The nurse is teaching a patient how a medication works to treat an
illness. To do this, the nurse will rely on knowledge of which
a. Clinical pharmacology
b. Drug efficacy
Pharmacotherapeutics is the study of the use of drugs to
diagnose, treat, and prevent conditions. Clinical pharmacology is
concerned with all aspects of drug-human interactions. Drug efficacy
measures the extent to which a given drug causes an intended effect.
Pharmacokinetics is the study of the impact of the body on a drug.
What is a desired outcome when a drug is described as easy to
a. It can be stored indefinitely without need for
b. It does not interact significantly with other
c. It enhances patient adherence to the drug
d. It is usually relatively inexpensive to produce.
A major benefit of drugs that are easy to administer is that
patients taking them are more likely to comply with the drug regimen.
Drugs that are easy to give may have the other attributes listed, but
those properties are independent of ease of administration.
A patient tells the nurse that an analgesic he will begin taking may
cause drowsiness and will decrease pain up to 4 hours at a time. Based
on this understanding of the drug's effects by the patient, the nurse
will anticipate which outcome?
a. Decreased chance of having a
b. Decreased motivation to take the drug
Improved compliance with the drug regimen
d. Increased likelihood
of drug overdose
A drug is effective if it produces the intended effects, even
if it also produces side effects. Patients who understand both the
risks and benefits of taking a medication are more likely to comply
with the drug regimen.
What are the properties of an ideal drug? (Select all that
a. Irreversible action
Ease of administration
d. Chemical stability
recognizable trade name
B, C, D
In addition to predictability, ease of administration,
and chemical stability, other properties include a reversible action
so that any harm the drug may cause can be undone and a simple generic
name, because generic names are usually complex and difficult to
remember and pronounce.
Before administering a medication, what does the nurse need to know
to evaluate how individual patient variability might affect the
patient's response to the medication? (Select all that apply.)
Chemical stability of the medication
b. Ease of
c. Family medical history
e. Patient's diagnosis
C, D, E
The family medical history can indicate genetic factors
that may affect a patient's response to a medication. Patients of
different ages can respond differently to medications. The patient's
illness can affect how drugs are metabolized. The chemical stability
of the medication and the ease of administration are properties of drugs.
A patient is using a metered-dose inhaler containing albuterol for
asthma. The medication label instructs the patient to administer
"2 puffs every 4 hours as needed for coughing or wheezing."
The patient reports feeling jittery sometimes when taking the
medication, and she doesn't feel that the medication is always
effective. Which action is outside the nurse's scope of
a. Asking the patient to demonstrate use of the
b. Assessing the patient's exposure to tobacco
c. Auscultating lung sounds and obtaining vital
d. Suggesting that the patient use one puff to reduce side effects
It is not within the nurse's scope of practice to change the
dose of a medication without an order from a prescriber. Asking the
patient to demonstrate inhaler use helps the nurse to evaluate the
patient's ability to administer the medication properly and is part of
the nurse's evaluation. Assessing tobacco smoke exposure helps the
nurse determine whether nondrug therapies, such a smoke avoidance, can
be used as an adjunct to drug therapy. Performing a physical
assessment helps the nurse evaluate the patient's response to the medication.
A postoperative patient is being discharged home with
acetaminophen/hydrocodone [Lortab] for pain. The patient asks the
nurse about using Tylenol for fever. Which statement by the nurse is
a. "It is not safe to take over-the-counter drugs
with prescription medications."
b. "Taking the two
medications together poses a risk of drug toxicity."
"There are no known drug interactions, so this will be
d. "Tylenol and Lortab are different drugs, so
there is no risk of overdose."
Tylenol is the trade name and acetaminophen is the generic
name for the same medication. It is important to teach patients to be
aware of the different names for the same drug to minimize the risk of
overdose. Over-the-counter (OTC) medications and prescription
medications may be taken together unless significant harmful drug
interactions are possible. Even though no drug interactions are at
play in this case, both drugs contain acetaminophen, which could lead
The nurse is preparing to care for a patient who will be taking an
antihypertensive medication. Which action by the nurse is part of the
assessment step of the nursing process?
a. Asking the prescriber
for an order to monitor serum drug levels
b. Monitoring the
patient for drug interactions after giving the medication
Questioning the patient about over-the-counter medications
Taking the patient's blood pressure throughout the course of treatment
The assessment part of the nursing process involves gathering
information before beginning treatment, and this includes asking about
other medications the patient may be taking. Monitoring serum drug
levels, watching for drug interactions, and checking vital signs after
giving the medication are all part of the evaluation phase.
A postoperative patient reports pain, which the patient rates as an 8
on a scale from 1 to 10 (10 being the most extreme pain). The
prescriber has ordered acetaminophen [Tylenol] 650 mg PO every 6 hours
PRN pain. What will the nurse do?
a. Ask the patient what
medications have helped with pain in the past.
b. Contact the
provider to request a different analgesic medication.
c. Give the
pain medication and reposition the patient to promote comfort.
Request an order to administer the medication every 4 hours.
The nursing diagnosis for this patient is severe pain.
Acetaminophen is given for mild to moderate pain, so the nurse should
ask the prescriber to order a stronger analgesic medication. Asking
the patient to tell the nurse what has helped in the past is part of
an initial assessment and should be done preoperatively and not when
the patient is having severe pain. Because the patient is having
severe pain, acetaminophen combined with nondrug therapies will not be
sufficient. Increasing the frequency of the dose of a medication for
mild pain will not be effective.
A patient newly diagnosed with diabetes is to be discharged from the
hospital. The nurse teaching this patient about home management should
begin by doing what?
a. Asking the patient to demonstrate how to
measure and administer insulin
b. Discussing methods of storing
insulin and discarding syringes
c. Giving information about how
diet and exercise affect insulin requirements
d. Teaching the
patient about the long-term consequences of poor diabetes control
Because insulin must be given correctly to control symptoms
and because an overdose can be fatal, it is most important for the
patient to know how to administer it. Asking for a demonstration of
technique is the best way to determine whether the patient has
understood the teaching. When a patient is receiving a lot of new
information, the information presented first is the most likely to be
remembered. The other teaching points are important as well, but they
are not as critical and can be taught later.
The nurse receives an order to give morphine 5 mg IV every 2 hours
PRN pain. Which action is not part of the six rights of drug
a. Assessing the patient's pain level 15 to 30
minutes after giving the medication
b. Checking the medication
administration record to see when the last dose was
c. Consulting a drug manual to determine whether the
amount the prescriber ordered is appropriate
d. Documenting the
reason the medication was given in the patient's electronic medical record
Assessing the patient's pain after administering the
medication is an important part of the nursing process when giving
medications, but it is not part of the six rights of drug
administration. Checking to see when the last dose was given helps
ensure that the medication is given at the right time. Consulting a
drug manual helps ensure that the medication is given in the right
dose. Documenting the reason for a pain medication is an important
part of the right documentation—the sixth right.
A patient tells a nurse that a medication prescribed for recurrent
migraine headaches is not working. What will the nurse do?
the patient about the number and frequency of tablets taken.
Assess the patient's headache pain on a scale from 1 to 10.
Report the patient's complaint to the prescriber.
biofeedback as an adjunct to drug therapy.
When evaluating the effectiveness of a drug, it is important
to determine whether the patient is using the drug as ordered. Asking
the patient to tell the nurse how many tablets are taken and how often
helps the nurse determine compliance. Assessing current pain does not
yield information about how well the medication is working unless the
patient is currently taking it. The nurse should gather as much
information about compliance, symptoms, and drug effectiveness as
possible before contacting the prescriber. Biofeedback may be an
effective adjunct to treatment, but it should not be recommended
without complete information about drug effectiveness.
A nurse is preparing to administer medications. Which patient would
the nurse consider to have the greatest predisposition to an adverse
a. A 30-year-old man with kidney disease
75-year-old woman with cystitis
c. A 50-year-old man with an
upper respiratory tract infection
d. A 9-year-old boy with an ear infection
The individual with impaired kidney function would be at risk
of having the drug accumulate to a toxic level because of potential
excretion difficulties. Cystitis is an infection of the bladder and
not usually the cause of excretion problems that might lead to an
adverse reaction from a medication. A respiratory tract infection
would not predispose a patient to an adverse reaction, because drugs
are not metabolized or excreted by the lungs. A 9-year-old boy would
not have the greatest predisposition to an adverse reaction simply
because he is a child; nor does an ear infection put him at greater risk.
A nurse consults a drug manual before giving a medication to an
80-year-old patient. The manual states that older-adult patients are
at increased risk for hepatic side effects. Which action by the nurse
a. Contact the provider to discuss an order for
pretreatment laboratory work.
b. Ensure that the drug is given in
the correct dose at the correct time to minimize the risk of adverse
c. Notify the provider that this drug is contraindicated
for this patient.
d. Request an order to give the medication
intravenously so that the drug does not pass through the liver.
The drug manual indicates that this drug should be given with
caution to elderly patients. Getting information about liver function
before giving the drug establishes baseline data that can be compared
with post-treatment data to determine whether the drug is affecting
the liver. Giving the correct dose at the correct interval helps to
minimize risk, but without baseline information, the effects cannot be
determined. The drug is not contraindicated.
A patient has been receiving intravenous penicillin for pneumonia for
several days and begins to complain of generalized itching. The nurse
auscultates bilateral wheezing and notes a temperature of 38.5°C
(101°F). Which is the correct action by the nurse?
the next dose and continue to evaluate the patient's symptoms.
Ask the prescriber if an antihistamine can be given to relieve the
c. Contact the prescriber to request an order for a
d. Hold the next dose and notify the prescriber
of the symptoms.
Prurient and wheezing are signs of a possible allergic
reaction, which can be fatal; therefore, the medication should not be
given and the prescribes should be notified. When patients are having
a potentially serious reaction to a medication, the nurse should not
continue giving the medication. Antihistamines may help the symptoms
of an allergic reaction, but the first priority is to stop the
medication. Obtaining a chest radio-graph is not helpful
A postoperative patient has orders for morphine sulfate 1 to 2 mg IV
every 1 hour PRN for severe pain and acetaminophen-hydrocodone
[Lortab] 7.5 mg PO every 4 to 6 hours PRN for moderate pain. The
patient reports pain at a level of 8 on a scale of 1 to 10, with 10
being the worst pain. Which action by the nurse is
a. Administer acetaminophen-hydrocodone 7.5 mg PO
every 4 hours.
b. Administer acetaminophen-hydrocodone 7.5 mg PO
every 6 hours and change to every 4 hours if not effective.
Administer morphine sulfate 1 mg IV every 1 hour until pain
d. Administer morphine sulfate 2 mg IV and evaluate the
patient's pain in 15 to 30 minutes.
With PRN medications, the schedule is not fixed and the
administration of these medications depends on the patient's
condition. It is the nurse's responsibility to assess the patient's
condition and then give the appropriate PRN medication. In this case,
the patient has severe pain and should receive MS IV. Either 1 mg or 2
mg may be given, but the nurse must evaluate the effectiveness of the
pain medication within 15 to 30 minutes to help determine subsequent
doses. Acetaminophen-hydrocodone is not appropriate because it is
ordered for moderate pain and this patient reports severe pain. Giving
MS IV every hour is not appropriate for a PRN medication unless the
patient's condition warrants it.
The nurse is teaching a patient about home administration of insulin
to treat diabetes mellitus. As part of the teaching, the patient and
nurse identify goals to maintain specific blood glucose ranges. This
represents which aspect of the nursing process?
In the planning step, the nurse delineates specific
interventions directed at solving or preventing problems. When
creating the care plan, the nurse defines goals, sets priorities, and
establishes criteria for evaluating success. The assessment step
involves collecting data about the patient. The evaluation step
involves evaluating the medication effectiveness. The implementation
step identifies actions that are taken to administer the drug.
A nurse is reviewing a patient's medical record before administering
a medication. Which factors can alter the patient's physiologic
response to the drug? (Select all that apply.)
a. Ability to
c. Genetic factors
B, C, D
Age, genetic factors, and gender influence an individual
patient's ability to absorb, metabolize, and excrete drugs; therefore,
these factors must be assessed before a medication is administered. A
patient's ability to swallow pills, although it may determine the way
a drug is administered, does not affect the physiologic response.
Height does not affect response; weight and the distribution of
adipose tissue can affect the distribution of drugs.
A nurse educator is conducting a continuing education class on
pharmacology. To evaluate the learning of the nurses in the class, the
nurse educator asks, "Which drug name gives information about the
drug's pharmacologic classification?" Which is the correct
Amoxicillin is the generic name, and the suffix
"-cillin" indicates that it belongs to the penicillin class
of antibiotics. Tylenol, Cipro, and Motrin are all trade names without
segments that indicate their pharmacologic class.
The FDA Amendments Act (FDAAA) was passed in 2007 to address which
aspect of drug safety?
a. Allowing pharmaceutical companies to
identify off-label uses of medications approved for other uses
Evaluating drug safety information that emerges after a drug has been
approved and is in use
c. Expediting the approval process of the
U.S. Food and Drug Administration (FDA) so that needed drugs can get
to market more quickly
d. Requiring manufacturers to notify
patients before removing a drug from the market
The FDAAA was passed to enable the Food and Drug
Administration to continue oversight of a drug after granting it
approval so that changes in labeling could be made as necessary and
postmarketing risks could be tracked and identified. A provision of
the FDA Modernization Act (FDAMA), passed in 1997, allows drug
companies to promote their products for off-label uses as long as they
promise to conduct studies to support their claims. Regulations to
permit accelerated approval of drugs for life-threatening diseases
were adopted in 1992 by the FDA. The requirement that drug companies
notify patients 6 months before removing a drug from the market is a
provision of the FDAMA.
A nursing student asks a nurse about pharmaceutical research and
wants to know the purpose of randomization in drug trials. The nurse
explains that randomization is used to do what?
a. To ensure that
differences in outcomes are the result of treatment and not
differences in subjects
b. To compare the outcome caused by the
treatment to the outcome caused by no treatment
c. To make sure
that researchers are unaware of which subjects are in which
d. To prevent subjects from knowing which group they are in
and prevent preconception bias
Randomization helps prevent allocation bias, which can occur
when researchers place subjects with desired characteristics in the
study group and other subjects in the control group so that
differences in outcome are actually the result of differences in
subjects and not treatment. Comparing treatment outcome to no
treatment outcome is the definition of a controlled study. The last
two options describe the use of blinding in studies; blinding ensures
that researchers or subjects (or both) are unaware of which subjects
are in which group so that preconceptions about benefits and risks
cannot bias the results.
Someone asks a nurse about a new drug that is in preclinical testing
and wants to know why it cannot be used to treat a friend's illness.
Which statement by the nurse is correct?
a. "A drug at this
stage of development can be used only in patients with serious
b. "At this stage of drug development, the
safety and usefulness of the medication is unknown."
"Clinical trials must be completed to make sure the drug is safe
to use in humans."
d. "Until postmarketing surveillance
data are available, the drug cannot be used."
Preclinical testing must be completed before drugs can be
tested in humans. In this stage, drugs are evaluated for toxicities,
pharmacokinetic properties, and potentially useful effects. Some drugs
can be used in patients before completion of Phase III studies, but
this is after preclinical testing is complete. Clinical trials proceed
in stages, and each stage has guidelines defining how a new drug may
be used and which patients may receive it. Postmarketing surveillance
takes place after a drug is in general use.
A patient asks a nurse why drugs that have been approved by the FDA
still have unknown side effects. What will the nurse tell the
a. Testing for all side effects of a medication would be
b. Patients in drug trials often are
biased by their preconceptions of a drug's benefits.
