazine (antipsychotic medication) —> Side effect neuroleptic malignant syndrome, , dantrolene/bromocriptine —> relieve muscle rigidity and decrease body temperature 

11) isotretinoin —> teratogenic effects (pregnancy list)

12) Nitroglycerin (remove patch each evening for a medication free time before applying an new one to avoid developing a tolerance to the medication’s effectiveness 

13) Oral contraceptives, carbamazepine causes an accelerated inactivation of oral contraceptives because of its action on hepatic medication - metabolizing enzymes 

14) Hydrochlorothiazide (antihypertensive thiazide diuretic) —> adverse effect orthostatic hypotension and light headedness 

15) Asprin —> salicylate poisoning or respiratoratory alkalosis 

16) Allopurinol —> treatment of gout and eliminated through the kidneys 

17) Hydrochlorothiazide (thiazide diuretic administered to promote urine output and reduce blood pressure and edema) —> obtain blood pressure prior to administration of the medication 

18) nitroglycerin is used for angina —> check blood pressure 

19) Atropine —> anticholinergic agent to reverse cholinergic toxicity 

20) Ciprofloxacin (quinolone antibiotic)—>  tendonitis is a contraindication due to risk of tendon rupture 

21) haloperidol —> used for schizophrenia, and is a neuroleptic malignant syndrome (fever, respiratory distress, diaphoresis, and either hyper or hypotension 

22) Propranolol, incident report should be clearly and thoroughly report the facts of the error 

23) tamoxifen —> adverse effects include hot flashes because tamoxifen blocks the estrogen receptors 

24) Morphine —> administered for pain assessed by patient description 

25) dopamine (adrenergic) —> effective if it causes a receptor specificity effect that increases cardiac output and improves perfusion 

26) atropine —> effective if eye drops cause blurred vision because of cycloplegia effects that can cause near objects to appear blurry to the client 

27) insulin —> should be stored in the refrigerator and once opened can remain at room temperature for up to 1 month 

28) Dosage calc 

29) nitroglycerin —> the client should remove the patch after 12-14 hr to prevent medication tolerance 

30) Digoxin —> monitor for and report yellow tinged vision which is a sign of digoxin toxicity 

31) metformin, metoclopramide —> metformin puts the client at risk for hypoglycemia and the nurse should monitor the client’s blood glucose and provide the client with a snack to reduce the risk for hypoglycemia 

32) Fluoxetine —> suppresses platelet aggregation which increases the risk of bleeding when used concurrently with NSAIDs and anticoagulants (take acetaminophen instead) 

33) Magnesium, calcium gluconate —> prepare to provide ventilatory support and client is at risk for respiratory depression and cardiac dysrhythmias (magnesium gluconate is administered to treat hypomagnesemia) 

34) ceftriaxone —> risk for anaphylaxis including urticaria and dyspnea requiring discontinuation of the infusion 

35) calcium gluconate —> used for hypocalcemia, but can cause hypercalcemia which increases risk for digoxin toxicity 

36) filgrastim —> stimulates the bone marrow to produce neutrophils and decrease risk of infection with increased neutrophil count 

37) spironolactone —> monitor client’s potassium level as spironolactone is a potassium sparing diuretic that can cause hyperkalemia 

38) The nurse has the responsibility to verify that the client understands the risks of refusing the medication so that an informed decision can be made. The nurse should then document the refusal in the client’s medical record and notify the health care provider. 

39) methadone —> administer methadone for treatment of opioid use disorder that can be used for widthrdwl and to assist with maintenance and suppressive therapy 

40) dosage calc 

41) famotidine —> used to treat gastric ulcers, famotidine can be hepatotoxic and cause jaundice. The nurse should instruct the client to monitor for an report yellowing of skin or eyes to the provider 

42) epoetin alfa —> used to treat anemia and nurse should monitor for increased blood pressure, the therapeutic effect of epoetin alfa is an increase in hematocrit levels, which can result in an increase in a client’s blood pressure. If the client’s hematocrit level rises too rapidly, hypertension, and seizures can result. The nurse should monitor the client’s blood pressure and ensure hypertension is controlled prior to administering them medication 

43) The nurse should ask the provider to spell out the name of the medication if the stated name is one the nurse is not familiar with. 

44) Oxybutynin (anticholinergic) —> taken for urinary incontinence and can cause dry mouth, dry eyes, and blurred vision 

45) Mannitol (osmotic diuretic) —> adverse effects include precipitated heart failure and pulmonary edema therefore the nurse should recognize lung crackles as an indicator of a potential complication and stop the infusion 

46) cyclobenzaprine —>  a client should taper off cyclobenzaprine before discontinuing it to prevent abstinence syndrome or rebound insomnia 

47) fentanyl patches —> constipation is an adverse effect of opioid use, stool softeners can decrease the severity of this adverse effect 

48) chlordiazepoxide —>  a client should take chlordiazepoxide to prevent delirium tremens during acute alcohol withdrawal 

49) haloperidol —> an adverse effect associated with haloperidol is the development of extrapyramidal manifestations such as dystonia, pseudoparkinsonism, and akathisia ie. Restlessness 

50) risedronate —> used for the treatment of osteoporosis and user should sit upright for at least 30 minutes after taking risedronate will reduce the adverse gastrointestinal effects of esophagitis and dyspepsia, Risedronate is contraindicated for a client who cannot sit or stand upright for this length of time 

51) oral transmucosal fentanyl raspberry flavored lozenges —> the nurse should instruct the client to store unused, used, or partially used medication sticks in the safe storage container that comes in the kit when medication is initially prescribed 

52) Cromolyn sodium —> stabilizes mast cells which inhibit the release of histamine and other inflammatory mediators. The client should use cromolyn 10-15 minutes before planning to exercise to prevent bronchospasmss 

53) The nurse should identify that an antibiotic can be administered 30 minutes before or after the scheduled time to maintain therapeutic blood levels without requiring and incident report 

54) diltiazem (calcium channel blocker) —> cardio-suppressant effects at the Sa and Av nodes which can lead to bradycardia. The client should check their heart rate before taking the medication and notify the provider if it falls below the expected reference range 

55) The nurse should conduct medication reconciliation anytime the client is undergoing a change in care, such as admission, transfer from one unit to another or discharge. A complete listing of all prescribed and over the counter medications should be reviewed 

56) Digoxin is taken for heart failure —> the nurse should notify the provider if a client has hypokalemia prior to administration of digoxin due to the increased risk of developing digoxin toxicity and cardiac dysrhythmias 

57) decussate sodium —>  is a surfactant that softens stool by reducing surface tension, allowing water to penetrate the stool more easily, reduces surface tension of the stools to change their consistency 

58) clozapine —> the nurse should review the client’s total cholesterol before administering clozapine because this medication can cause hyperlipidemia 

59) furosemide —>  used for heart failure and is an indication of hypokalemia which creates U waves as a manifestation of hypokalemia, and adverse effect of furosemide 

60) A nurse should identify that the client is developing hypoglycemia and experiencing a complication with the central venous line. Hypoglycemia can occur if TPN is stopped abruptly. A CVAD can become occluded or infected. Findings of a CVL complication can include difficulty flushing, pain while flushing, fever, or chills. 

• Isotretinoin is teratogenic. Therefore, it is contraindicated in women of childbearing age who are not taking oral contraceptives. If sexually active, the client must agree to use two forms of effective contraception for 1 month before and during treatment, and at least 1 month following treatment.

Oral contraceptive effectiveness decreases with use of carbamazepine, phenobarbital, ritonavir, rifampin, St. John Wort. Some sources suggest that antibiotics can decrease the effectiveness of oral contraceptives.

Achilles tendon rupture

Client education

• Observe for and report pain, swelling, and redness at the Achilles tendon site.

• Stop taking ciprofloxacin and avoid exercise until the inflammation subsides.

Tamoxifen —> endometrial cancer warn clients about adverse effects of tamoxifen including hot flashes 

Anticholonergics (atropine ophthalmic solution) provide mydriasis (dilation of the pupil) and cycloplegia (ciliary paralysis) for examinations and surgery Client Education: Adverse effects include reduced accommodation, blurred vision, and photophobia. 

Cardiac glycosides: digoxin has CNS effects that include fatigue, weakness, vision changes (blurred vision, yellow-green or white halos around objects), monitor for these effects and report to the provider if they occur 

Priority interventions and nursing actions for allergy include • Before administering any medications, obtain a complete medication and allergy history.

• Administer diphenhydramine to treat mild rashes and hives, and to decrease angioedema and urticaria.

• Monitor closely if a client is receiving a medication known to be highly allergenic.

• Provide rapid intervention including epinephrine administration for severe allergic reaction. Notify the Rapid Response team if anaphylaxis is suspected.

• Remove or prevent further exposure to the allergen.

• Treat anaphylaxis with epinephrine, bronchodilators, and antihistamines. Provide respiratory support and notify the provider.

• Monitor ABGs and administer inhaled beta-adrenergic agonists (albuterol). The client can require intubation or a tracheostomy for severe manifestations.

• Monitor hemodynamic status. The client usually experiences extensive vasodilation and capillary leak (tachycardia, weak pulse).

• Monitor the client frequently, as manifestations can recur as treatment wears off.

Safety/Risk Reduction QS

• Look first for a safety risk. For example, is there a finding that suggests a risk for airway obstruction, hypoxia, bleeding, infection, or injury?

• Next ask, “What’s the risk to the client?” and “How significant is the risk compared to other posed risks?”

• Give priority to responding to whatever finding poses the greatest (or most imminent) risk to the client’s physical well-being.

Erythropoietic growth factors (epoetin alfa: erythropoietin) complications Hypertension

Secondary to elevations in hematocrit level

Nursing actions: Monitor Hgb levels and blood pressure. If elevated, administer antihypertensive medications.

Muscarnaric antagonist : oxybutynin complications include anticholinergic effects such as Constipation, dry mouth, blurred vision, photophobia, dry eyes, tachycardia, anhidrosis

Client Education: Increase dietary fiber, consume 2 to 3 L/day fluid from beverage and food sources, sip fluids, and avoid driving or other hazardous activities if vision is impaired.

Contraindications for mannitol (osmotic diuretic) include heart failure, pulmonary edema and Nursing actions: If manifestations of heart failure develop (dyspnea, weakness, fatigue, distended neck veins, and/or weight gain), stop the medication immediately, and notify the provider.

Adverse effects of fentanyl patch (opioid agonist ie. Morphine) include Constipation

Nursing Actions

• Teach the client to increase fluid/fiber intake and physical activity.

• Administer a stimulant laxative (bisacodyl) to counteract decreased bowel motility, or a stool softener (docusate sodium) to prevent constipation.

• For clients who have end-stage disorders (cancer or AIDS), administer an opioid antagonist (methylnaltrexone) designed to treat severe constipation in opioid-dependent clients.

Adverse effects of haloperidol (first generation antipsychotics ie. Chlorpromazine) that control mainly positive manifestations of psychotic disorders including hallucinations, delusions, and bizarre behavior) 

Akathisia

The client is unable to stand still or sit, and is continually pacing and agitated.

Nursing Actions

• Observe for akathisia within 2 months of the initiation of treatment.

• Manage effects with beta blocker, benzodiazepine, or anticholinergic medication 

Documenting effectiveness of filgrastim (leukopoietic growth factor) therapy Expected pharmacological action: Leukopoietic growth factors stimulate the bone marrow to increase production of neutrophils.

Therapeutic Uses

• Decreases the risk of infection in clients who have neutropenia, from cancer and other conditions

• To build up numbers of hematopoietic stem cells prior to harvesting for autologous transplant

Therapeutic effect of chlordiazepoxide (benzodiazepines) first line treatment for alcohol withdrawal (include chlordiazepoxide, diazepam, lorazepam) with intended effects: • Maintenance of vital signs within expected limits

• Decrease in the risk of seizures

• Decrease in the intensity of withdrawal manifestations

• Substitution therapy during alcohol withdrawal

Client teaching about sucralfate (mucosal protectant) Expected Pharmacological Action

• The acidic environment of the stomach and duodenum changes sucralfate into a protective barrier that adheres to an ulcer. This protects the ulcer from further injury from acid and pepsin.