Researchers tend to conduct studies that will prove the benefits of
their new drugs.
d. Subjects in drug trials do not always
represent the full spectrum of possible patients.
All drug trials are limited by a relatively small group of
subjects who may not have all the characteristics of people who will
be using the drug; therefore, some side effects go undetected until
the drug is in use. Although drug trials are very expensive, this is
only an indirect reason they do not detect all side effects before
approval. In theory, well-designed drug trials, using blinded studies,
minimize or eliminate subject bias. Designing studies to prove desired
results is unethical.
A nurse is teaching nursing students about the use of nonproprietary
names for drugs. The nurse tells them which fact about nonproprietary
a. They are approved by the FDA and are easy to
b. They are assigned by the U.S. Adopted Names
c. They clearly identify the drug's pharmacologic
d. They imply the efficacy of the drug and are
Nonproprietary, or generic, names are assigned by the U.S.
Adopted Names Council, which ensures that each drug has only one name.
Trade names, or brand names, are approved by the FDA and are easier to
remember. Some nonproprietary names contain syllables that identify
the classification, although not all do. Drug names are not supposed
to identify the use for the drug, although some brand names do so.
A patient tells the nurse that the oral drug that has been prescribed
has caused a lot of stomach discomfort in the past. What will the
nurse ask the prescriber?
a. Whether a sublingual form of the
medication can be given
b. Whether the medication can be given by
a parenteral route instead
c. Whether an enteric-coated form of
the drug is available
d. Whether the patient can receive a
sustained-release preparation of the drug
Enteric-coated drugs are preparations that have been coated
with a material that dissolves in the intestines, not the stomach.
This coating is used either to protect the drug from stomach acid and
pepsin or to protect the stomach from a drug that can cause gastric
upset. Sublingual forms often are used for drugs that undergo rapid
inactivation during the first pass through the hepatic circulation so
that the drug can be absorbed directly into the systemic circulation.
Parenteral routes are more costly and less safe than oral
administration and should not be used unless necessary. A
sustained-release preparation is used to release the drug into the
body over a specific period to reduce the number of daily doses
required to sustain therapeutic drug levels.
A patient claims to get better effects with a tablet of Brand X of a
drug than with a tablet of Brand Y of the same drug. Both brands
contain the same amount of the active ingredient. What does the nurse
know to be most likely?
a. Advertising by pharmaceutical
companies can enhance patient expectations of one brand over another,
leading to a placebo effect.
b. Because the drug preparations are
chemically equivalent, the effects of the two brands must be
c. Tablets can differ in composition and can have
differing rates of disintegration and dissolution, which can alter the
drug's effects in the body.
d. The bioavailability of a drug is
determined by the amount of the drug in each dose.
Even if two brands of a drug are chemically equivalent (i.e.,
they have identical amounts of the same chemical compound), they can
have different effects in the body if they differ in bioavailability.
Tablets made by different manufacturers contain different binders and
fillers, which disintegrate and dissolve at different rates and affect
the bioavailability of the drug. Two brands may be chemically
equivalent and still differ in bioavailability, which is not
determined by the amount of drug in the dose.
A patient receives a drug that has a narrow therapeutic range. The
nurse administering this medication will expect to do what?
Administer the drug at intervals longer than the drug
b. Administer this medication intravenously.
Monitor plasma drug levels.
d. Teach the patient that maximum
drug effects will occur within a short period.
A drug with a narrow therapeutic range is more difficult to
administer safely, because the difference between the minimum
effective concentration and the toxic concentration is small. Patients
taking these medications must have their plasma drug levels monitored
closely to ensure that they are getting an effective dose that is not
toxic. Administering medications at longer intervals only increases
the time required to reach effective plasma drug levels. Drugs that
have a narrow therapeutic range may be given by any route and do not
differ from other medications in the amount of time it takes for them
to take effect, which is a function of a drug's half-life and dosing frequency.
A patient is given a prescription for azithromycin [Zithromax] and
asks the nurse why the dose on the first day is twice the amount of
the dose on the next 4 days. Which reply by the nurse is
a. "A large initial dose helps to get the drug to
optimal levels in the body faster."
b. "The first dose
is larger to minimize the first pass effect of the
c. "The four smaller doses help the body taper
the amount of drug more gradually."
reabsorption is faster with initial doses, so more is needed at first."
A large initial dose is often used as a loading dose to help
get serum drug levels to plateau levels more quickly. Larger doses do
not prevent first pass effects in drugs susceptible to this type of
metabolism. Tapering of doses sometimes is used to prevent rebound or
withdrawal effects and is done by stepping down the amount of drug
with each dose. Tubular reabsorption is a process that allows drugs to
be reabsorbed from the urine into the blood
A nurse is giving an enteral medication. The patient asks why this
method is preferable for this drug. How will the nurse reply?
"This route allows more rapid absorption of the
b. "This route is safer, less expensive, and
c. "This route is the best way to
control serum drug levels."
d. "This route prevents
inactivation of the drug by digestive enzymes."
Parenteral routes include the intravenous, intramuscular, and
subcutaneous routes. Enteral routes include oral administration,
including pills and liquid suspensions. Enteral routes are safer,
cheaper, and easier to use. Parenteral routes are used when rapid
absorption, precise control of plasma drug levels, and prevention of
digestive inactivation are important.
The nurse is preparing to administer penicillin G intramuscularly to
a child. The child's parents ask why the drug cannot be given in an
oral liquid form. What is the nurse's reply?
a. "This drug
causes severe gastric upset if given orally."
drug has a narrow therapeutic range, and the dose must be tightly
c. "This drug is absorbed much too quickly
in an oral form."
d. "This drug would be inactivated by
enzymes in the stomach."
Penicillin G is inactivated by digestive enzymes in the
stomach and cannot be given orally. It does not have a narrow
A provider has written an order for a medication: drug 100 mg PO
every 6 hours. The half-life for the drug is approximately 6 hours.
The nurse is preparing to administer the first dose at 8:00 AM on
Tuesday. On Wednesday, when will the serum drug level reach
a. 2:00 AM
b. 8:00 AM
c. 2:00 PM
d. 8:00 PM
It takes four half-lives for a drug to reach plateau. Total
body stores reach their peak at the beginning of the fifth dose of a
drug if all doses are equal in amount; in this case, this will be at
8:00 AM the following day.
An adult male patient is 1 day postoperative from a total hip
replacement. On a pain scale of 0 to 10, with 10 being the greatest
pain, the patient reports a pain level of 10. Which medication would
be most appropriate for the nurse to administer to this
a. 60 mg morphine sulfate PO
b. 75 mg meperidine
c. 6 mg morphine sulfate
d. Fentanyl [Duragesic] patch 50 mcg transdermally
The intravenous route is the fastest route of absorption and
the one most appropriate for a patient in extreme pain. With the oral
route, the medication would take at least 45 minutes to be effective,
too long for a patient in extreme pain. With the intramuscular route,
the medication would take at least 15 minutes to be effective;
although faster than the oral route, this is not as fast as the
intravenous route. A Duragesic patch would be the most inappropriate
route because of the long drug half-life. This is a more appropriate
route for long-term use.
A nurse is explaining drug metabolism to a nursing student who asks
about glucuronidation. The nurse knows that this is a process that
allows drugs to be:
a. excreted in hydrolyzed form in the feces
to reduce drug toxicity.
b. reabsorbed from the urine into the
renal circulation to minimize drug loss.
c. recycled via the
enterohepatic recirculation to remain in the body longer.
transported across the renal tubules to be excreted in the urine.
Glucuronidation of some drugs in the liver allows drugs to
enter the bile, pass into the duodenum, and then be hydrolyzed to
release the free drug. This is a repeating cycle of enterohepatic
recirculation, which allows drugs to remain in the body longer.
Glucuronidated drugs that are more resistant to hydrolysis are
excreted in the feces. Glucuronidation occurs in the enterohepatic
circulation and not in the renal circulation.
A patient is receiving intravenous gentamicin. A serum drug test
reveals toxic levels. The dosing is correct, and this medication has
been tolerated by this patient in the past. Which could be a probable
cause of the test result?
a. A loading dose was not
b. The drug was not completely dissolved in the IV
c. The patient is taking another medication that binds
to serum albumin.
d. The medication is being given at a frequency
that is longer than its half-life.
Gentamicin binds to albumin, but only weakly, and in the
presence of another drug that binds to albumin, it can rise to toxic
levels in blood serum. A loading dose increases the initial amount of
a drug and is used to bring drug levels to the desired plateau more
quickly. A drug that is not completely dissolved carries a risk of
causing embolism. A drug given at a frequency longer than the drug
half-life will likely be at subtherapeutic levels and not at toxic levels.
The nurse is caring for a child who has ingested a toxic amount of
aspirin. The provider orders an intravenous drug that will increase pH
in the blood and urine. The nurse understands that this effect is
a. decrease the gastric absorption of
b. decrease the lipid solubility of aspirin.
increase the serum protein binding of aspirin.
d. increase the
urinary excretion of aspirin.
The phenomenon of pH-dependent ionization can be used to
accelerate renal excretion of drugs. When children have been exposed
to toxic amounts of aspirin, they can be treated, in part, by giving
an agent that elevates urinary pH, leading to less passive
reabsorption of the now ionized molecules of aspirin and, hence, more
excretion. Elevating the pH of the blood and urine does not affect
absorption in the stomach. Ionization of aspirin does not affect lipid
solubility or protein binding.
A patient is taking a drug that does not bind to albumin. Which
aspect of renal drug excretion is affected by this
a. Active tubular secretion
c. Passive tubular reabsorption
d. pH-dependent ionization
As blood flows through the glomerular capillaries, fluids and
small molecules are forced through the pores of the capillary wall.
Large molecules, such as drugs bound to albumin, remain behind in the
blood. Active tubular secretion requires active transport systems to
pump molecules from one side of the membrane to another. Passive
tubular reabsorption allows substances in high concentrations in the
tubule to be reabsorbed into the blood, and lipid-soluble drugs
readily cross this membrane by passive reabsorption. pH-dependent
ionization affects drugs that ionize in either acid or alkaline environments.
When administering medications to infants, it is important to
remember which of the following? (Select all that apply.)
Breast-feeding infants are more likely to develop toxicity when given
b. Immaturity of renal function in infancy
causes infants to excrete drugs less efficiently.
c. Infants have
immature livers, which slows drug metabolism.
d. Infants are more
sensitive to medications that act on the central nervous system
e. Oral medications are contraindicated in infants,
because PO administration requires a cooperative patient.
B, C, D
Immature renal function causes infants to excrete drugs
more slowly, and infants are at risk for toxicity until renal function
is well developed. Infants' livers are not completely developed, and
they are less able to metabolize drugs efficiently. Because the
blood-brain barrier is not well developed in infants, caution must be
used when administering CNS drugs. Lipid-soluble drugs may be excreted
in breast milk if the mother is taking them, but breast-feeding does
not affect medications given directly to the infant. Oral medications
may be given safely to infants as long as they are awake and can
swallow the drug.
A patient is receiving digoxin twice daily. When assessing the
patient before giving a dose, the nurse counts a pulse of 60 beats per
minute and learns that the patient is experiencing nausea. The nurse
consults a drug manual and verifies that the ordered dose is correct.
What should the nurse do?
a. Contact the prescriber to report the
b. Delay the dose so the drug can clear from receptor
c. Give the medication as ordered, because the dose is
d. Request an antinausea medication from the prescriber.
The symptoms indicate toxicity, and even though the dose is
safe and effective in most cases, an individual patient may have toxic
effects with a standard dose. The nurse should contact the prescriber
to discuss the next steps. Delaying a dose without a change in order
is not within the scope of practice for a nurse. The nurse should not
give a dose of a medication when toxicity is suspected, because
additional drug will compound the symptoms. Antiemetics are useful for
counteracting drug side effects, but they should not be used when the
patient's symptoms indicate toxicity.
A patient reports becoming "immune" to a medication because
it no longer works to alleviate symptoms. The nurse recognizes that
this decreased effectiveness is likely caused by:
produced by the body that compete with the drug for receptor
b. decreased selectivity of receptor sites, resulting in a
variety of effects.
c. desensitization of receptor sites by
continual exposure to the drug.
d. synthesis of more receptor
sites in response to the medication.
Continual exposure to an agonist would cause the cell to
become less responsive or desensitized. The body does not produce
antagonists as a response to a medication. Receptor site selectivity
is determined by physiologic factors and not by the substances that
bind to them. Medications do not cause more receptors to be produced.
A patient has been receiving an antibiotic with a small therapeutic
index for 10 days. Upon assessment, the nurse notes an increase in the
drug's side effects. What would be the nurse's priority
a. Call the prescriber and have the antibiotic
b. Suspect an allergic reaction and administer a PRN
c. Ask the prescriber to order a plasma drug level
d. Set up oxygen and obtain an order for an antagonist.
A narrow therapeutic index indicates that a drug is relatively
unsafe and should be monitored closely. The nurse should have a blood
level drawn to confirm suspicions of toxicity. The nurse would not
have the antibiotic changed, because there is no cause at this time.
The patient is unlikely to be experiencing an allergic reaction,
because the antibiotic has been in the system for 10 days. The patient
shows no signs of anaphylaxis, so oxygen and an antagonist are not indicated.
A patient who is taking morphine for pain asks the nurse how a pain
medication can also cause constipation. What does the nurse know about
a. It binds to different types of receptors in the
b. It can cause constipation in toxic doses.
causes only one type of response, and the constipation is
d. It is selective to receptors that regulate more
than one body process.
Morphine is a medication that is selective to receptor type
that regulates more than one process. Because it is selective to
receptor type, it does not bind to different types of receptors.
Constipation is a normal side effect and is not significant for toxicity.
What occurs when a drug binds to a receptor in the body?
alters the receptor to become nonresponsive to its usual endogenous
b. It increases or decreases the activity of that
c. It gives the receptor a new function.
prevents the action of the receptor by altering its response to
When a drug binds to a receptor, it mimics or blocks the
actions of the usual endogenous regulatory molecules, either
increasing or decreasing the rate of the physiologic activity normally
controlled by that receptor. It does not alter the activity of the
receptor and does not give the receptor a new function
The nurse administers naloxone [Narcan] to a patient who has received
a toxic dose of morphine sulfate. The nurse understands that the
naloxone is effective because of which action?
a. Countering the
effects of morphine sulfate by agonist actions
b. Increasing the
excretion of morphine sulfate by altering serum pH
activation of opioid receptors through antagonist actions
Regulating the sensitivity of opioid receptors by neurochemical alterations
Naloxone acts by blocking the action of opioids at opioid
receptors. An opioid agonist would increase the effects of morphine.
Naloxone does not affect serum pH or excretion of opioids. Naloxone
does not alter the sensitivity of opioid receptors.
Two nurses are discussing theories of drug-receptor interaction.
Which statements are true regarding the affinity of a drug and its
receptor? (Select all that apply.)
a. Affinity and intrinsic
activity are dependent properties.
b. Affinity refers to the
strength of the attraction between a drug and its receptor.
Drugs with high affinity are strongly attracted to their
d. Drugs with low affinity are strongly attracted to
e. The affinity of a drug for its receptors is
reflected in its potency.
B, C, E
Affinity refers to the strength of the attraction
between a drug and its receptor. Drugs with high affinity are strongly
attracted to their receptors, and the affinity of a drug and its
receptors is reflected in its potency. Affinity and intrinsic activity
are independent properties. Drugs with low affinity are weakly
attracted to their receptors.