• This viscous substance can stick to the ulcer for up to 6 hr.

• Therapeutic Uses

• Treatment of acute duodenal ulcers and maintenance therapy.

Teaching a client who is taking zolpidem (nonbenzodiazepines) that Enhance the action of GABA in the CNS. This results in prolonged sleep duration and decreased awakenings. These medications do not function as antianxiety, muscle relaxant, or antiepileptic agents. There is a low risk of tolerance, substance use disorder, and dependence.

Therapeutic Uses: Short-term management of insomnia

Glucocoorticoids (prednisolone, beclomethasone) prevent inflammation, suppress airway mucus production and promote responsiveness of beta 2 receptors in the bronchial tree with reduction in airway mucosa edema. The use of glucocorticoids does not provide immediate effects but rather promotes decreased frequency and severity of exacerbations and acute attacks. Clients should be taught to rinse mouth or gargle with water after use • Monitor for redness, sores, or white patches and report to provider if they occur. Treat candidiasis with nystatin oral suspension.

• Use a spacer with inhaler.

Application of nytroglycerin patch (organic nitrates) that dilate veins, decrease venous return (preload), which decreases cardiac oxygen demand, prevents or reduces coronary artery spasm, thus increasing oxygen supply. Oxygen demand is not decreased. Patches are used for long-term prohphylaxisis against anginal attacks and patches should not be cut to ensure appropriate dose, • Place the patch on a hairless area of skin (chest, back, or abdomen) and rotate sites to prevent skin irritation.

• Remove old patch, wash skin with soap and water, and dry thoroughly before applying new patch.

• Remove the patch at night to reduce the risk of developing tolerance to nitroglycerin. Be medication-free between 10 and 12 hr/day. 

(colchicine —> anti-inflammatory agents / antigout medications) 

Allopurinol —> agent for hyperuricemia, for clients who have chronic gout or frequent gout attacks and inhibit uric acid production, probenecid inhibits uric acid reabsorption by renal tubules . Aide effects of allopurinol include hypersensitivity syndrome, fever, rash, and kidney/liver damage Nursing Actions: If administering IV, stop infusion. Severe reaction can require hemodialysis or glucocorticoids.

Kidney injury

Nursing Actions: Alkalinize the urine and encourage intake of 2 to 3 L of fluids/day. Monitor I&O, BUN, and creatinine.

Client self administration of nitroglycerine patch • To ensure appropriate dose, patches should not be cut.

• Place the patch on a hairless area of skin (chest, back, or abdomen) and rotate sites to prevent skin irritation.

• Remove old patch, wash skin with soap and water, and dry thoroughly before applying new patch.

• Remove the patch at night to reduce the risk of developing tolerance to nitroglycerin. Be medication-free between 10 and 12 hr/day. QEBP

Evaluating client understanding of fluoxetine (selective serotonin reuptake inhibitors/ssri antidepressants): including caution for GI bleeding GI bleeding

Nursing Actions: Use caution in clients who have a history of GI bleed or ulcers and in clients taking other medications that affect blood coagulation.

Client Education: Report indications of bleeding (dark stool, coffee-ground emesis).

Teaching for cyclobenzaprine (hepatic toxicity with tizanidine) is a tricyclic antidepressant that helps to treat muscle pain and stiffness caused by muscle spasms and has a physical dependence from long term chronic use, do not discontinue the medication abruptly 

Teaching about oral transmucosal fentanyl (opioid agonist) • Assess pain level on a regular basis. Document the client’s response. QEBP

• Take baseline vital signs. If the respiratory rate is less than 12/min, notify the provider and withhold the medication.

• Follow controlled substance procedures.

• Double-check opioid doses with another nurse prior to administration.

• Administer IV opioids slowly over 4 to 5 min. Have naloxone and resuscitation equipment available.

• Warn clients not to increase dosage without consulting the provider.

• For clients who have cancer, administer opioids on a fixed schedule around the clock. Administer supplemental doses as needed.

• Advise clients who have physical dependence not to discontinue opioids abruptly. Opioids should be withdrawn slowly, and the dosage should be tapered over a period of 3 days.

• Closely monitor patient-controlled analgesia (PCA) pump settings (dose, lockout interval, 4-hr limit). Reassure clients regarding safety measures that safeguard against self-administration of excessive doses. Encourage clients to use PCA prophylactically prior to activities likely to augment pain levels.

• When switching clients from PCA to oral doses of opioids, make sure the client receives adequate PCA dosing until the onset of oral medication takes place.

• The first administration of a transdermal fentanyl patch will take several hours (up to 24 hours) to achieve the desired therapeutic effect. Administer short-acting opioids as needed prior to onset of therapeutic effects and for breakthrough pain.

Medication to prevent excise induced bronchospasm  include anti-inflammatory agents that are for prophylaxis’s and used to decrease airway inflammation such as mast cell stabilizers including cromolyn 

Evaluating client understanding of diltiazem (calcium channel blocker • Blocking of calcium channels in blood vessels leads to vasodilation of peripheral arterioles and arteries/arterioles of the heart.

• Blocking of calcium channels in the myocardium, SA node, and AV node leads to a decreased force of contraction, decreased heart rate, and slowing of the rate of conduction through the AV node.

• These medications act on arterioles and the heart at therapeutic doses.

• Veins are not significantly affected.

  • For IV administration of verapamil, administer injections slowly over a period of 2 to 3 min.

• Teach clients to monitor blood pressure and heart rate, as well as keep a blood pressure record. Withhold medication and notify provider for pulse less than 50/min and systolic blood pressure less than 90 mm Hg.

Teaching about decussate sodium (surfactant laxative) 

Expected Pharmacological Action: Surfactant laxatives lower surface tension of the stool to allow penetration of water. This softens the stool so it can be passed more easily.

Therapeutic uses

• Treatment of constipation.

• Softening of fecal impaction.

Review laboratory results prior to administering clozapine The first atypical antipsychotic developed. Despite its effectiveness for schizophrenia spectrum disorders, it is no longer considered a first-line medication because of its serious adverse effects.

FORMULATIONS: Tablets, orally disintegrating tablets

COMPLICATIONS

• Low risk of EPS

• High risk of weight gain, diabetes mellitus, dyslipidemia

• Agranulocytosis can occur. Obtain baseline WBC and monitor weekly, bi-weekly, to monthly per protocol.

• Monitor for indications of infection (fever, sore throat, lesions in mouth), and notify the provider if manifestations occur.

• Other adverse effects: sedation, hypersalivation, orthostatic hypotension, and anticholinergic effects

• Pregnancy Risk Category B

Identifying client data that requires immediate follow-up for aminoglycosides (gentamicin) or bactericidal antibiotics that destroy micro-organisms by disrupting protein synthesis 

Nephrotoxicity

Due to high total cumulative doses resulting in acute tubular necrosis (proteinuria, casts in the urine, dilute urine, elevated BUN, elevated creatinine)

Nursing actions

• Monitor I&O, BUN, and creatinine.

• Report hematuria and cloudy urine.

Actions to take for a client who is experiencing serious adverse effects of fluphenazine (first generation antipsychotics). Neuroleptic malignant syndrome, Life-threatening medical emergency.

Manifestations include sudden high-grade fever, blood pressure fluctuations, dysrhythmias, muscle rigidity, diaphoresis, tachycardia, and change in level of consciousness developing into coma. QS

Nursing Actions

• Stop antipsychotic medication.

• Monitor vital signs.

• Apply cooling blankets.

• Administer antipyretics (aspirin, acetaminophen).

• Increase fluid intake.

• Administer diazepam to control anxiety.

• Administer dantrolene and bromocriptine to induce muscle relaxation.

• Administer medication as prescribed to treat dysrhythmias.

• Assist with immediate transfer to intensive care.

• Wait 2 weeks before resuming therapy. Consider switching to an atypical agent

Preparing to administer medications via various routes: Transdermal

Medication in a skin patch for absorption through the skin, producing systemic effects

Client Education

• Apply patches as prescribed to ensure proper dosing.

• Wash the skin with soap and water and dry it thoroughly before applying a new patch.

• Place the patch on a hairless area and rotate sites to prevent skin irritation.

Preventing IV Infections

• Perform hand hygiene before and after handling IV systems.

• Use standard precautions.

• Change IV sites according to the facility’s policy (usually every 72 hr).

• Replacement of the administration set is dependent upon the type of infusion. Administration sets with a continuous infusion of fluids with or without secondary fluids should be changed every 96 hr. Intermittent infusions should be changed every 24 hr. Some products (blood) or medications (propofol) should be changed more frequently, according to facility policy.

• Remove catheters as soon as there is no clinical need for them.

• Replace catheters when suspecting any break in surgical aseptic technique (during emergency insertions).

• Use a sterile needle or catheter for each insertion attempt.

• Avoid writing on IV bags with pens or markers, because ink can contaminate the solution.

• Change tubing immediately for potential contamination.

• Do not allow fluids to hang for more than 24 hr unless it is a closed system (pressure bags for hemodynamic monitoring).

• Wipe all ports with alcohol or an antiseptic swab before connecting IV lines or inserting a syringe to prevent the introduction of micro-organisms into the system.

• Never disconnect tubing for convenience or to reposition the client.

Intravenous therapy 

Intraprocedure

Nursing Actions

• Apply a clean tourniquet or blood pressure cuff (especially for older adults) 10 to 15 cm (4 to 6 in) above the insertion site to compress only venous blood flow.

• Select the vein by using visualization, gravity, fist clenching, friction with the cleaning solution, or heat, and choose

  • Distal veins first on the nondominant hand

  • A site that is not painful or bruised and will not interfere with activity

  • A vein that is resilient with a soft, bouncy sensation on palpation

  • Avoid the following:

    • Varicose veins that are permanently dilated and tortuous

    • Veins in the inner wrist with bifurcations, in flexion areas, near valves (appearing as bumps), in lower extremities, and in the antecubital fossa (except for emergency access)

    • Veins in the back of the hand

    • Veins that are sclerosed or hard

    • Veins in an extremity with impaired sensitivity (scar tissue, paralysis), lymph nodes removed, recent infiltration, a PICC line, or an arteriovenous fistula or graft

    • Veins that had previous venipunctures

• Untie the tourniquet or deflate the blood pressure cuff.

• Cleanse the area at the site using friction in a circular motion from the middle and outwardly with chlorhexidine or the cleaning agent the facility’s protocol specifies. Allow it to air dry for 1 to 2 min.

• Remove the cover from the catheter, grasp the plastic hub, and examine the device for smooth edges.

• Retie the tourniquet or reinflate the blood pressure cuff.

• Place the extremity in a dependent position (below the level of the heart).

• Ask the client to slowly open and close their fist.

• Anchor the vein below the site of insertion.

• Pull the skin taut and hold it.

• Warn the client of a sharp, quick stick.

• Use a steady, smooth motion to insert the catheter into the skin at an angle of 10° to 30° with the bevel up.

• Advance the catheter through the skin and into the vein, maintaining a 10° to 30° angle. A flashback of blood will confirm placement in the vein.

• Lower the hub of the catheter close to the skin to prepare for threading it into the vein approximately 0.6 cm (0.24 in).

• Loosen the needle from the catheter and pull back slightly on the needle so that it no longer extends past the tip of the catheter.

• Use the thumb and index finger to advance the catheter into the vein until the hub rests against the insertion site.

• Stabilize the IV catheter with one hand and release the tourniquet or blood pressure cuff with the other.

• Apply pressure approximately 3 cm (1.2 in) above the insertion site with the middle finger and stabilize the catheter with the index finger.