Which drugs will not be affected by interpatient variability? (Select
all that apply.)
a. Antiseptics applied to the skin to slow
b. Antacids to help with the discomfort of
c. Broad-spectrum antibiotics that are effective
against many organisms
d. Chelating agents that remove metal
compounds from the body
e. Topical analgesics used to treat
A, B, D
Antiseptics, antacids, and chelating agents are all
receptorless drugs that do not depend on the body's processes for
effects; these agents react with other molecules. Broad-spectrum
antibiotics and topical analgesics bind with receptors to produce
desired effects, and these processes can be influenced by individual
The nurse is teaching a patient about taking warfarin and asks if the
patient takes aspirin. This assessment by the nurse reflects a
knowledge of which type of drug interaction?
a. Creation of
b. Increased therapeutic effects
d. Potentiative effects
A potentiative effect is one in which one drug intensifies the
effects of another. Both warfarin and aspirin suppress blood clotting,
and the combination may increase the risk of bleeding, which is an
intensified adverse effect. Creation of a unique effect is a rare
occurrence in which the combination of two drugs creates a response
not seen with either drug when given alone. Increased therapeutic
effects are a type of potentiative effect; however, in this case the
combination of two drugs would increase the desired effects. An
inhibitory effect is a type of pharmacodynamic effect that occurs when
an antagonist drug inhibits the action of an agonist drug at the same
A young adult postoperative patient is receiving morphine 2 to 4 mg
IV every 2 hours PRN pain. The last dose was 3 mg given 2 hours ago.
The patient is asleep, and the nurse notes a heart rate of 86 beats
per minute and a respiratory rate of 8 breaths per minute. Which PRN
medication will the nurse give this patient?
[Benadryl] to counter morphine side effects
b. Morphine 4 mg for
increased pain, as indicated by tachycardia
c. Naloxone [Narcan]
to block the effects of the morphine
d. Nothing at this time,
because the patient is resting comfortably
A respiratory rate of 8 breaths per minute indicates
respiratory depression, which is a significant adverse effect
indicating morphine toxicity. Naloxone blocks the actions of morphine
at cell receptor sites and is given to quickly reverse the effects.
This patient does not have signs of an allergic response, which would
include shortness of breath, a rapid respiratory rate, and wheezing.
The tachycardia might be a sign of worsening pain, but the toxic
effects must be treated first. Patients who are sleeping are not
always pain free.
In a discussion of drug-drug interactions, which would be the best
example of a beneficial inhibitory interaction?
[Narcan] blocking morphine sulfate's actions
b. Antacids blocking
the action of tetracycline [Sumycin]
c. Propanolol [Inderal]
blocking the effects of albuterol
d. Cholestyramine blocking the
actions of antihypertensive drugs
Naloxone is used when a narcotic overdose has occurred. As a
narcotic antagonist, it provides a beneficial inhibitory interaction.
An antacid blocking tetracycline's antibiotic effects would not be
beneficial, but rather detrimental to the desired effects of the
tetracycline. Alcohol would not block the effects of opiates, but
would contribute to CNS depression. Cholestyramine and certain other
adsorbent drugs, which are administered orally but do not undergo
absorption, can adsorb other drugs onto themselves, thereby preventing
absorption of the other drugs into the blood.
A patient is taking drug X and receives a new prescription for drug
Y, which is listed as an inducing agent. The nurse caring for this
patient understands that this patient may require ____ doses of drug
a. lower; X
b. lower; Y
c. higher; X
An inducing agent stimulates the synthesis of CYP isoenzymes,
which may increase the metabolism of other drugs as much as two- to
threefold, thereby lowering the level of those drugs in the body and
requiring higher doses to maintain drug effectiveness.
A patient taking oral contraceptives thinks she may be pregnant. As
part of this patient's history, what will the nurse ask the
a. "Do you drink grapefruit juice?"
"Do you take seizure medication?"
c. "Do you take
your contraception with milk?"
d. "Do you use laxatives regularly?"
Patients taking oral contraceptives along with phenobarbital,
which is used to treat seizures, will have lower levels of the
contraceptive, because phenobarbital is an inducing agent, which
causes an increase in the metabolism of oral contraceptives.
Grapefruit juice inhibits the metabolism of some drugs, leading to
toxic effects. Dairy products interfere with the absorption of
tetracyclines, because the calcium binds with the drug to form an
insoluble complex. Laxatives reduce the absorption of some drugs by
speeding up the transit time through the gut.
A child ingests a parent's aspirin tablets, and the prescriber orders
sodium bicarbonate to block the toxic effects of the aspirin. The
nurse caring for this patient knows that sodium bicarbonate is
effective against the aspirin because it:
a. accelerates its
passage through the intestine.
b. alters urinary pH to enhance
c. induces CYP isoenzymes to increase drug
d. raises the pH of the interstitial fluid to
facilitate passage out of the cells.
Sodium bicarbonate increases the pH of interstitial fluid and
plasma, allowing the acidic aspirin ions to move outside the cells and
thus removing them from the site where they have toxic effects. It
does not have laxative effects and does not alter the rate of passage
through the gut. It is not a CYP isoenzyme inducer and therefore has
no effect on drug metabolism. It does not alter renal excretion of aspirin.
Which statement about food and drug interactions is true?
Foods alter drug absorption and metabolism but not drug
b. Medications are best absorbed on an empty
c. Patient discomfort is the food and drug interaction
of most concern.
d. Some foods can inhibit CYP isoenzymes and
alter drug metabolism.
Grapefruit juice inhibits CYP3A4, which lowers the metabolism
of some drugs, leading to toxic effects of drugs affected by these
isoenzymes. Foods can alter all pharmacokinetic and pharmacodynamic
processes. Not all medications are absorbed better on an empty
stomach; some require certain foods to enhance absorption. Patient
comfort is a concern, but it is not as important as more severe and
possibly life-threatening food and drug interactions.
A nurse is teaching a patient about a prescription for a monoamine
oxidase (MAO) inhibitor for depression. What will the nurse teach the
patient to avoid while taking this drug?
b. Aged cheeses
c. Brussels sprouts and
d. Grapefruit juice
Aged cheeses are rich in tyramine, which interacts with MAO
inhibitors to raise blood pressure to life-threatening levels.
Patients taking MAO inhibitors should be taught to avoid tyramine-rich
foods. Chianti wine contains tyramine, but other alcoholic beverages
do not. Brussels sprouts and cabbage are foods rich in vitamin K,
which can interfere with the effects of warfarin. Grapefruit juice
inhibits CYP3A4 and interferes with the metabolism of many medications.
A nurse is teaching a patient about a drug that induces
P-glycoprotein. The nurse will explain that this drug may cause which
effect on other drugs?
a. Decreased absorption in the
b. Decreased elimination through the kidneys
Increased brain exposure
d. Increased fetal absorption
Drugs that induce PGP can increase drug export from cells of
the intestinal epithelium into the intestinal lumen, thus decreasing
absorption of the drug. PGP inducers also increase drug elimination
and decrease brain and fetal drug exposure.
The nurse is providing multiple medications to a patient whose spouse
brings grapefruit juice every morning. The nurse will be concerned
about which classes of drugs? (Select all that apply.)
b. Selective serotonin reuptake
d. Beta blockers
Calcium channel blockers and selective serotonin reuptake
inhibitors have been shown to reach increased and/or toxic levels when
taken with grapefruit juice. Grapefruit juice is not contraindicated
with aminoglycosides, beta blockers, or penicillins.
The nurse is administering morning medications. The nurse gives a
patient multiple medications, two of which compete for plasma albumin
receptor sites. As a result of this concurrent administration, the
nurse can anticipate that what might occur? (Select all that
a. Binding of one or both agents will be reduced.
Plasma levels of free drug will rise.
c. Plasma levels of free
drug will fall.
d. The increase in free drug will intensify
e. The increase in bound drug will intensify effects.
A, B, D
When two drugs bind to the same site on plasma albumin,
coadministration of those drugs produces competition for binding. As a
result, binding of one or both agents is reduced, causing plasma
levels of free drug to rise. The increase in free drug can intensify
the effect, but it usually undergoes rapid elimination. The increase
in plasma levels of free drug is rarely sustained.
A nurse is caring for a patient who is taking multiple medications.
To help ensure that adverse drug reactions are prevented or minimized,
the nurse will do which of the following? (Select all that
a. Ask the patient about over-the-counter medications
b. Contact the prescriber to request cytochrome P450
c. Limit the patient's calcium intake.
d. Obtain a
thorough diet history.
e. Request orders for PRN medications to
treat any anticipated symptoms of drug interactions.
A, B, D
Over-the-counter medications add to drug interactions,
and a thorough history of all medications taken by the patient is
essential to minimize adverse drug reactions. Cytochrome P450 levels
yield important information about a patient's ability to metabolize
drugs and can help predict whether drugs will reach toxic levels or be
ineffective. A diet history allows providers to anticipate significant
known food-drug interactions. Limiting calcium intake is necessary
only if the patient is taking drugs known to interact with calcium,
such as tetracycline. Asking for PRN medications to treat drug
reactions may only compound the risk, because the risk of drug
interactions increases with the number of medications taken.
The prescriber has ordered an antibiotic for a patient with a
bacterial infection. The nurse provides patient education at discharge
and instructs the patient to take the drug on an empty stomach. When
should the patient take the drug? (Select all that apply.)
hour or more before a meal
b. Only after an 8-hour fast
Only after the patient has missed a meal
d. At least 2 hours
after a meal
e. Shortly before a meal
The absorption of some drugs can be significantly reduced
by food; these drugs should be taken on an empty stomach, which is 1
hour or more before a meal or at least 2 hours after a meal. An 8-hour
fast is not necessary; the patient does not need to miss a meal to
take the medication; and it is not reasonable to have the patient on
thin liquids for 12 hours.
A patient is given a new medication and reports nausea within an hour
after taking the drug. The nurse consults the drug information manual
and learns that nausea is not an expected adverse effect of this drug.
When the next dose is due, what will the nurse do?
the drug and tell the patient to report further nausea.
the drug and notify the provider of the patient's symptoms.
Report the symptoms of nausea to the MEDWATCH program.
an order for an antiemetic to counter this drug's effects.
Not all adverse drug reactions (ADRs) can be detected during
clinical trials, and nurses should be alert to any effects that may
result from drug administration. Because nausea is not a serious
effect and because it is not yet known whether the drug is the cause
of this patient's nausea, the nurse should administer the medication
and observe the patient for recurrence of the symptom. It is not
necessary to hold the drug, because nausea is not a serious side
effect. The MEDWATCH program should be notified when there is a
greater suspicion that the drug may have caused the nausea if the
nausea occurs with subsequent doses. Until there is greater suspicion
that the drug actually caused this patient's nausea, giving an
antiemetic is not indicated.
A patient is being discharged after surgery. During the admission
history, the nurse learned that the patient normally consumes two or
three glasses of wine each day. The prescriber has ordered hydrocodone
with acetaminophen [Lortab] for pain. What will the nurse do?
Request an order for acetaminophen without hydrocodone for
b. Suggest that the patient use ibuprofen for pain.
Tell the patient not to drink wine while taking Lortab.
the patient to limit wine intake to one or two glasses per day.
Combining a hepatotoxic drug with certain other drugs may
increase the risk of hepatotoxicity. When even therapeutic doses of
acetaminophen are taken with alcohol, the acetaminophen can cause
liver damage. Patients should be cautioned not to drink alcohol; even
two drinks with acetaminophen can produce this effect. Hydrocodone
does not contribute to hepatotoxicity. Ibuprofen is not indicated for
postoperative pain unless the pain is mild. Limiting wine to one or
two glasses per day still increases the risk of hepatotoxicity.
A nurse is reviewing a medication administration record before
administering medications. Which order will the nurse
a. Furosemide [Lasix] 20 mg QD PO
[Lasix] 20 mg qd PO
c. Furosemide [Lasix] 20 mg daily
Furosemide [Lasix] 20 mg PO daily
The correct answer is a complete order; it contains the
medication, dose, route, and time. "qd" is no longer an
accepted abbreviation; it should be written out as "daily"
or "every day." The order of "20 mg daily" does
not specify the route to be used.
A patient is given a drug for the first time and develops shortness
of breath. The patient's heart rate is 76 beats per minute, the
respiratory rate is 20 breaths per minute, and the blood pressure is
120/70 mm Hg. The nurse checks a drug administration manual to make
sure the correct dose was given and learns that some patients taking
the drug experience shortness of breath. The nurse will contact the
provider to report what?
a. An allergic reaction
c. An iatrogenic response
d. A side effect
A side effect is a secondary drug effect produced at
therapeutic doses. This patient received the correct dose of the drug
and developed shortness of breath, which, in this case, is a drug side
effect. To experience an allergic reaction, a patient must have prior
exposure to a drug and sensitization of the immune response. An
idiosyncratic effect results from a genetic predisposition to an
uncommon drug response. An iatrogenic response occurs when a drug
causes symptoms of a disease.
A nurse is preparing to give an antibiotic to a patient who reports
being allergic to antibiotics. Before giving the medication, what will
the nurse do first?
a. Ask whether the patient has taken this
antibiotic for other infections
b. Question the patient about
allergies to other medications
c. Request an order for a lower
dose of the antibiotic
d. Request an order for an antihistamine
A drug that causes disease-like symptoms is known to be
iatrogenic. Nurses should be prepared for this possibility and be
prepared to withdraw the drug if necessary and treat the symptoms.
Such effects are not teratogenic. Patients with a genetic
predisposition to respond differently to drugs are known to have
idiosyncratic effects. Iatrogenic effects, even when known, are not
typically expected side effects.
A nurse provides teaching to a patient who will begin taking a drug
with a known risk of hepatotoxicity. Which statement by the patient
indicates a need for further teaching?
a. "I should avoid
taking acetaminophen while taking this drug."
will need periodic evaluation of aspartate aminotransferase and
alanine aminotransferase levels."
c. "If I experience
nausea, vomiting, or abdominal pain, I should call my
d. "Routine testing and early detection of
problems will prevent liver failure."
Drug-induced liver injury can progress from undetectable to
advanced between routine tests; therefore, routine testing does not
always prevent liver failure. Patients taking known hepatotoxic drugs
should avoid other drugs, such as acetaminophen, that can cause liver
damage. Aspartate aminotransferase (AST) and alanine aminotransferase
(ALT) are liver enzymes that are routinely monitored when a patient is
taking hepatotoxic drugs. Nausea, vomiting, and abdominal pain are
signs of liver injury and should be reported.
A patient is taking sertraline [Zoloft] for depression, and the
provider orders azithromycin [Zithromax] to treat an infection. What
will the nurse do?
a. Contact the provider to discuss an
alternative to azithromycin.
b. Request an order for a different
c. Request an order to reduce the dose
d. Withhold the sertraline while giving the azithromycin.
Both sertraline and azithromycin prolong the QT interval, and
when taken together, they increase the risk of fatal dysrhythmias.
Because the antibiotic is used for a short time, it is correct to
consider using a different antibiotic. Reducing the dose of sertraline
does not alter the combined effects of two drugs that lengthen the QT
interval. Sertraline should not be stopped abruptly, so withholding it
during antibiotic therapy is not indicated.
A patient is taking a drug that has known toxic side effects. What
will the nurse do?
a. Discontinue the drug at the first signs of
b. Ensure that complete blood counts are ordered
c. Monitor the function of all organs potentially
affected by the drug.
d. Teach the patient how to treat the
symptoms if they develop.