• Remove the needle and activate the safety device.

• Maintain pressure above the IV site and connect the appropriate equipment to the hub of the IV catheter.

• Apply a dressing and leave it in place until catheter removal, unless it becomes damp, loose, or soiled.

• Avoid encircling the entire extremity with tape and taping under the sterile dressing.

• For a continuous IV infusion, regulate the infusion rate according to the prescription.

• Dispose of used equipment and supplies.

• Document the following in the medical record:

  • The date and time of insertion

  • The insertion site and appearance

  • The catheter’s size

  • The type of dressing

  • The IV fluid and rate

  • The number, locations, and conditions of previously attempted catheterizations

  • The client’s response

Guidelines for safe IV medication administration 

• Use an infusion pump to administer medications that can cause serious adverse reactions. Never administer them by IV bolus. Double-check the dose prescribed, the dilution or amount of fluid, and the rate at which to give the medication.

• Add medications to a new IV fluid container, not to an IV container that is already hanging.

• Never administer IV medications through tubing that is infusing blood, blood products, or parenteral nutrition solutions.

• Verify the compatibility of medications with IV solutions before infusing a medication through tubing that is infusing an IV solution.

• Perform any assessments required prior to administration, based on the medication, and determine if continuous monitoring is required during administration (ECG).

• Use the IV port closest to the client to administer the medication.

• Ensure the IV is patent prior to administration. If the client does not have IV fluids infusing or has fluids that are not compatible with the medication, flush the IV access before and following administration.

Caring for the client who is prescribed total parental nutrition 

Occlusion

Occlusion is a blockage in the central IV catheter that impedes flow. Thrombosis/emboli can coagulate and cause an occlusion.

Nursing Actions

• Flush the line according to INS recommendations or facility policy.

• Do not force fluid if resistance is encountered (can dislodge thrombosis).

• Use a 10 mL to avoid excess pressure per square inch that could cause catheter fracture/rupture.

Complications 

Metabolic complications include hyperglycemia, hypoglycemia, hyperkalemia, hypophosphatemia, hypocalcemia, dehydration (related to hyperosmolar diuresis resulting from hyperglycemia), and fluid overload (as evidenced by weight gain greater than 1 kg/day and edema).

Evaluating a client after receiving a new prescription of levothyroxine (thyroid hormone)  

Overmedication can result in manifestations of thyrotoxicosis (anxiety, tachycardia, chest pain, nervousness, tremors, palpitations, abdominal cramping, heat intolerance, fever, diaphoresis, weight loss).

Client education: Report manifestations of overmedication to the provider.

Receiving a telephone prescription 

Telephone or verbal prescriptions

It is best to avoid these, but they are sometimes necessary during emergencies and at unusual times.

• Have a second nurse listen to a telephone prescription.

• Repeat it back, making sure to include the medication’s name (spell if necessary), dosage, time, and route.

• Question any prescription that seems inappropriate for the client.

• Make sure the provider signs the prescription in person within the time frame the facility specifies, typically 24 hr.

Identifying medication interaction with calcium gluconate (calcium supplement) 

Digoxin: concurrent use of digoxin and parenteral calcium can lead to severe bradycardia (iv injection of calcium must be given slowly with careful monitoring of client cardiac status) 

Due to Hypokalemia, an Electrocardiogram (ECG) presents as inverted/flat T waves, ST depression. An elevated U wave is a finding specific to hypokalemia. Other dysthymia’s are possible 

Safety and infection control: priority action following a medication error: 

Nursing process framework

The nursing process includes sequential but overlapping steps:

• Assessment/data collection*

• Analysis/Diagnosis/data collection*

• Planning

• Implementation

• Evaluation

*PNs combine the assessment and analysis steps into a single data collection step.

The accuracy and thoroughness of assessment/analysis/diagnosis/data collection and planning have a direct effect on implementation and evaluation. Use of the nursing process results in a comprehensive, individualized, client-centered plan of nursing care that nurses can deliver in a timely and reasonable manner.

Assessment/Data Collection First

Use the nursing process to gather pertinent information prior to deciding on a plan of action. For example, determine if additional information is needed prior to calling the provider to ask for pain medication for a client.

Assessment/data collection involves the systematic collection of information about the health status of clients to identify needs and additional data to collect. Nurses can collect data during an initial assessment (baseline data), focused assessment, and ongoing assessments 

• Methods of data collection include observation, interviews with clients and families, medical history, comprehensive or focused physical examination, diagnostic and laboratory reports, and collaboration with other members of the health care team.

• To collect data effectively, nurses must ask clients appropriate questions, listen carefully to responses, and have excellent head-to-toe physical assessment skills. Nurses must employ clinical judgment and critical thinking in accurately recognizing when to collect assessment data. They must recognize the need to collect assessment data prior to interventions.

• Nurses collect subjective data (manifestations) during a nursing history. Subjective data includes clients’ feelings, perceptions, and descriptions of health status. Clients are the only ones who can describe and verify their own manifestations.

• Nurses observe and measure objective data (findings) during a physical examination. Nurses feel, see, hear, and smell objective data through observation or physical assessment of the client.

• During this assessment/data collection, the nurse validates, interprets, and clusters data.

• Documentation of the assessment data must be thorough, concise, and accurate.

Laboratory result that increases the risk for digoxin toxicity (cardiac glycoside); increased force of myocardial contraction and decreased heart rate (treatment of heart failure, dysrhythmias, and reduce manifestations). To manage dioxin toxicity, stop digoxin and potassium wasting diuretics immediately. • Monitor K+ levels. For levels less than 3.5 mEq/L, administer potassium IV infusion or by mouth. Do not give any further K+ if the level is greater than 5.0 mEq/L or AV block is present.

• Treat dysrhythmias with phenytoin or lidocaine.

• Treat bradycardia with atropine.

• For excessive toxicity, activated charcoal, cholestyramine, or digoxin immune Fab can be used to bind digoxin and prevent absorption.

Action to take for a client who is receiving diazepam during a colonoscopy  (diazepam - benzodiazepines) enhance the action of gamma-aminobutyric acid (GABA) in the CNS, resulting in depressant effects on the CNS 

Acute toxicity

• Oral: drowsiness, lethargy, confusion

• IV: respiratory depression, cardiac arrest, and profound hypotension.

Nursing Actions

• Oral: Gastric lavage can be used, followed by the administration of activated charcoal or saline cathartics.

• IV: Administer flumazenil to counteract sedation and reverse adverse effects.

• Monitor vital signs, maintain patent airway, and provide fluids to maintain blood pressure.

* have resuscitation equipment available 

A nurse is assessing a client who started a prescription for phenytoin 3 weeks ago. Which of the following assessment findings should the nurse identify as an indication of a hypersensitivity reaction to the phenytoin? —> enlargement of the cervical lymph nodes: lymphadenopathy (enlargement of the lymph nodes is an indication of a hypersensitivity reaction to phenytoin that usually manifests 3 to 12 weeks after beginning to take the medication 

Pregabilin —> weight gain is an adverse effect of taking pregabalin, the nurse should identify that taking pregabalin is contraindicated for a client who is breastfeeding. Therefore, the nurse should notify the provider of this finding 

Butorphanol —> contraindicated with opioid analgesics such as methadone which if administered will result n manaifestations of opioid withdrawal, butorphanol is used to treat moderate to severe pain. The nurse should identify that a loss of feeling in the extremity distal to the fracture site might indicate nerve damage. Nurse should document allergies on medication record 

Epoeitin alfa —> Poetin alfa increase the rate of red blood cell production in clients who have anemia. Effective treatment would present as increase reticulocyte count or immature blood cells. An increase in reticulocytes indicates the treatement is effective. Effective treatment with epoetin alpha should increase client’s hemoglobin levels. Epoetin alpha should increase the rate of red blood cell production but has no effect on white blood cells such as neutrophils or triglycerides 

Rh0(D) immune globulin —> Rh0 (D) immune globulin is administered into either the deltoid or the anterolateral portion of the upper thigh 

Dopamine —> evidence based practice indicates the nurse should first aspirate any remaining dopamine from the IV cannula to prevent injecting additional dopamine into the tissues during treatment and removal of the cannula, nurse should inject phentolamine into the affected areas to neutralize the dopamine and minimize tissue damage, nurse should apply a cold compress to the site to minimize discomfort and the extension of extravasation, nurse should moonier injury over time and photograph the site 

Peripherally inserted central catheter site (picc line) —? The nurse should measure the length of the external portion of the catheter and compare this to the documented length to determine if the catheter has become displaced, the nurse should use a back and forth motion with an approved cleansing agent for at least 30 seconds, dressing changes for central line catheters should be completed every 7 days if a transparent dressing is used or every 48 hours if gauze dressing is used, the nurse should use strict aseptic technique when performing central line care, including the use of sterile gloves and mask to minimize the risk of koi a catheter related bloodstream infection 

For rqeuired initiation of IV access on a child, the nurse should apply a local anesthetic cream to the child’s skin to reduce discomfort and trauma of IV initiation, should not administer oral medications if scheduled for surgery, avoid initiating IV access in the foot of any client who is learning to walk or has a vascular disorder, a nurse should use a 22 or 24 gauge catheter when initiating IV access on a child 

Phenytoin —> can cause overgrowth of gum tissue as an adverse effect or gingival hyperplasia. The nurse should instruct the client to brush and floss their teeth frequently and perform gum massage 

Digoxin —> withhold if client reports nausea, vomiting, and yellow vision as a sign of digoxin toxicity which is a contraindication of administration of this medication. Other manifestations of digoxin toxicity include bradycardia, abdominal pain, and seeing halos around dark objects 

Verapamil —> adverse effect is hypotension, constipation, headache, dizziness, gingival hyperplasia, rash and flushing 

Enalapril —> ACE inhibitor with urgent manifestations of angioedema, client should report any swelling of the tongue, lips, or around the eye to the provider immediately. This finding can indicate a potentially fatal reaction due to a toxic accumulation of bradykinin. The client should not take any subsequent doses of enalapril or any other ACE inhibitor. Nonurgent manifestations include dizziness, nausea, and headache 

Warfarin —> acetaminophen interacts with warfarin to inhibit its metabolism and increase the effects, putting the client at risk for bleeding. The nurse should check the client’s INR and monitor it carefully (international normalized ratio : how fast your blood clots calculated by prothrombin time). Both acetaminophen and warfarin can affect gastrointestinal, genitourinary, and hematological systems. Asprin is also contraindicated with warfarin. 

Levothyroxine —> used to treat hypothyroidism with manifestations of cool skin, thick, brittle nails, and decreased heart rate. If effective, patient should loose weight, and expect increased heart rate as well as warmer skin 

Alendronate —> stay upright for at least 30 minutes after taking the medication. Alendronate (bisphophonate) can cause esophagitis. Client should sit upright or stand for at least 30 minutes after taking this medication to reduce the risk for esophageal injury. Client should not consume food or beverage except plain water for at least 30 minutes after taking this medication. Client should take alendronate in the morning before breakfast for optimal bioavailabilty. Antacids that contain aluminum, calcium, or magnesium can reduce the absorption of alendronate. The client should not take an antacid for at least 30 minutes after taking this medication. 