When a drug is administered that has known toxic side effects,
the nurse is responsible for monitoring all organ systems potentially
affected by the drug. Not all toxic side effects warrant
discontinuation of the drug, and a nurse cannot discontinue a drug
without an order from the provider. Complete blood counts are
indicated only for drugs that affect the blood. Some drugs need to be
discontinued, so teaching a patient to treat symptoms is not correct
in all cases.
A nursing student is preparing to give a medication that has a boxed
warning. The student asks the nurse what this means. What will the
nurse explain about boxed warnings?
a. They indicate that a drug
should not be given except in life-threatening circumstances.
They provide detailed information about the adverse effects of the
c. They alert prescribers to measures to mitigate potential
harm from side effects.
d. They provide information about
antidotes in the event that toxicity occurs.
Boxed warnings (also known as black box warnings) are used to
alert providers to potential side effects and to ways to prevent or
reduce harm from these side effects. A boxed warning is placed on any
drug that, although useful, has serious side effects; this is a way to
keep drugs on the market while protecting patients. Many of these
drugs are used in situations that are not life threatening. The boxed
warning provides a concise summary and not a detailed explanation of
drug side effects. The boxed warning does not include antidotes to toxicity.
Which actions occur in 90% of fatal medication errors? (Select all
a. Confusing drugs with similar packaging
Giving a drug intravenously instead of intramuscularly
Nasarel instead of Nizoral
d. Using an infusion device that
e. Writing a prescription illegibly
B, C, E
Ninety percent of fatal medication errors fall into
three categories: human factors, communication mistakes, and name
confusion. Giving a drug IV (intravenously) instead of IM
(intramuscularly) is an example of a human factor; writing a
prescription so that it is illegible is an example of a communication
mistake; and giving a drug with a name that sounds like the name of
another drug is an example of name confusion. Confusion of drugs with
similar packaging and using a faulty device also can cause fatal drug
errors, but these factors do not fall into the categories that account
for 90% of fatal errors.
Which are effective ways to help prevent medication errors? (Select
all that apply.)
a. Developing nonpunitive approaches to track
b. Focusing on caregivers who make errors
patients to be active, informed members of the healthcare team
Naming, blaming, and shaming those who make errors
electronic medical order entry systems
A, C, E
To help prevent medication errors, it is important to
create an environment for tracking errors that is nonpunitive so that
caregivers can learn from mistakes and work together to change systems
appropriately. Helping patients be active, informed members of the
healthcare team is a useful tool in this process. Using electronic
order entry helps eliminate confusion from poor handwriting and allows
built-in systems to warn caregivers about possible overdoses, side
effects, and drug interactions; it also helps ensure the right dose at
the right time to the right patient. An approach that focuses on those
who make mistakes by naming, blaming, and shaming is not productive
and often results in personnel who cover up mistakes instead of
working to make things better.
Which patients are at increased risk for adverse drug events? (Select
all that apply.)
a. A 2-month-old infant taking a medication for
gastroesophageal reflux disease
b. A 23-year-old female taking an
antibiotic for the first time
c. A 40-year-old male who is
intubated in the intensive care unit and taking antibiotics and
d. A 7-year-old female receiving insulin for
e. An 80-year-old male taking medications for COPD
A, C, E
Patients at increased risk for adverse drug events
include the very young, the very old, and those who have serious
illnesses. Females, children, and young adults taking single
medications do not have increased risks for adverse events.
A postoperative patient who is worried about pain control will be
discharged several days after surgery. The nurse providing discharge
teaching tells the patient that the prescribed Lortab is not as strong
as the morphine the patient was given in the immediate postoperative
period. Which response is the patient likely to experience?
decreased likelihood of filling the prescription for the drug
A negative placebo effect when taking the medication
increased compliance with the drug regimen
realistic expectations about the drug
The full extent of placebo effects, if they truly occur, is
not well documented or understood, although a decrease in pain as a
placebo effect has been demonstrated to some extent. To foster a
beneficial placebo effect, it is important for all members of the
healthcare team to present an optimistic and realistic assessment of
the effects of the drug the patient is taking. If the nurse tells an
anxious patient that the medication being given is not as strong as
what has been given, the patient is likely to have lowered
expectations of the effectiveness of the drug, causing a negative
placebo effect. Lowered expectations do not mean that the patient will
give up on the drug entirely; in fact, the patient may actually fill
the prescription and then take more drug than what is prescribed to
get a better effect.
A nurse administers the same medication in the same preparation in
the same dose to several patients and notes that some patients have a
better response to the drug than others. What is the most likely
explanation for this phenomenon?
a. Altered bioavailability of
b. Patient compliance with the therapeutic
c. Pharmacogenomic differences among individuals
Placebo effects enhancing expectations of drug efficacy
Each patient's genetic makeup can determine how that patient
responds to drugs quantitatively and qualitatively, and this is the
most likely cause of individual variation when the same drug is given
at the same dose. The bioavailability of a drug is determined by the
drug's composition and varies across formulations of the drug. The
patients in this example were given the same drug. The nurse was
administering the medication to the patients, so compliance is not an
issue. Nothing in this example indicates that a placebo effect was in play.
The U.S. Food and Drug Administration (FDA) recommends genetic
testing of patients receiving certain medications. Genetic testing
a. better establish a drug's therapeutic
b. determine whether a patient is a rapid or slow
metabolizer of the drug.
c. identify racial characteristics that
affect psychosocial variation in drug response.
d. produce a drug
that is tailored to an individual patient's genetic makeup.
Pharmacogenomics is the study of the ways genetic variations
affect individual responses to drugs through alterations in genes that
code for drug-metabolizing enzymes and drug receptors. For some drugs,
the FDA requires genetic testing, and for others, this testing is
recommended but not required. Genetic testing does not determine a
drug's therapeutic index; this is a measure of a drug's safety based
on statistics of the drug's use in the general population (see Chapter
5). Any distinct physiologic differences in drug response among
various racial populations are related to genetic differences and do
not affect psychosocial differences in drug responses. Genetic testing
is recommended to identify how a patient will respond to a drug and
not to design a drug specific to an individual.
A patient asks a nurse why a friend who is taking the same drug
responds differently to that drug. The nurse knows that the most
common variation in drug response is due to differences in each
a. drug receptor sites.
c. metabolism of drugs.
d. psychosocial response.
The most common source of genetic variation in drug response
is related to alterations in drug metabolism and is determined by
genetic codes for various drug-metabolizing isoenzymes. There are
known genetic differences in codes for drug target sites, but these
are not as numerous as those for metabolic isoenzymes.
Hypersensitivity potential is also genetically determined, but
variations produce differences in adverse reactions to drugs and not
in drug effectiveness. Psychosocial responses vary for many less
measurable reasons, such as individual personalities and variations in cultures.
A nurse is preparing to care for a patient who is receiving digoxin.
When screening for potential adverse effects from this drug, the nurse
will review which of this patient's laboratory results?
b. Blood urea nitrogen (BUN) and creatinine
d. Serum electrolytes
Pharmacodynamic tolerance results when a patient takes a drug
over a period of time. Adaptive processes occur in response to chronic
receptor occupation. The result is that the body requires increased
drug, or an increased MEC, to achieve the same effect. This patient is
getting adequate pain relief, so there is no negative placebo effect.
Tachyphylaxis is a form of tolerance that can be defined as a
reduction in drug responsiveness brought on by repeated dosing over a
short time; this occurs over several months. Barbiturates induce
synthesis of hepatic enzymes that cause increased metabolism of the
drug, but it does not increase the MEC.
A nurse is caring for a woman with breast cancer who is receiving
tamoxifen. A review of this patient's chart reveals a deficiency of
the CYP2D6 gene. The nurse will contact the provider to
a. a different medication.
b. an increased
c. a reduced dose.
d. serum drug levels.
Women with a deficiency of the CYP2D6 gene lack the ability to
convert tamoxifen to its active form, endoxifen, and will not benefit
from this drug. Another drug should be used to treat this patient's
breast cancer. Increasing the dose, reducing the dose, or monitoring
serum drug levels will not make this drug more effective in these women.
A nurse is teaching a group of women about medications. The women
want to know why so many drugs have unpredictable effects in women.
The nurse will tell them that:
a. drugs usually have more toxic
effects in women.
b. most known drug effects are based on drug
trials in men.
c. women have varying responses to drugs during
d. women metabolize drugs more slowly.
Until 1997 almost all clinical drug trials were performed in
men. Women may have more toxic effects with some drugs and fewer toxic
effects with others. Not all drugs are influenced by hormonal changes.
Women metabolize some drugs more slowly and other drugs more quickly.
Unless drug trials are performed in both women and men, the effects of
drugs in women will not be clear.
The nurse is assessing a newly admitted older patient who has
recently lost 15 pounds. The nurse notes that the patient is taking
warfarin (Coumadin). Which laboratory tests will the nurse discuss
with this patient's provider?
a. Blood glucose and C-reactive
b. Complete blood count and hepatic function
c. Renal function tests and serum electrolytes
Serum albumin and coagulation studies
Older patients and those who are malnourished are at increased
risk for low serum albumin. Since warfarin binds to albumin, such
patients are at increased risk for elevated warfarin levels, which can
cause increased bleeding. The nurse should request albumin levels and
Which groups of people are especially sensitive to medication
effects? (Select all that apply.)
a. Older adults
Older adults and infants are the two groups most sensitive
to drugs because of differences in organs that absorb, metabolize, and
excrete drugs. In the older adult, organ degeneration accounts for
these differences, whereas in infants the differences are related to
organ immaturity. Racial and gender differences tend to be related to
genetic differences and not race and gender per se. These groups are
more sensitive to drug effects in some cases and less sensitive in
A patient receives morphine and shows signs of toxicity. The
prescriber orders naloxone [Narcan] to reverse the effects of the
morphine. The nurse understands that the naloxone reverses morphine
toxicity by which action on morphine receptor sites?
b. Inhibiting transmitter release
Interfering with transmitter storage
d. Preventing activation of receptors
Morphine and its antagonist, naloxone, act directly at the
same receptors. Morphine causes activation, and naloxone prevents
activation. Neither morphine nor naloxone acts to alter transmitter
reuptake, release, or storage.
A nurse is teaching a group of nursing students about
neuropharmacology. Which statement by a student about peripheral
nervous system (PNS) drugs indicates a need for further
a. "Drugs affecting axonal conduction have a
variety of uses."
b. "Drugs that alter synaptic
transmission can be highly selective."
c. "Many PNS
drugs act by altering synaptic transmission."
drugs work by influencing receptor activity."
Local anesthetics are drugs that work by altering axonal
conduction. Any drug affecting axonal conduction would be
nonselective, because axonal conduction of impulses is essentially the
same in all neurons. In contrast, drugs that affect synaptic
transmission can be highly selective, because each transmitter has
different effects on receptor sites. Most PNS drugs work on synaptic
transmission processes. Through their effects on transmitters, they
influence receptor activity.
A nurse is preparing to administer a medication and learns that it is
a nonselective agonist drug. What does the nurse understand about this
a. It directly activates receptors to affect many
b. It directly activates receptors to
affect a specific physiologic process.
c. It prevents receptor
activation to affect many physiologic processes.
d. It prevents
receptor activation to affect a specific physiologic processes.
Drugs that directly activate receptors are called agonists, so
this drug will directly activate the receptor site. Drugs that are
nonselective activate a variety of receptor sites. A selective agonist
would directly activate specific receptors to affect a specific
process. An antagonist would prevent receptor activatio
A nurse is administering drug X to a patient. The drug information
states that the drug acts by activating receptors in the peripheral
nervous system by increasing transmitter synthesis. The nurse
understands that the effect of this drug is to:
b. enhance transmitter storage.
increase receptor activation.
d. synthesize supertransmitters.
Drugs that increase transmitter synthesis increase receptor
activation. Other drugs that alter transmitter synthesis can decrease
synthesis and would cause decreased receptor activation. Drugs that
affect transmitter production do not exert their effects on axonal
conduction. The amount of transmitter produced does not directly
affect transmitter storage. Some drugs that alter transmitter
synthesis cause the synthesis of transmitter molecules that are more
effective than the transmitter itself.
A nurse learns about a drug that interferes with transmitter storage
in the PNS. The transmitter affected by this drug causes an increased
heart rate. What response will the nurse expect to see when this drug
b. Positive inotropic
c. Prolonged receptor activation
Drugs that interfere with transmitter storage reduce receptor
activation, because disruption of storage decreases the amount of
transmitter available for release. Because this transmitter increases
the heart rate, the result will be a decrease in the heart rate.
Inotropic effects control the force of contraction, not the rate of
contraction. Decreased transmitter storage would result in decreased
receptor activation. Tachycardia would occur if transmitter
availability were increased.
A patient receiving botulinum toxin injections to control muscle
spasticity asks how the drug works. The nurse knows that this drug
affects the transmitter acetylcholine by:
a. inhibiting its
b. interfering with its storage.
c. preventing its
d. promoting its synthesis.
Acetylcholine is a neurotransmitter that activates receptors
that increase skeletal muscle contraction. Botulinum toxin inhibits
the release of this transmitter. It does not interfere with storage,
reuptake, or synthesis of acetylcholine.
A patient has allergies and takes an antihistamine. The patient wants
to know how the drug works. The nurse understands that antihistamines
work because they are what?
Antihistamines bind to receptors to prevent activation by
histamine; this makes antihistamines antagonist drugs. Antihistamines
do not activate receptors. Agonist drugs activate receptors; they are
A nursing student asks about drugs that interfere with the
termination of transmitter action. Which statement by the nurse is
a. "Drugs act on this process by altering the
diffusion of the transmitter away from the synaptic gap."
"Drugs can interfere with termination by either increasing or
decreasing reuptake of the transmitter."
c. "Drugs in
this category lead to decreased activation by the transmitter in the
d. "These drugs reduce either reuptake or
degradation of the transmitter, causing an increase in receptor activation."
Drugs that interfere with termination of transmitter action do
so by blocking transmitter reuptake or inhibiting transmitter
degradation, resulting in increased receptor activation, because more
of the transmitter remains available. Diffusion of the transmitter
occurs naturally, but it is a slow process with little clinical
significance. Drugs that alter this process cause a decrease in
reuptake, not an increase. The effect of drugs that interfere with
termination of transmitter action is increased activation.
What is the target organ when a beta1 agonist is
A beta1 agonist increases the patient's heart rate and blood
pressure and is used in heart failure. Beta1 agonists would not be
used for kidney, respiratory, or liver failure.
A nurse is teaching a patient about a medication that alters
sympathetic nervous system functions. To evaluate understanding, the
nurse asks the patient to describe which functions the sympathetic
nervous system regulates. Which answer indicates the need for further
a. "The digestive functions of the
b. "The cardiovascular system"
"The fight-or-flight response"
d. "Body temperature"
The sympathetic nervous system does not regulate digestive
functions of the body—the parasympathetic nervous system does; further
education is needed. The sympathetic nervous system regulates the
cardiovascular system, the fight-or-flight response, and the body
temperature; no further education is needed.
A patient is wheezing and short of breath. The nurse assesses a heart
rate of 88 beats per minute, a respiratory rate of 24 breaths per
minute, and a blood pressure of 124/78 mm Hg. The prescriber orders a
nonspecific beta agonist medication. Besides evaluating the patient
for a reduction in respiratory distress, the nurse will monitor for
which side effect?
d. Urinary retention
Beta agonists are used for asthma because of their beta2
effects on bronchial smooth muscle, causing dilation. Beta1 effects
cause tachycardia and hypertension. Beta receptors do not exert
effects on the bladder.
A nurse is teaching a group of nursing students about
neurotransmitters. Which statement by a student about acetylcholine
indicates a need for further teaching?
a. "It activates
three cholinergic receptor subtypes."
b. "It has
effects in the parasympathetic, sympathetic, and somatic nervous
c. "It is used at most junctions of the
peripheral nervous system."
d. "Its transmission is
terminated by reuptake into the cholinergic nerve terminal."
Acetylcholine (ACh) is destroyed by acetylcholinesterase, an
enzyme that degrades ACh into two inactive products: acetate and
choline. Choline is taken up into the nerve terminal. ACh activates
three receptor sites: nicotinicN, nicotinicM, and muscarinic. ACh has
effects throughout the peripheral nervous system (PNS) and is used at
most junctions in the PNS.
A nurse is administering an agonist drug that acts on postganglionic
neurons of the sympathetic nervous system. Which response will the
nurse expect to see?
a. Decreased sweating
c. Increased cardiac output
d. Pinpoint pupils
Norepinephrine (NE) is the most common neurotransmitter
released by all postganglionic neurons of the sympathetic nervous
system except those going to sweat glands where ACh is the
neurotransmitter. NE acts on alpha1, alpha2, and beta1 receptors to
increase the force and rate of cardiac contraction, thus increasing
cardiac output. ACh would increase sweating. Bronchodilation occurs
when epinephrine activates beta2 receptors on bronchial smooth muscle.
NE affects alpha1 receptors to dilate the pupils.
Many medications list side effects that include dry mouth,
constipation, and urinary retention. What kinds of effects are
a. Alpha adrenergic
Cholinergic stimulation by ACh causes increased salivation,
increased gastrointestinal (GI) motility, and relaxation of the
bladder trigone and sphincter. Anticholinergic medications inhibit
these responses, causing dry mouth, constipation, and urinary
retention. Alpha-adrenergic agents effect processes in the sympathetic
nervous system, causing peripheral vasoconstriction and pupil
dilation, among other effects. The effects of beta-adrenergic
medications are seen mostly in the heart and blood vessels. The
sympathetic nervous system has both cholinergic and adrenergic transmitters.
A nurse is explaining activation of beta2 receptors to nursing
students during a clinical rotation at the hospital. Which statement
by a student demonstrates a need for further teaching?
"Beta2 activation results in bronchodilation."
"Beta2 activation results in contraction of uterine
c. "Beta2 activation results in
d. "Beta2 activation results in
vasodilation of skeletal muscles."
Beta2 activation would result in relaxation of uterine smooth
muscle, not contraction; this statement indicates a need for further
teaching. Bronchodilation is an effect of beta2 activation; no further
teaching is needed. Beta2 activation does result in glycogenolysis; no
further teaching is needed. Beta2 activation does result in
vasodilation of skeletal muscle; no further teaching is needed.
A pregnant patient is in premature labor. Which class of drug will
she be given?
a. Alpha1 agonist
d. Beta2 antagonist
Beta2 agonists cause relaxation of uterine muscle, slowing or
stopping the contractions that precipitate labor. An alpha1 agonist
would have effects on the heart and arterioles. Anticholinergic drugs
generally are given for their effects on the urinary and GI tracts and
do not affect uterine muscle. A beta2 antagonist would cause increased
constriction of uterine muscle.
A patient is to receive a beta agonist. Before administration of this
medication, which assessment finding would most concern the
a. Pulse oximetry reading of 88%
b. Blood pressure of
100/60 mm Hg
c. Respiratory rate of 28 breaths per minute
Heart rate of 110 beats per minute
A beta agonist dilates respiratory smooth muscle, but as a
side effect, it can stimulate the heart. A heart rate of 110 beats per
minute is a concern, because this medication may further increase the
already elevated heart rate. A pulse oximetry reading of 88% is a
concern, but the medication causes bronchodilation and increased
oxygenation; this should increase the pulse oximetry reading. A blood
pressure of 100/60 mm Hg is on the low side, but this medication may
actually cause an increase in blood pressure as a side effect; this
should not concern the nurse before administration of the medication.
A respiratory rate of 28 breaths per minute is elevated; however, this
medication should increase oxygenation by bronchodilation, and the
patient's respiratory rate should decrease once oxygenation has
improved. Therefore, this should not concern the nurse.
A prescriber has ordered pilocarpine [Pilocar]. A nurse understands
that the drug stimulates muscarinic receptors and would expect the
drug to have which action?
a. Reduction of excessive secretions
in a postoperative patient
b. Lowering of intraocular pressure in
patients with glaucoma
c. Inhibition of muscular activity in the
d. Prevention of hypertensive crisis
Pilocarpine is a muscarinic agonist used mainly for topical
therapy of glaucoma to reduce intraocular pressure. Pilocarpine is not
indicated for the treatment of excessive secretions and mucus; in
fact, pilocarpine is used to treat dry mouth. Pilocarpine does not
inhibit muscular activity in the bladder. Pilocarpine is not used to
prevent hypertensive crisis.
A patient has developed muscarinic antagonist toxicity from ingestion
of an unknown chemical. The nurse should prepare to administer which
a. Atropine [Sal-Tropine] IV
c. An acetylcholinesterase activator
Physostigmine is indicated for muscarinic antagonist toxicity.
Atropine is a drying agent and would only complicate the drying action
that arises from the muscarinic antagonist. An acetylcholinesterase
activator would only contribute to dryness that arises from the
muscarinic antagonist. Ephedrine is not indicated for muscarinic
A prescriber has ordered bethanechol [Urecholine] for a postoperative
patient who has urinary retention. The nurse reviews the patient's
chart before giving the drug. Which part of the patient's history
would be a contraindication to using this drug?
a. Asthma as a
b. Gastroesophageal reflux
Bethanechol is contraindicated in patients with active or
latent asthma, because activation of muscarinic receptors in the lungs
causes bronchoconstriction. It increases the tone and motility of the
gastrointestinal (GI) tract and is not contraindicated in patients
with reflux. It causes vasodilation and would actually lower blood
pressure in a hypertensive patient. It causes dysrhythmias in
A patient will begin using a transdermal preparation of a muscarinic
antagonist for overactive bladder (OAB). The nurse teaches the patient
what to do if side effects occur. Which statement by the patient
indicates the need for further teaching?
a. "I can use
sugar-free gum for dry mouth."
b. "I may need laxatives
c. "I should keep the site covered
to prevent other people from getting the medicine."
"I will take Benadryl for any itching caused by a local reaction
to the patch."
Benadryl is an antihistamine, and even though it is not
classified as a muscarinic antagonist, it has anticholinergic effects.
Giving it with a muscarinic antagonist greatly enhances these effects,
so it should not be used. Muscarinic antagonists cause dry mouth, and
patients should be taught to use sugar-free gum or candies to help
with this. Muscarinic antagonists can cause constipation, and
laxatives may be used. Medication applied topically can be transferred
to others who come in contact with the skin, so the site should be covered.
An older adult patient who lives alone and is somewhat forgetful has
an overactive bladder (OAB) and reports occasional constipation. The
patient has tried behavioral therapy to treat the OAB without adequate
results. Which treatment will the nurse anticipate for this
a. Oxybutynin short-acting syrup
[Ditropan XL] extended-release tablets
c. Oxybutynin [Oxytrol]
d. Percutaneous tibial nerve stimulation (PTNS)
The transdermal patch is applied weekly and may be the best
option for a patient who is more likely to forget to take a daily
medication. The transdermal preparation has fewer side effects than
the systemic dose, so it is less likely to increase this patient's
constipation. The syrup has a high incidence of dry mouth and other
anticholinergic side effects. The extended-release tablets must be
given daily, and this patient may not remember to take them. PTNS is
used after behavioral and drug therapies have failed.
A patient received atropine intravenously before surgery. The
recovery room nurse notes that the patient is delirious upon awakening
and has a heart rate of 96 beats per minute, a respiratory rate of 22
breaths per minute, and a blood pressure of 110/78 mm Hg. The nurse
notifies the anesthesiologist, who will order:
charcoal to minimize intestinal absorption of the antimuscarinic
b. an acetylcholinesterase inhibitor to compete with the
antimuscarinic agent at receptors.
c. an antipsychotic medication
to treat the patient's central nervous system symptoms.
ipratropium bromide [Atrovent] to counter the respiratory effects of
the antimuscarinic agent.
This patient is showing signs of antimuscarinic toxicity,
caused by the atropine given during surgery. The most effective
antidote is physostigmine, which inhibits acetylcholinesterase,
allowing acetylcholine to build up at cholinergic junctions and
compete with the antimuscarinic agent for receptor binding. Activated
charcoal is useful only if an antimuscarinic agent has been ingested,
because it impedes absorption from the GI tract. Because this
patient's psychotic symptoms are caused by an antimuscarinic agent,
physostigmine should be given to treat the cause; an antipsychotic
medication would only treat the symptom. Ipratropium bromide is an
antimuscarinic agent and would only compound the effects. This
patient's respiratory rate is only mildly elevated.
Bethanechol [Urecholine] is used to treat urinary retention but is
being investigated for use in which other condition?
b. Gastroesophageal reflux
Bethanechol is being investigated for treatment for
gastroesophageal reflux disease (GERD) because of its effects on
esophageal motility and the lower esophageal sphincter. Bethanechol
stimulates acid secretion and could intensify ulcer formation.
Bethanechol can cause hypotension. Because bethanechol increases the
motility and tone of intestinal smooth muscle, the presence of an
obstruction could lead to bowel rupture.
A patient receives topical atropine to facilitate an eye examination.
The nurse will tell the patient to remain in a darkened room or to
wear sunglasses for several hours until the effects of the medication
wear off. This teaching is based on the nurse's knowledge that
muscarinic antagonists cause:
a. elevation of intraocular
b. miosis and ciliary muscle contraction.
paralysis of the iris sphincter.
d. relaxation of ciliary muscles.
By blocking muscarinic receptors in the eye, atropine causes
paralysis of the iris sphincter, which prevents constriction of the
pupil; consequently, the eye cannot adapt to bright light. This also
causes an elevation in intraocular pressure, which increases the risk
of glaucoma. However, it is not an indication for wearing darkened
glasses. Muscarinic agonists cause miosis; atropine causes mydriasis.
The effect of relaxing ciliary muscles focuses the eye for far vision,
causing blurred vision
A patient who has esophageal cancer is experiencing dry mouth and the
provider orders oral pilocarpine to treat this symptom. What will the
nurse expect to teach this patient about this medication?
"This medication may cause rapid heart rate and elevated blood
b. "This medication may cause constipation
and gastric discomfort in large doses."
c. "You should
experience sweating with this medication and should not have other
d. "You will begin taking 5 mg three
times daily and may increase the dose to 10 mg."
The dosing for pilocarpine, when used for dry mouth associated
with head and neck cancers, is 5 mg three times daily, which may be
titrated up to 10 mg three times daily. Tachycardia and constipation
are side effects of atropine. Sweating occurs with low doses of
pilocarpine. Higher doses, such as this, are associated with the full
range of muscarinic effects.
A nurse is teaching a nursing student about the two classes of
adrenergic agonist drugs. Which statement by the nursing student
indicates understanding of the teaching?
may be given orally."
b. "Catecholamines often require
continuous infusion to be effective."
"Noncatecholamines do not cross the blood-brain
d. "Noncatecholamines undergo rapid
degradation by monoamine oxidase."
Catecholamines undergo rapid degradation by monoamine oxidase
(MAO) and catechol-O-methyltransferase (COMT). Consequently, they have
a brief duration of action, and continuous infusion often is required
to maintain the drug's effects. Catecholamines cannot be used orally.
Catecholamines do not cross the blood-brain barrier; noncatecholamines
do. Noncatecholamines are not degraded by MAO.
Dopamine is administered to a patient who has been experiencing
hypotensive episodes. Other than an increase in blood pressure, which
indicator would the nurse use to evaluate a successful
a. Decrease in pulse
b. Increase in urine
c. Weight gain
d. Improved gastric motilit
Dopamine would cause an increase in urine output, because
cardiac output is increased as a result of the increase in blood
pressure. The effectiveness of dopamine would not be measured by a
decrease in pulse, because dopamine's primary effect is to increase
blood pressure. Dopamine's effectiveness would not be evaluated by a
weight gain. Dopamine's effectiveness would not be evaluated by
improved gastric motility.
A nursing student asks the nurse about receptor specificity of
adrenergic agonist medications. What will the nurse say?
"As the dosage of these medications increases, drugs in this
class are more selective."
b. "Dopamine is selective
for dopamine receptors and has no effects on alpha or beta
c. "Epinephrine is the most selective
alpha-adrenergic agonist medication."
is relative and is dose dependent."
Receptor specificity is relative, not absolute, and is dose
dependent. At low doses, selectivity is maximal, and selectivity
declines as the dose increases. Dopamine is the only drug in this
class that acts on dopamine receptors, but it also has effects on
alpha and beta receptors. Epinephrine is the least selective of this class.
A patient brought to the emergency department requires sutures. The
prescriber orders a local anesthetic with epinephrine. The nurse
understands that epinephrine is ordered to:
hypertension induced by the anesthetic.
b. allow a reduced dose
of the anesthetic.
c. reduce anesthetic-induced nausea.
reduce the pain of an injection.
Epinephrine prolongs absorption of the anesthetic, because it
is an alpha1 agonist. It is frequently combined with a local
anesthetic for this purpose, so that the amount of anesthetic required
may be reduced. Local anesthetics do not induce hypertension;
therefore, epinephrine would not be needed to prevent it. Epinephrine
does not act as an antiemetic and would not reduce anesthetic-induced
nausea. Epinephrine is not used to reduce the pain of an injection.
A nurse is administering intravenous dopamine [Intropin] to a patient
in the intensive care unit. Which assessment finding would cause the
a. Blood pressure of 100/70 mm Hg
c. Edema at the IV insertion site
The nurse would be concerned if the patient's peripheral IV
were edematous, because this could signal infiltration of the solution
into the tissues. Dopamine can cause necrosis if it extravasates.
Dopamine is indicated to increase the patient's blood pressure; this
blood pressure reading is acceptable. When dopamine is effective at
increasing cardiac output, it also causes an increase in urine output.
Headache is not a contraindication to the use of dopamine.
A patient with asthma uses albuterol [Ventolin] for wheezing. The
nurse assesses the patient and notes vital signs of HR, 96 beats per
minute; RR, 18 breaths per minute; and BP, 116/78 mm Hg. The patient
has clear breath sounds and hand tremors. What will the nurse
a. Ask the patient how often the inhaler is used.
Check the patient's blood glucose level.
c. Request an order for
isoproterenol [Isuprel] to reduce side effects.
d. Stop the
medication and report the tremors to the provider.
Tachycardia is a response to activation of beta1 receptors. It
can occur when large doses of albuterol are used and selectivity
decreases. The nurse should question the patient about the number of
inhalations used. Isoproterenol can cause hyperglycemia in diabetic
patients. Isoproterenol has more side effects than albuterol. Tremors
are an expected side effect and are not an indication for stopping the drug.
A nurse is teaching parents how to use an Epi-Pen for their child,
who has a peanut allergy. Which statement by the parents indicates
understanding of the teaching?
a. "After using the Epi-Pen,
we must go to the emergency department."
Epi-Pen should be stored in the refrigerator, because epinephrine is
sensitive to heat."
c. "The teacher should call us when
symptoms start so that we can bring the Epi-Pen to
d. "We should jab the device into the thigh
until it is empty of solution."