Safe medication administration —>  the nurse should discard medications that are refused by clients rather than returning them to the original container for purposes of infection control and client safety. Crushing an extended-release tablet changes the properties of metabolism and distribution of the medication, negating the extended-release action. The nurse should apply an estradiol transdermal patch to the client’s trunk and avoid placing the patch anywhere where the skin is sensitive where the skin folds or where clothing can rub against the patch such as on breast tissue or the waistline. The nurse should administer an antibiotic cephalexin within 30 minutes of the scheduled administration time to ensure that the client maintains theraputic medication levels 

Morphine PCA —> Morphine and other opioids are given through a PCA pump. An adverse effect of opioids such as morphine is orthostatic hypotension. Sitting at the side of the bed prior to standing can decrease the risk of this adverse effect. An adverse effect of opioids such as morphine is constipation. The client should increase fluid intake to prevent or relieve constipation. The PCA pump is programmed so that a client can self administer a dose prior to a procedure or activity that cause discomfort. The nurse should instruct the client that having someone administer doses while they are sleeping can lead to the client receiving doses of the medication that they do not need. Therefore only the client should activate the PCA button for dosing 

Clopidogrel —> platelet inhibitor / blood thinner and reduces risk of harmful blood clots. Some clients including 14% of asians have a cyp2c19 genotype which causes decreased metabolism of clopidogrel.  Depression is an adverse reaction to clopidogrel. Clopidogrel interacts with NSAIDS and thrombolytic agents and increases the client’s risk for bleeding. Ezetimibe is a medication that lowers cholesterol and does not affect platelet aggregation. Garlic has anti platelet and coagulation properties that can increase the effectiveness of clopidogrel and therefore increase the risk for bleeding. The nurse should notify the provider that the client takes a garlic supplement. 

Allopurinol —> therapeutic response to the medication includes a decreased uric acid level as the medication is prescribed to clients who have gouty arthritis 

Vancomycin —> the nurse should report to the provider increased creatine levels as kidney failure is an adverse effect of vancomycin (antibiotic). The nurse should monitor the client/s intake and output when taking vancomycin. Kidney failure is an adverse effect of vancomycin and a decrease in urination could indicate potential kidney failure. 

Atenolol —> Atenolol is a beta blocker that can cause orthostatic hypotension. The nurse should check the client’s blood pressure supine, sitting, and standing, and instruct the client to change positions slowly. The nurse should check heart rate before administration, and hold the medication and notify the provider for a heart rate less than 60 / min, the nurse should expect a client who is taking an angiotensin converting enzyme inhibitor to develop a cough

Naproxen —> NSAID that can be sued to treat fever and pain as well as arthritis. Here the priority finding is black stools which are a manifestation of gastrointestinal bleeding which can lead to ulceration, perforation, and hemorrhage. The nurse should also monitor for ringing in the ears, nausea, and seating as non-urgent adverse effects. 

Midazolam and morphine —>  midazolam can cause respiratory depression or arrest so the nurse should follow up on low respiratory rates. The combination of midazolam and morphine results in sedation, analgesia, lack of anxiety, and amnesia which can last for up to one hour following surgery. Client retains the ability to follow simple commands. 

Care of a client who has had a seizure: Chronic neurological disorders, identifying hypersensitivity reaction to phenytoin 

• Administer prescribed antiepileptic drugs (AEDs), such as phenytoin.

• Initial goal is to control seizure activity using one medication. If the chosen medication is not effective, either the dose is increased, or another medication is added or substituted.

• Therapeutic levels are determined by blood tests. These are performed on a routine schedule to ensure compliance and effectiveness of the medication. QEBP

• Allergic reactions to these medications are rare, yet can occur immediately or late in therapy. If the client is allergic, another medication may be substituted.

Opioid agonists and antagonists: 

Agonist-antagonist opioids: butorphanol, these medications act as antagonists on mu receptors and agonists on kappa receptors except for buprenorphine, whose agonist/antagonist activity is on opposite receptors 

contraindications for the administration of butorphanol: abstinence syndrome: cramping, hypertension, vomiting, fever, and anxiety 

Nursing Actions

• This syndrome can be precipitated when these medications are given to clients who are physically dependent on opioid agonists.

• Advise clients to stop opioid agonists (morphine) before using agonist-antagonist medications (pentazocine). 

• Avoid giving to clients if undisclosed opioid use is suspected.

Medications affecting labor and delivering: administering Rho(d) immune globulin) 

Rh: all Rh-negative clients who have newborns who are Rh-positive must be given Rho(d) immune globulin administered IM within 72 hours of the newborn being born to suppress antibody formation in the mother. The nurse should check to see if the client has been sensitized prior to administering Rho (D) immune globulin. Observe the client for at least 20 minutes post administration for an allergic reaction 

 Strategies for the new nurse to use to promote EBP 

• Use data gathering resources to stay current with new evidence – professional journal, textbooks, experts in the field, and colleagues. 

• Use multiple resources to gather evidence on a topic.

• Support clinical interventions and teaching strategies with evidence.

• Use resources that have already been established in your area of specialty to find current evidence.

• Use nationally sanctioned clinical practice guidelines when implementing and evaluating your practice.

• Promote spirits of inquiry and risk taking in questioning and then challenging longstanding nursing traditions.

• Do not subscribe to myths or traditions that are not supported by evidence.

• Widen your network and collaborate with nurses on a local and global level.

• Practice interdisciplinary collaboration to bring nursing evidence to play in decision-making.

Guidelines for safe IV medication administration 

> IV solution or medication leaks into the subcutaneous tissue. Infiltration is the leak of a nonvesicant, extravasation is the leak of a vesicant solution with can damage the tissues. With extravasation, prior to regular treatment, the nurse should withdraw the solution from the client’s IV catheter and might need to administer an antidote prior to discontinuing the IV access. Findings include pallor, local swelling at the site, decreased skin temperature around the site, damp dressing, or slowed rate of infusion. 

Treatment: 

• Stop the infusion and remove the catheter.

• Elevate the extremity.

• Encourage active range of motion.

• Apply a warm or cold compress depending on the solution infusing.

• Restart the infusion proximal to the site or in another extremity.

• Use current data to make informed clinical decisions to provide the best practice. Best practice is determined by current research collected from several sources that have desirable outcomes.

• Use knowledge of evidence-based practice to guide prioritization of care and interventions (responding to clients experiencing wound dehiscence or crisis). For example, initiating CPR in the proper steps for a client experiencing cardiac arrest.

Methods to promote evidence-based practice

• Use a variety of sources of research.

• Keep current on new research by reading professional journals and collaborating with other nurses and professionals in other disciplines.