After using the Epi-Pen, it is important that the individual
get medical attention as quickly as possible. The effects of
epinephrine fade in 10 to 20 minutes, and the anaphylactic reaction
can be biphasic and prolonged. Epinephrine is sensitive to heat, but
storing the device in the refrigerator can compromise the injection
mechanism; the device should be stored at room temperature in a dark
place. Individuals who need an Epi-Pen must have the device with them
at all times; any delay in treatment can be fatal, because anaphylaxis
can occur within minutes after exposure. The Epi-Pen contains 2 mL of
epinephrine, but only 0.3 mL is injected; the device will not be empty
with a successful injection.
Because they cause vasoconstriction, alpha1-adrenergic agonists are
especially useful for:
a. causing hemostasis in skin and mucous
b. producing mydriasis to facilitate ophthalmic
c. slowing the heart rate in tachycardic
d. treating hypotension.
The vasoconstrictive effects of alpha1-adrenergic agonists,
such as epinephrine, help produce hemostasis in skin and mucous
membranes. These agents can increase blood pressure but are not the
primary drugs used except in emergency situations. Alpha1 receptors in
the radial muscles of the iris, not vasoconstriction, cause mydriasis.
Reflex bradycardia is a side effect and not a clinical use of these agents.
A patient is admitted to the intensive care unit for treatment of
shock. The prescriber orders isoproterenol [Isuprel]. The nurse
expects this drug to increase tissue perfusion in this patient by
a. alpha1 receptors to cause
b. alpha1 receptors to increase blood
c. beta1 receptors to cause a positive inotropic
d. beta2 receptors to cause bronchodilation.
Isoproterenol is used for shock because of its actions on
beta1 receptors in the heart. It has a positive inotropic effect,
which improves cardiac output and thus increases tissue perfusion.
Isoproterenol does not affect alpha1 receptors. Although it activates
beta2 receptors to cause bronchodilation, this is not indicated for
the treatment of shock.
A nursing student asks the nurse why epinephrine, and not other
adrenergic agonists, is used to treat anaphylactic shock. What will
the nurse tell the student?
a. "Epinephrine is the only
adrenergic agonist that may be given parenterally."
"Epinephrine has the ability to activate multiple types of
c. "Other adrenergic agonists
have more severe adverse effects and are not safe in the doses needed
to treat anaphylaxis."
d. "Other adrenergic agonists
have little or no effects on beta2-adrenergic receptors."
Epinephrine is used to treat anaphylactic shock because of its
ability to activate multiple adrenergic receptor types. Activation of
beta1 receptors helps to increase cardiac output and improve blood
pressure as well as suppress glottal edema. Activation of beta2
receptors helps to counteract bronchoconstriction. Activation of
alpha1 receptors also causes vasoconstriction, which improves blood
pressure. Isoproterenol may also be given parenterally but does not
activate multiple receptor types. Other adrenergic agonists, such as
albuterol, are more specific to beta2 receptors and have fewer side effects.
A nursing student asks why albuterol, which is selective for beta2
receptors, causes an increased heart rate in some patients. How should
the nurse respond?
a. "Adrenergic agonists can lose their
selectivity when given at higher doses."
"Bronchodilation lowers blood pressure, which causes a reflex
c. "Some patients metabolize the drug
differently and have unusual side effects."
"Systemic effects are intensified with inhaled doses."
Although albuterol affects the beta2 receptors, at higher
doses it may also activate beta1 receptors, causing an increase in the
heart rate. Bronchodilation does not lower the blood pressure, and
activation of beta1 receptors actually may increase it. Tachycardia is
a common side effect. The inhaled route reduces the likelihood of
systemic side effects.
A patient is receiving dobutamine [Dobutrex] as a continuous infusion
in the immediate postoperative period. The patient also is receiving a
diuretic. What adverse drug reactions are possible in this patient?
(Select all that apply.)
A, B, E
Angina, dysrhythmias, and tachycardia are the most
common adverse effects of dopamine; general anesthetics can increase
the likelihood of dysrhythmias. Dopamine elevates blood pressure by
increasing cardiac output. Diuretics complement the beneficial effects
of dopamine on the kidney, so urine output would be increased, not decreased.
A nurse is teaching nursing students about the use of
alpha-adrenergic antagonists. Which statement by a student indicates
the need for further teaching?
antagonists block alpha1 receptors on arterioles and
b. "Dilation of arterioles has a direct effect
on arterial pressure."
c. "Dilation of veins by
alpha-adrenergic antagonists improves cardiac output."
"Venous dilation by alpha-adrenergic antagonists indirectly
lowers arterial pressure."
Cardiac output is decreased as a result of the venous dilation
caused by alpha-adrenergic antagonists. Alpha-adrenergic antagonists
block alpha1 receptors on arterioles and veins. When alpha1 receptors
on arterioles are blocked by alpha-adrenergic antagonists, a direct
effect on arterial pressure occurs. When alpha1 receptors on veins are
blocked by alpha-adrenergic antagonists, an indirect effect on
arterial pressure occurs.
A patient with pheochromocytoma is admitted for surgery. The surgeon
has ordered an alpha-blocking agent to be given preoperatively. What
does the nurse understand about this agent?
a. It is ordered to
prevent perioperative hypertensive crisis.
b. It prevents
secretion of catecholamines by the adrenal tumor.
c. It reduces
contraction of smooth muscles in the adrenal medulla.
d. It is
given chronically after the surgery to prevent hypertension.
Manipulation of the adrenal tumor in patients with
pheochromocytoma can cause a massive catecholamine release.
Alpha-adrenergic antagonists are given to reduce the risk of acute
hypertension during surgery. These agents do not prevent secretion of
catecholamines; they block catecholamine receptor sites. They do not
act on the tissue of the adrenal medulla. They are given chronically
in patients who have inoperable tumors.
A patient with type 1 diabetes is taking NPH insulin, 30 units every
day. A nurse notes that the patient is also taking metoprolol
[Lopressor]. What education should the nurse provide to the
a. "Metoprolol has no effect on diabetes mellitus
or on your insulin requirements."
interferes with the effects of insulin, so you may need to increase
your insulin dose."
c. "Metoprolol may mask signs of
hypoglycemia, so you need to monitor your blood glucose
d. "Metoprolol may potentiate the effects of
the insulin, so the dose should be reduced."
Because metoprolol may mask the signs of hypoglycemia, the
patient should monitor the blood glucose closely and report changes to
the prescriber. Metoprolol does have an indirect effect on diabetes
mellitus and/or insulin requirements in that it may mask the signs of
hypoglycemia, causing the patient to make a healthcare decision based
on the drug-to-drug interaction rather than actual physiologic
factors. The patient should not increase the insulin, because
metoprolol will cause a decrease in blood glucose, increasing the risk
of a hypoglycemic reaction. The patient should not reduce the dose of
insulin when taking metoprolol, because this might alter serum glucose levels.
The nurse is discussing home management with a patient who will begin
taking an alpha-adrenergic antagonist for hypertension. Which
statement by the patient indicates understanding of the
a. "I need to stop the medication if my heart rate
b. "I should not drive while taking this
c. "I should take the first dose at
d. "I will stop taking the medication if I
Orthostatic hypotension is a common side effect of this class
of drugs and is most severe with the first dose. Administering the
first dose at bedtime eliminates the risk associated with this
first-dose effect. Tachycardia is an expected side effect; if severe,
it can be treated with other medications. Patients should not drive
during the first 12 to 24 hours after taking these agents, because
fainting and dizziness may occur, but they may drive after that.
Dizziness is not an indication for stopping the drug; patients who
experience dizziness are instructed to sit or lie down until symptoms pass.
A nurse prepares to administer propranolol [Inderal] to a patient
recovering from acute myocardial infarction. The patient's heart rate
is 52 beats per minute, and the rhythm is regular. What action should
the nurse take next?
a. Administer the drug as
b. Request an order for atropine.
the dose and document the pulse rate.
d. Withhold the dose and
notify the prescriber.
A beta blocker, such as propranolol, should not be given if
the pulse is lower than 60 beats per minute; therefore, the nurse
should withhold the dose and notify the prescriber. Administering the
dose as prescribed would not be appropriate, because the patient's
pulse rate is too slow at this time. The dose should be withheld and
the prescriber notified. The patient's heart rate is slow, and
atropine may be necessary if the bradycardia persists, but the first
step is to withhold the dose of propranolol. Withholding the dose and
documenting the pulse rate is an appropriate but incomplete nursing
intervention. The nurse must notify the prescriber to obtain further
orders related to the medication.
The nurse assesses a patient who has been given phentolamine
[OraVerse] to treat pheochromocytoma. The nurse notes a blood pressure
of 76/52 mm Hg and a heart rate of 90 beats per minute. Which action
by the nurse is correct?
a. Contact the provider to request an
order for epinephrine.
b. Continue to monitor the patient's vital
signs and notify the provider if the heart rate increases.
Notify the provider and request an order for a beta blocker.
Notify the provider and request an order for norepinephrine.
Phentolamine can cause orthostatic hypotension, reflex
tachycardia, nasal congestion, and inhibition of ejaculation. Overdose
can produce profound hypotension. When this occurs, blood pressure can
be elevated with norepinephrine. Epinephrine should not be used
because, in the presence of alpha1 blockade, the ability of
epinephrine to promote vasodilation by activation of beta2 receptors
may outweigh its ability to cause vasoconstriction, causing further
lowering of blood pressure. Norepinephrine does not activate beta2
receptors. Beta blockers may be used to treat severe reflex
tachycardia. This patient has significant hypotension, so it is not
correct to continue to monitor without notifying the provider.
A nurse is discussing phentolamine [OraVerse] with a nursing student.
Which statement by the student indicates the need for further
a. "Phentolamine can be used to block both
epinephrine- and norepinephrine-mediated
b. "Phentolamine can be used to
prevent tissue necrosis after extravasation of drugs such as
c. "Phentolamine is a competitive
adrenergic agonist that acts selectively on alpha1
d. "Side effects of phentolamine may
include tachycardia and hypotension."
Phentolamine has actions on both alpha1 and alpha2 receptors;
it is not selective for alpha1 receptors only. It blocks both
epinephrine- and norepinephrine-mediated vasoconstriction. It is used
to prevent tissue necrosis after extravasation of drugs such as
norepinephrine and other drugs that produce alpha1-mediated
vasoconstriction. Side effects include tachycardia and hypotension.
A patient taking a beta blocker complains of shortness of breath. The
patient has respirations of 28 breaths per minute, a blood pressure of
162/90 mm Hg, and a pulse of 88 beats per minute. The nurse
auscultates crackles in all lung fields. The nurse understands that
these assessments are consistent with:
b. left-sided heart failure.
d. sinus bradycardia.
The signs and symptoms describe left-sided heart failure, in
which the blood normally handled by the left ventricle and forced out
through the aorta into the body backs up into the lungs, producing
respiratory signs and symptoms. The patient's signs and symptoms are
not indicative of bronchoconstriction, which would cause wheezing and
diminished breath sounds. Rebound cardiac excitation occurs when the
beta blocker is withdrawn, not during administration of the drug. The
patient's heart rate is elevated, so sinus bradycardia is not present.
A male patient is being treated for benign prostatic hyperplasia and
has stopped taking his alpha-adrenergic antagonist medication because
of ejaculatory difficulties. Which medication does the nurse expect
the provider to prescribe?
a. Alfuzosin [Uroxatral]
c. Silodosin [Rapaflo]
d. Tamsulosin [Flomax]
Alfuzosin is used for BPH and does not interfere with
ejaculation. All of the other drugs have ejaculatory side effects.
Prazosin may be useful for BPH, but it is not approved for this use.
A patient is taking a beta-adrenergic antagonist medication for
angina pectoris and asks the nurse how the drug works to relieve the
discomfort associated with this condition. Which statement by the
patient after the nurse's teaching indicates understanding of the
a. "It causes bronchodilation, which
increases oxygen flow."
b. "It helps reduce the heart's
c. "It improves blood flow to the
d. "It increases cardiac output."
Blockade of beta1 receptors in the heart reduces cardiac work
by reducing the heart rate, the force of contraction, and the velocity
of impulse conduction through the AV node. Beta blockers result in
bronchoconstriction, not bronchodilation. They do not increase blood
flow to the heart. Cardiac output is decreased, not increased.
A nurse is caring for a newborn 1 day after delivery. The infant's
mother used betaxolol during pregnancy. The nurse will expect to
monitor this infant for which condition?
c. Respiratory distress
Use of beta blockers during pregnancy can affect a newborn for
several days after birth. Newborns are at risk for bradycardia,
respiratory distress, and hypoglycemia. Hyperglycemia,
hyperthyroidism, and tachycardia are not expected residual effects.
A patient will begin taking propranolol [Inderal] for hypertension.
Which statement by the nurse is important when teaching this patient
about the medication?
a. "Check your hands and feet for
swelling and report that to your provider."
b. "It is
safe to take this medication with a calcium channel
c. "Stop taking the drug if you become short
d. "Take your pulse and do not take the
medication if your heart rate is fast."
Patients taking propranolol can develop heart failure because
of the suppression in myocardial contractility. Patients should be
taught to watch for signs, which include shortness of breath, night
coughs, and swelling of the extremities. Use of these agents with
calcium channel blockers is contraindicated, because the effects are
identical and excessive cardiosuppression can occur. Shortness of
breath should be reported to the provider, but abrupt cessation of the
drug can cause rebound cardiac excitability. Propranolol reduces the
heart rate and should not be given if the pulse is less than 60 beats
A patient with migraines is started on a beta blocker. The nurse
explains the benefits of taking the medication for migraines. Which
statement by the patient indicates an understanding of the
a. "I need to take it every day to
reduce the frequency of migraines."
b. "I will take it
as needed to get relief from migraines."
c. "I will
take it to shorten the duration of my migraines."
will take this drug when a migraine starts."
When taken prophylactically, beta blockers can reduce the
frequency of migraine attacks. Beta blockers do not provide complete
relief from migraines. They do not reduce the duration of migraines.
They are not effective for treating a migraine once the migraine has begun.
Which are adverse effects of alpha blockade? (Select all that
b. Reflex tachycardia
B, C, E
Adverse effects of alpha blockade include reflex
tachycardia, nasal congestion, and hypernatremia. Other adverse
effects include orthostatic hypotension and inhibition of ejaculation.
Hypertension and ejaculation are not adverse effects of alpha blockade.
Which are conditions that may be treated using beta blockers? (Select
all that apply.)
a. Cardiac dysrhythmias
e. Stage fright
A, B, E
Beta blockers are used to treat cardiac dysrhythmias,
heart failure, and stage fright. They are used to treat hypertension
A prescriber has ordered clonidine [Catapres] for a patient who has
hypertension. The nurse teaches the patient about side effects of this
drug. Which statement by the patient indicates understanding of the
a. "I should chew sugar-free gum or drink water to
reduce dry mouth."
b. "I should not drive as long as I
am taking this drug."
c. "I should stand up slowly when
taking this medication."
d. "I should stop taking this
drug if I feel anxious or depressed."
Xerostomia is a common side effect of clonidine and is often
uncomfortable enough that patients stop using the drug. Counseling
patients to chew sugar-free gum and take frequent sips of liquid can
help alleviate this discomfort. Drowsiness is common, but this side
effect becomes less intense over time. Patients should be counseled to
avoid hazardous activities in the first weeks of therapy if they feel
this effect. The hypertensive effects of clonidine are not posture
dependent, as they are with the peripheral alpha-adrenergic blockers,
so orthostatic hypotension is minimal with this drug. Clonidine causes
euphoria, hallucinations, and sedation in high doses and can cause
anxiety or depression, although the last two effects are less common.
The drug should not be stopped abruptly because of the risk of rebound
hypertension, so patients experiencing unpleasant central nervous
system (CNS) effects should consult their provider about withdrawing
the medication slowly.
A prescriber has ordered methyldopa for a patient with hypertension.
The nurse teaches the patient about drug actions, adverse effects, and
the ongoing blood tests necessary with this drug. The nurse is correct
to tell the patient what?
a. "If you have a positive Coombs'
test result, you will need to discontinue the medication, because this
means you have hemolytic anemia."
b. "Methyldopa can be
used for its analgesic effects and for its hypertensive
c. "Xerostomia and orthostatic hypotension
are serious side effects and indications for withdrawing the
d. "You will need to contact the provider
and stop taking the medication if your eyes look yellow."
Hepatotoxicity is a serious adverse effect of methyldopa and
is an indication for withdrawal of the drug to prevent fatal hepatic
necrosis. Jaundice is a sign of liver toxicity. Patients should
undergo periodic liver function tests while taking the drug. Liver
function usually improves when the drug is withdrawn. A positive
Coombs' test result is not an indication for withdrawal of the drug in
itself. About 5% of patients with a positive Coombs' test result
develop hemolytic anemia; withdrawal of the drug is indicated for
those patients. Methyldopa does not have analgesic effects. Xerostomia
and orthostatic hypotension are known side effects of methyldopa but
usually are not serious.
A patient complains to the nurse that the clonidine [Catapres]
recently prescribed for hypertension is causing drowsiness. Which
response by the nurse to this concern is appropriate?
"Drowsiness is a common side effect initially, but it will lessen
b. "You may also experience orthostatic
hypotension along with the drowsiness."
c. "You may be
at risk for addiction if you have central nervous system side
d. "You should discontinue the medication and
contact your prescriber."
CNS depression, evidenced in this patient by drowsiness, is
common in about 35% of the population. These responses become less
intense with continued drug use. Orthostatic hypotension is less
likely with clonidine, because its antihypertensive effects are not
posture dependent. The experience of drowsiness does not indicate
abuse potential. The patient should not discontinue the medication
abruptly because of the potential for rebound hypertension; the
patient should contact the prescriber before stopping the medication.
A nurse is teaching nursing students about the pharmacology of
methyldopa. Which statement by a student indicates the need for
a. "Methyldopa results in alpha2 agonist
activation, but it is not itself an alpha2 agonist."
"Methyldopa is not effective until it is converted to an active
c. "Methyldopa reduces blood pressure by
reducing cardiac output."
d. "Methyldopa's principal
mechanism is vasodilation, not cardiosuppression."
Methyldopa does not reduce the heart rate or cardiac output,
so its hypotensive actions are not the result of cardiac depression.
The drug is not, in itself, an alpha2 agonist. When taken up into
brainstem neurons, it is converted into methylnorepinephrine, which is
an alpha2 agonist; it is not effective until converted to this active
compound. Its hypotensive effects are the result of vasodilation, not cardiosuppression.
A nurse is teaching a patient about a new prescription for reserpine
[Serpasil] for hypertension. Which statement by the patient indicates
the need for further teaching?
a. "Depressive side effects
are common and will improve over time."
b. "I should
report gastrointestinal side effects to the provider."
"I should stand up slowly when getting up and lie down if I feel
d. "Therapeutic effects may not be optimal for
a couple of weeks."
Reserpine can produce severe depression, which may persist for
months during drug therapy and after the drug is withdrawn. Reserpine
can stimulate the secretion of gastric acid, which can cause ulcers;
it also can increase the tone and motility of intestinal smooth
muscle, which can cause cramps and diarrhea. Reserpine can cause
orthostatic hypotension, so patients should be counseled to rise
slowly when standing up and to sit or lie down if they feel dizzy.
Reserpine works by depleting norepinephrine, and the processes
necessary for this may take 1 to 2 weeks.
A patient who has been taking clonidine [Catapres] for several weeks
complains of drowsiness and constipation. What will the nurse
a. Recommend that the patient take most of the daily dose at
b. Suggest asking the provider for a transdermal
preparation of the drug.
c. Suspect that the patient is overusing
d. Tell the patient to stop taking the drug and
call the provider.
CNS depression is common with clonidine, but this effect
lessens over time. Constipation is also a common side effect. Patients
who take most of the daily amount at bedtime can minimize daytime
sedation. Transdermal forms of clonidine do not alter adverse effects.
Patients who are abusing clonidine often experience euphoria and
hallucinations along with sedation, but they generally find these
effects desirable and would not complain about them to a healthcare
provider. Clonidine should not be withdrawn abruptly, because serious
rebound hypertension can occur.
A patient with hypertension has a previous history of opioid
dependence. Which medication would the nurse question?
b. Guanabenz [Wytensin]
d. Reserpine [Serpasil]
Patients who abuse cocaine, opioids, and other such drugs also
frequently abuse clonidine, so this agent would not be the best choice
for this patient. The other drugs do not share this abuse potential.
A prescriber orders transdermal clonidine [Catapres TTS] for a
patient with hypertension. What will the nurse teach this
a. That medication given by transdermal patch has fewer
systemic side effects
b. That localized skin reactions are
c. To apply the patch to intact skin on the forearm or
d. To change the patch every week
Transdermal patches are to be changed every 7 days. Medication
administered by patch has the same therapeutic effect and adverse
effects as that given by other routes, except that localized skin
reactions may occur and are common with clonidine patches. The patch
should be applied to intact, hairless skin on the upper arm or torso.
A prescriber orders clonidine [Kapvay] ER tablets for a 12-year-old
child. The nurse understands that this drug is being given to treat
d. Tourette's syndrome
Kapvay ER is used to treat ADHD and is given as a single dose
at bedtime. This form of clonidine is not used for hypertension,
severe pain, or treatment of Tourette's syndrome.
A prescriber has ordered methyldopa for a female patient with
hypertension. The nurse understands that which laboratory tests are
important before beginning therapy with this drug? (Select all that
a. Coombs' test
b. Hemoglobin and hematocrit
c. Liver function tests
d. Pregnancy test
A, B, C
A positive Coombs' test result occurs in 10% to 20% of
patients who take methyldopa chronically. A few of these patients (5%)
develop hemolytic anemia. Blood should be drawn for a Coombs' test and
an H&H before treatment is started and at intervals during
treatment. Because methyldopa is associated with liver disorders,
liver function tests should be performed before therapy is started and
periodically during treatment. Clonidine, not methyldopa, is
contraindicated during pregnancy. A urinalysis is not indicated.
Clonidine is approved for the treatment of which conditions? (Select
all that apply.)
d. Severe pain
e. Smoking cessation
A, B, D
Clonidine has three approved uses: treatment of ADHD,
hypertension, and severe pain. It has investigational uses for
management of opioid withdrawal and for smoking cessation
A psychiatric nurse is teaching a patient about an antidepressant
medication. The nurse tells the patient that therapeutic effects may
not occur for several weeks. The nurse understands that this is likely
the result of:
a. changes in the brain as a result of prolonged
b. direct actions of the drug on specific synaptic
functions in the brain.
c. slowed drug absorption across the
d. tolerance to exposure to the drug over time.
It is thought that beneficial responses to central nervous
system (CNS) drugs are delayed because they result from adaptive
changes as the CNS modifies itself in response to prolonged drug
exposure, and that the responses are not the result of the direct
effects of the drugs on synaptic functions. The blood-brain barrier
prevents protein-bound and highly ionized drugs from crossing into the
CNS, but it does not slow the effects of drugs that can cross the
barrier. Tolerance is a decreased response to a drug after prolonged use.
A nurse is teaching a group of nursing students how the CNS adapts to
psychotherapeutic medications. Which statement by a nursing student
indicates a need for further teaching?
a. "Adaptation can
lead to tolerance of these drugs with prolonged use."
"Adaptation helps explain how physical dependence
c. "Adaptation often must occur before
therapeutic effects develop."
d. "Adaptation results in
an increased sensitivity to side effects over time."
With adaptation of the central nervous system to prolonged
exposure to CNS drugs, many adverse effects diminish and therapeutic
effects remain. Adaptation helps explain how tolerance and physical
dependence occur, as the brain adapts to the presence of the drug.
Therapeutic effects can take several weeks to manifest, because they
appear to work by initiating adaptive changes in the brain.
A group of nursing students asks a nurse to explain the blood-brain
barrier. The nurse would be correct to say that the blood-brain
a. prevents some potentially toxic substances from
crossing into the central nervous system.
b. causes infants to be
less sensitive to CNS drugs and thus require larger doses.
allows only ionized or protein-bound drugs to cross into the central
d. prevents lipid-soluble drugs from entering the
central nervous system.
The blood-brain barrier can prevent some drugs and some toxic
substances from entering the CNS. The blood-brain barrier in infants
is not fully developed, so infants are more sensitive to CNS drugs and
often require lower doses. The blood-brain barrier prevents highly
ionized and protein-bound drugs from crossing into the CNS and allows
lipid-soluble drugs and those that can cross via specific transport
systems to enter.
A nurse is teaching a group of students about how CNS drugs are
developed. Which statement by a student indicates a need for further
a. "Central nervous system drug development relies
on observations of their effects on human behavior."
"Studies of new central nervous system drugs in healthy subjects
can produce paradoxical effects."
c. "Our knowledge of
the neurochemical and physiologic changes that underlie mental illness
d. "These drugs are developed based on
scientific knowledge of CNS transmitters and receptors."
The deficiencies in knowledge about how CNS transmitters and
receptors work make systematic development of CNS drugs difficult.
Testing in healthy subjects often leads either to no effect or to
paradoxical effects. Medical knowledge of the neurochemical and
physiologic changes underlying mental illness is incomplete. The
development of CNS drugs depends less on knowledge of how the CNS
functions and how these drugs affect that process and more on how
administering one of these agents leads to changes in behavior.
A patient asks a nurse to explain what drug tolerance means. The
nurse responds by telling the patient that when tolerance occurs, it
means the patient:
a. has developed a psychologic dependence on
b. may need increased amounts of the drug over
c. will cause an abstinence syndrome if the drug is
d. will have increased sensitivity to drug
When tolerance develops, a dose increase may be needed,
because a decreased response may occur with prolonged use. Psychologic
dependence involves cravings for drug effects and does not define
tolerance. Physical dependence occurs when the drug becomes necessary
for the brain to function "normally," meaning the patient
should be weaned from the drug slowly to prevent an abstinence
syndrome. Patients may have a decreased sensitivity to drug side
effects over time as the brain adapts to the medication.
An infant who receives a drug that does not produce CNS side effects
in adults exhibits drowsiness and sedation. The nurse understands that
this is because of differences in which physiologic system in infants
a. Blood-brain barrier
c. Gastrointestinal absorption
d. Renal filtration
The blood-brain barrier is not fully developed at birth,
making infants much more sensitive to CNS drugs than older children
and adults. CNS symptoms may include sedation and drowsiness. The
first-past effect and GI absorption affect metabolism and absorption
of drugs, and renal filtration affects elimination of drugs, all of
which may alter drug levels.
Which monoamines act as neurotransmitters in the central nervous
system? (Select all that apply.)
B, C, D, E
Acetylcholine and histamines are not monoamines.
Which are medical applications of central nervous system drugs?
(Select all that apply.)
e. Seizure control
A, B, E
CNS drugs have medical uses for pain management,
anesthesia, and seizure control. Depression and euphoria are side
effects that can contribute to abuse of these drugs.
A patient has taken levodopa [Dopar] for Parkinson's disease for 2
weeks but reports no improvement in the symptoms. Which response by
the nurse is correct?
a. "Another agent will be needed to
manage your symptoms."
b. "Double the dose to see
whether an effect occurs."
c. "It may take several
months for a response to occur."
d. "The prescriber may
need to change your drug regimen."
A full therapeutic response with levodopa may take several
months to develop. Until the true effect of the dose is seen, it is
not necessary to change to another drug, increase the dose, or change
the drug regimen.
A nurse provides teaching for a patient who is newly diagnosed with
Parkinson's disease. Which statement by the patient indicates
understanding of the drug therapy for this disease?
levodopa/carbidopa combination is used to improve motor
b. "There are several drugs available to
c. "When 'off' times occur, I may
need to increase my dose of levodopa."
adequate drug therapy, the disease progression may be slowed."
Levodopa combined with carbidopa is the initial drug of choice
to treat motor symptoms. Amantadine is the only drug recommended to
treat dyskinesias. Entacapone and rasagiline are used to treat abrupt
loss of effect, or "off" times. Drug therapy does not slow
the progression of the disease.
A patient has been diagnosed with Parkinson's disease (PD) and begins
treatment with levodopa/carbidopa [Sinemet]. After several months of
therapy, the patient reports no change in symptoms. The nurse will
expect the provider to:
a. add a dopamine agonist.
discuss the "on-off" phenomenon.
c. increase the dose
d. re-evaluate the diagnosis.
Patients beginning therapy with levodopa/carbidopa should
expect therapeutic effects to occur after several months of treatment.
Levodopa is so effective that a diagnosis of PD should be questioned
if the patient fails to respond in this time frame. Adding a dopamine
agonist is not indicated. The "on-off" phenomenon occurs
when therapeutic effects are present. Increasing the dose of
levodopa/carbidopa is not indicated.
A patient with Parkinson's disease is taking levodopa/carbidopa
[Sinemet] and reports occasional periods of loss of drug effect
lasting from minutes to several hours. The nurse questions the patient
further and discovers that these episodes occur at different times
related to the medication administration. The nurse will contact the
provider to discuss:
a. administering a
catechol-O-methyltransferase (COMT) inhibitor, such as
b. adding the DA-releasing agent amantadine to the
c. giving a direct-acting dopamine agonist.
shortening the dosing interval of levodopa/carbidopa.
This patient is describing abrupt loss of effect, or the
"off" phenomenon, which is treated with entacapone or
another COMT inhibitor. Amantadine is used to treat dyskinesias. A
direct-acting dopamine agonist is useful for gradual loss of effect,
which occurs at the end of the dosing interval as the dose is wearing
off. Shortening the dosing interval does not help with abrupt loss of effect.
A patient newly diagnosed with Parkinson's disease has been taking
levodopa/carbidopa [Sinemet] for several weeks and complains of nausea
and vomiting. The nurse tells the patient to discuss what with the
a. Taking a lower dose on an empty stomach
Taking an increased dose along with a high-protein snack
Taking a lower dose with a low-protein snack
d. Taking dopamine
in addition to levodopa/carbidopa
Because levodopa activates the chemoreceptive trigger zone
(CTZ) of the medulla, causing nausea and vomiting (N/V), the patient
may need to take a lower dose temporarily until tolerance develops. A
meal helps slow absorption to minimize this side effect. A high
protein intake contributes to abrupt loss of effect, so meals should
be low in protein. Taking a dose on an empty stomach increases
absorption and also N/V. An increased dose with a high-protein snack
increases N/V and also abrupt loss of effect. Dopamine increases N/V,
because it activates the CTZ of the medulla.
A nurse is discussing motor symptoms with a patient with Parkinson's
disease who has been taking levodopa/carbidopa [Sinemet] for 9 months
and who is now having regular tics. Which statement by the patient
indicates understanding of this symptom?
a. "I may need to
try a lower dose of Sinemet to reduce my tics."
provider may order clozapine to treat these tics."
"These tics are an indication that my dose of Sinemet is too
d. "This means I will have to have surgery to
stop the symptoms."
Levodopa can cause movement disorders, generally within the
first year of therapy. If they occur, a lower dose of levodopa may be
required to alleviate them. Clozapine is an antipsychotic used to
treat levodopa-induced psychoses. Movement disorders generally occur
as the dose of levodopa increases. Surgery is a last option for
treating movement disorders, after amantadine fails.