• Change traditional nursing practice with new research-based practices.

Chronic neurological disorders: adverse effects of phenytoin (hydatoins) / anticonvulsant—> adverse effect is gingival hyperplasia or softening and overgrowth of gum tissue, tenderness, and bleeding gums. Advesie clients to maintain good oral hygiene (dental flossing ,massaging gums) folic acid supplements can decrease the occurrence 

Cardiac glycosides and heart failure: Identifying contraindications for medication administrations 

Cardiac glycosides —> Digoxin: increased force of myocardial contraction and decreased heart rate (antiarrhytmic and blood pressure support). 

Nursing administration: 

• Check pulse rate and rhythm before administration of digoxin and record. Notify the provider if heart rate is less than 60/min in an adult, less than 70/min in children, and less than 90/min in infants.

• Administer digoxin at the same time daily.

• Evaluate manifestations and the client’s digoxin level when toxicity is suspected.

• Avoid taking OTC medications to prevent adverse effects and medication interactions.

• Instruct clients to observe for indications of digoxin toxicity (fatigue, weakness, vision changes, GI effects), and to notify the provider if they occur.

• If administering IV digoxin, infuse over at least 5 min, (10 to 15 min in clients who have pulmonary edema) and monitor client for dysrhythmias.

Medications affecting cardiac rhythm: adverse effects of verapamil calcium channel blockers (block calcium channels in blood vessels leading to dilation of peripheral arterioles and arteries / arterials of the heart) Adverse effects include constipation and client education on increase intake of high fiber food and oral fluids if not restricted 

Thyroid hormone (levothyroxine) —> thyroid hormone preparations are a synthetic form of T3/T4 that increase metabolic rate, protein synthesis, cardiac output, renal perfusion, oxygen use, body temperature, blood volume, and growth processes 

Depending on therapeutic intent, evidence of effectiveness can include 

• Decreased TSH levels. Evaluation of TSH should not be done until 6 to 8 weeks following the start of treatment.

• T4 levels within expected reference range

• Absence of hypothyroidism manifestations (depression, weight gain, bradycardia, anorexia, cold intolerance, dry skin, menorrhagia)

Safe medication administration and error reduction: 

Right time

Administer medication on time to maintain a consistent therapeutic blood level. Refer to the drug reference or the facility’s policy for exceptions; general recommendations follow.

• Administer time-critical medications within 30 min of the prescribed time. Facilities define which medications are time-critical; usually this includes medications that require a consistent blood level (antibiotics).

• Administer non-time-critical medications prescribed once daily, weekly, or monthly within 2 hr of the prescribed time.

• Administer non-time-critical medications prescribed more than once daily (but not more than every 4 hr) within 1 hr of the prescribed time.

Opioid agonists and Antagonists: Evaluating a client’s understanding of a PCA pump: Opioid agonists including morphine act on mu receptors and to a lesser decree on kappa receptors. Activation of mu receptors produces alagesia, respiratory depression, euphoria, and sedation, whereas app receptor activation produces analgesia, sedation, and decreased GI motility. Activation of mu receptors can also be linked to physical dependence 

Orthostatic hypotension

Nursing Actions

• Advise clients to sit or lie down if lightheadedness or dizziness occur.

• Due to the dilation effect to the peripheral arterioles and veins, avoid sudden changes in position by slowly moving clients from a lying to a sitting or standing position.

• Provide assistance with ambulation as needed.

Medications affecting coagulation: identifying medication interactions with clopidogrel 

Natural products and herbal therapies 

Garlic

• When crushed, forms the enzyme allicin

• Blocks LDL cholesterol and raises HDL cholesterol; lowers triglycerides

• Suppresses platelet aggregation and disrupts coagulation

• Acts as a vasodilator (can lower blood pressure)

Adverse Effects: GI manifestations, bad breath, and body odor.

Interactions

• Due to antiplatelet qualities, can increase risk of bleeding in clients taking NSAIDs, warfarin, and heparin

• Decreases levels of saquinavir (a medication for HIV treatment) and cyclosporine

Nursing Administration

• Question clients about concurrent use of NSAIDs, heparin, and warfarin.

• Have clients who are taking antiplatelet or anticoagulant medication, cyclosporine, or saquinavir contact their provider.

Reduction of risk potential 

Priority assessment finding for a client who is taking naproxen 

Complications gastric bleeding: severe acute gastritis with deep tissue inflammation extending into the stomach muscle 

In chronic erosive gastritis bleeding can be slow or profuse as in a perforation of the stomach wall 

Client Education: Monitor for indications of slow gastric bleeding (coffee-ground emesis; black, tarry stools). Seek immediate medical attention with severe abdominal pain or vomiting blood. Take medications as directed.

Acute vs. Chronic, Urgent vs. Nonurgent, Stable vs. Unstable

• A client who has an acute problem takes priority over a client who has a chronic problem.

• A client who has an urgent need takes priority over a client who has a nonurgent need.

• A client who has unstable findings takes priority over a client who has stable findings.

Nonsteroidal anti-inflammatory drugs: aspirin inhibit cox-1 can result in decreased platelet aggregation and kidney damage while inhibition of COX-2 results in decreased inflammation, fever, and pain, and does not decrease platelet aggregation 

Complications include gastrintestinal discomfort including dyspepsia, abdominal pain, heartburn, and nauseas 

Nursing Actions

• Damage to gastric mucosa can lead to gastrointestinal (GI) bleeding and perforation, especially with long-term use.

• Risk is increased in older adults, clients who smoke or have alcohol use disorder, and those who have a history of peptic ulcers or previous inability to tolerate NSAIDs.

• Observe for indications of GI bleeding (passage of black or dark-colored stools, severe abdominal pain, nausea, vomiting).

• Administer a proton pump inhibitor (omeprazole) or an H2 receptor antagonist (cimetidine) to decrease the risk of ulcer formation.

• Use prophylaxis agents (misoprostol).

Client Education

• Take medication with food or with an 8 oz glass of water or milk.

• Avoid alcohol.