A patient who has begun taking levodopa/carbidopa [Sinemet] reports
feeling lightheaded and dizzy, especially when standing up from a
sitting position. What will the nurse recommend?
alpha-adrenergic antagonist medication
b. Discussing amantadine
with the prescriber
c. Increasing salt and water intake
Taking a drug holiday
Postural hypotension is common early in treatment and can be
reduced by increasing the intake of salt and water. An
alpha-adrenergic agonist, not an antagonist, can help. Amantadine is
used to treat levodopa-induced dyskinesias. Drug holidays are used
when adverse effects increase with long-term use of levodopa; the drug
holiday allows beneficial effects to be achieved with lower doses,
which reduces the incidence of side effects.
A nursing student wants to know why a patient who has been taking
levodopa [Dopar] for years will now receive levodopa/carbidopa
[Sinemet]. The nurse explains the reasons that levodopa as a single
agent is no longer available. Which statement by the student indicates
a need for further education?
a. "Carbidopa increases the
availability of levodopa in the central nervous system."
"Carbidopa reduces the incidence of nausea and
c. "Combination products reduce peripheral
cardiovascular side effects."
d. "Combination products
cause fewer dyskinesias and decreased psychosis."
Adding carbidopa to levodopa does not reduce the incidence of
dyskinesias or psychosis. In fact, carbidopa can increase the
intensity and the speed of onset of these effects. Carbidopa inhibits
decarboxylation of levodopa in the intestine and peripheral tissues,
leading to more levodopa in the CNS. Carbidopa cannot cross the
blood-brain barrier, so it does not have this action in the CNS.
Peripheral side effects are reduced, including nausea, vomiting, and
A nurse is teaching a group of nurses about Parkinson's medications.
The nurse is correct to state that one side effect associated with
pramipexole [Mirapex] that is less likely to occur with other dopamine
a. sleep attacks.
A few patients taking pramipexole have experienced sleep
attacks, or an overwhelming and irresistible sleepiness that comes on
without warning. Dizziness, hallucinations, and dyskinesias are listed
as side effects of pramipexole and other dopamine agonists.
A nursing student wants to know how carbidopa can be effective for
treating Parkinson's disease if it prevents the conversion of levodopa
to dopamine. The nurse explains that carbidopa:
a. can be taken
with high-protein meals.
b. does not cross the blood-brain
c. has dopamine-like effects of its own.
abrupt loss of effect.
Carbidopa inhibits decarboxylation of levodopa in the
intestine and peripheral tissues, leading to more levodopa in the CNS.
Carbidopa cannot cross the blood-brain barrier, so it does not have
this action in the CNS. Carbidopa is not given with high-protein
meals. Carbidopa does not have dopamine-like effects. Carbidopa does
not affect abrupt loss of effect.
A 25-year-old patient has been newly diagnosed with Parkinson's
disease, and the prescriber is considering using pramipexole
[Mirapex]. Before beginning therapy with this drug, the nurse will ask
the patient about:
a. any history of alcohol abuse or compulsive
b. any previous history of hypertension.
difficulty falling asleep or staying asleep.
d. whether any
family members have experienced psychoses.
Pramipexole has been associated with impulse control
disorders, and this risk increases in patients with a history of
alcohol abuse or compulsive behaviors. Pramipexole increases the risk
of hypotension and sleep attacks, so a history of hypertension or
insomnia would not be cautionary. Unlike with levodopa, the risk of
psychoses is not increased.
A hospitalized patient with Parkinson's disease who is receiving
apomorphine to treat "off" episodes develops nausea and
vomiting. The nurse will discuss the use of which medication with the
a. Levodopa [Dopar]
c. Prochlorperazine [Compazine]
Trimethobenzamide can be used as an antiemetic in patients
treated with apomorphine. Serotonin receptor agonists (eg,
ondansetron) and dopamine receptor antagonists (eg, prochlorperazine)
cannot be used, because they increase the risk of serious postural
hypotension. Levodopa only increases nausea and vomiting.
A patient with Parkinson's disease is taking levodopa/carbidopa
[Sinemet]. The prescriber orders bromocriptine [Parlodel] to treat
dyskinesias. The nurse notes that the patient is agitated, and the
patient reports having frequent nightmares. The nurse will contact the
provider to discuss:
a. adding an antipsychotic
b. changing from bromocriptine to cabergoline
c. reducing the dose of bromocriptine.
reducing the dose of levodopa/carbidopa.
Bromocriptine is used to treat levodopa-induced dyskinesias
and has dose-dependent psychologic side effects. The nurse should
suggest reducing the dose of this drug to minimize these side effects.
Adding an antipsychotic medication is not indicated. Cabergoline is
not approved for this use. Reducing the dose of levodopa/carbidopa is
A patient who is newly diagnosed with Parkinson's disease is
prescribed levodopa [Dopar]. The patient asks the nurse about drugs to
prevent disease progression. What will the nurse tell this
a. "Levodopa may prevent disease progression in
higher doses and is safe to use for this purpose."
"MAO-B inhibitors and dopamine agonists have both shown
neuroprotective effects in human studies."
E has been shown to delay neuron degeneration and may be used as
d. "While some drugs show promise,
there are no studies that have proven a neuroprotective effect."
To date, there is no definitive proof that any drug can
protect dopaminergic neurons from progressive degeneration. Levodopa
has shown neuroprotective effects, but studies have demonstrated toxic
effects in the doses required for this purpose. MAO-B inhibitors have
shown benefits, but only in animal studies. Vitamin E was once
theorized to offer this protection, but recent studies have provided
good evidence that this is not the case.
The nurse provides teaching for a patient who will begin taking
rotigotine [Neupro] to treat Parkinson's disease. What will the nurse
include in teaching?
a. "If you develop nausea and vomiting,
you should stop taking the medication."
b. "If you need
to stop this drug, your provider will order a gradual
c. "You will start this drug regimen with
a higher than usual loading dose."
d. "You will take
this medication by mouth with food."
Rotigotine is a nonergot dopamine agonist, which is given by
starting with a 2-mg dose that is increased by 2 mg each week until
the lowest effective dose is reached. It should not be stopped
abruptly but should be decreased by 2 mg per week until tapered off.
It undergoes extensive first-pass metabolism, so it is not given
orally and is currently available as a transdermal patch.
A patient with Parkinson's disease is taking levodopa/carbidopa
[Sinemet] along with amantadine [Symmetrel] 400 mg/day to treat
dyskinesias. The patient reports having increased dyskinesias several
months after beginning the amantadine. The nurse will contact the
provider to discuss which action?
a. Increasing the dose of
b. Interrupting treatment with amantadine
for several weeks
c. Ordering renal function tests
Ordering another anticholinergic medication
When amantadine is added to therapy to treat dyskinesias
associated with levodopa, it often loses effectiveness after several
months. If the effects diminish, they can be restored by either
increasing the dosage or by interrupting treatment for several weeks.
The maximum dosage of amantadine is 400 mg/day, so it is incorrect to
increase the dose. Altered renal function would result in drug
toxicity, not ineffectiveness of the drug. It is not necessary to
order another drug until determining whether the effectiveness can be restored.
A patient asks the nurse what can be given to alleviate severe,
chronic pain of several months' duration. The patient has been taking
oxycodone [OxyContin] and states that it is no longer effective. The
nurse will suggest discussing which medication with the
a. Fentanyl [Duragesic] transdermal patch
Hydrocodone [Vicodin] PO
c. Meperidine [Demerol] PO
Pentazocine [Talwin] PO
Transdermal fentanyl is indicated only for persistent, severe
pain in patients already opioid tolerant. Hydrocodone, a combination
product, has actions similar to codeine and is not used for severe,
chronic pain. Meperidine is not recommended for continued use because
of the risk of harm caused by the accumulation of a toxic metabolite.
Pentazocine is an agonist-antagonist opioid and is less effective for
pain; moreover, when given to a patient who is already opioid
tolerant, it can precipitate an acute withdrawal syndrome.
A patient who has had abdominal surgery has been receiving morphine
sulfate via a patient-controlled analgesia (PCA) pump. The nurse
assesses the patient and notes that the patient's pupils are dilated
and that the patient is drowsy and lethargic. The patient's heart rate
is 84 beats per minute, the respiratory rate is 10 breaths per minute,
and the blood pressure is 90/50 mm Hg. What will the nurse do?
Discuss possible opiate dependence with the patient's
b. Encourage the patient to turn over and cough and
take deep breaths.
c. Note the effectiveness of the analgesia in
the patient's chart.
d. Prepare to administer naloxone and
possibly ventilatory support.
Opioid toxicity is characterized by coma, respiratory
depression, and pinpoint pupils. Although pupils are constricted
initially, they may dilate as hypoxia progresses, which also causes
blood pressure to drop. This patient has a respiratory rate of fewer
than 12 breaths per minute, dilated pupils, and low blood pressure;
the patient also is showing signs of central nervous system (CNS)
depression. The nurse should prepare to give naloxone and should watch
the patient closely for respiratory collapse. Patients with opioid
dependence show withdrawal symptoms when the drug is discontinued.
When postoperative patients have adequate analgesia without serious
side effects, encouraging patients to turn, cough, and breathe deeply
is appropriate. This patient is probably relatively pain free, but
providing emergency treatment is the priority.
A patient with moderate to severe chronic pain has been taking
oxycodone [OxyContin] 60 mg every 6 hours PRN for several months and
tells the nurse that the medication is not as effective as before. The
patient asks if something stronger can be taken. The nurse will
contact the provider to discuss:
a. administering a combination
opioid analgesic/acetaminophen preparation.
b. changing the
medication to a continued-release preparation.
c. confronting the
patient about drug-seeking behaviors.
d. withdrawing the
medication, because physical dependence has occurred.
Oxycodone is useful for moderate to severe pain, and a
continued-release preparation may give more continuous relief. Dosing
is every 12 hours, not PRN. A combination product is not recommended
with increasing pain, because the nonopioid portion of the medication
cannot be increased indefinitely. This patient does not demonstrate
drug-seeking behaviors. Physical dependence is not an indication for
withdrawing an opioid, as long as it is still needed; it indicates a
need for withdrawing the drug slowly when the drug is discontinued.
A patient with cancer has been taking an opioid analgesic four times
daily for several months and reports needing increased doses for pain.
What will the nurse tell the patient?
a. PRN dosing of the drug
may be more effective.
b. The risk of respiratory depression
increases over time.
c. The patient should discuss increasing the
dose with the provider.
d. The patient should request the
addition of a benzodiazepine to augment pain relief.
This patient is developing tolerance, which occurs over time
and is evidenced by the need for a larger dose to produce the effect
formerly produced by a smaller dose. This patient should be encouraged
to request an increased dose. PRN dosing is less effective than
scheduled, around-the-clock dosing. The risk of respiratory depression
decreases over time as patients develop tolerance to this effect.
Benzodiazepines are CNS depressants and should not be given with
opioids, because they increase the risk of oversedation.
A woman in labor receives meperidine [Demerol] for pain. The nurse
caring for the infant will observe the infant closely for:
b. excessive crying and sneezing.
d. tremors and hyperreflexia.
Use of morphine or other opioids during delivery can cause
respiratory depression in the neonate, because the drug crosses the
placenta. Infants should be monitored for respiratory depression and
receive naloxone if needed. Opioids given during delivery do not
contribute to birth defects in the newborn. Excessive crying and
sneezing and tremors and hyperreflexia are signs of neonatal opioid
dependence, which occurs with long-term opioid use by the mother
during pregnancy and not with short-term use of these drugs during labor.
A patient who has biliary colic reports a pain level of 8 on a 1 to
10 pain scale with 10 being the most severe pain. The patient has an
order for ibuprofen as needed for pain. Which action by the nurse is
a. Administer the ibuprofen as ordered.
the provider to discuss nonpharmacologic pain measures.
Request an order for meperidine [Demerol].
d. Request an order
for morphine sulfate.
Opioids can induce spasm of the common bile duct and can cause
biliary colic. For patients with existing biliary colic, morphine may
intensify the pain. It is important to treat pain, however, and
certain opioids, such as meperidine, which cause less smooth muscle
spasm, may be given. Ibuprofen is used for mild to moderate pain and
is not appropriate for this patient. Nonpharmacologic methods are
appropriate when used as adjunctive therapy with an opioid.
A patient is brought to the emergency department by friends, who
report finding the patient difficult to awaken. The friends report
removing two fentanyl transdermal patches from the patient's arm. On
admission to the emergency department, the patient has pinpoint pupils
and a respiratory rate of 6 breaths per minute. A few minutes after
administration of naloxone, the respiratory rate is 8 breaths per
minute and the patient's pupils are dilated. The nurse recognizes
these symptoms as signs of:
a. a mild opioid overdose.
decreased opioid drug levels.
c. improved ventilation.
The classic triad of symptoms of opioid overdose are coma,
respiratory depression, and pinpoint pupils. The pupils may dilate as
hypoxia worsens, and this symptom, along with continued respiratory
depression (fewer than 12 breaths per minute), indicates worsening
hypoxia. Fentanyl is a strong opioid, so this is not likely to be a
mild overdose, because the patient was wearing two patches. Fentanyl
continues to be absorbed even after the patches are removed because of
residual drug in the skin, so the drug levels are not likely to be
decreasing. The patient does not have improved ventilation, because
the respiratory rate is still fewer than 12 breaths per minute.
A patient with chronic pain has been receiving morphine sulfate but
now has decreased pain. The prescriber changes the medication to
pentazocine [Talwin]. The nurse will monitor the patient for:
c. respiratory depression.
yawning and sweating.
Pentazocine is an agonist-antagonist opioid, and when given to
a patient who is physically dependent on morphine, it can precipitate
withdrawal. Yawning and sweating are early signs of opioid withdrawal.
Pentazocine does not produce euphoria, hypotension, or respiratory depression.
A patient will receive buprenorphine [Butrans] as a transdermal patch
for pain. What is important to teach this patient about the use of
a. Avoid prolonged exposure to the sun.
Cleanse the site with soap or alcohol.
c. Remove the patch daily
d. Remove hair by shaving before applying the patch.
Patients using the buprenorphine transdermal patch should be
cautioned against heat, heating pads, hot baths, saunas, and prolonged
sun exposure. The skin should be cleaned with water only. The patch
should stay on for 7 days before a new patch is applied. Patients
should remove hair by clipping, not shaving.
A nurse is preparing a pediatric patient for surgery and is teaching
the patient and the child's parents about the use of the
patient-controlled analgesia pump. The parents voice concern about
their child receiving an overdose of morphine. What will the nurse
a. Instruct the parents not to activate the device when their
child is sleeping.
b. Reassure the parents that drug overdose is
not possible with PCA.
c. Suggest that the child use the PCA
d. Tell the patient that the pump can be programmed
for PRN dosing only.
The nurse should instruct parents not to activate the PCA when
their child is sleeping because that can lead to drug overdose.
Postoperative pain should be treated appropriately with medications
that are effective. Nonopioid medications are not sufficient to treat
postoperative pain. Patients should be encouraged to use the PCA as
needed so that pain can be controlled in a timely fashion. PRN dosing
is not as effective as dosing that is continuous, so a basal dose
should be given as well as a PRN dose.
A patient has been taking methadone [Dolophine] for 5 months to
overcome an opioid addiction. The nurse should monitor the patient for
which of the following electrocardiographic changes?
b. Prolonged P-R interval
c. AV block
elevated QRS complex
Methadone prolongs the QT interval. It does not prolong the
P-R interval, cause AV block, or produce an elevated QRS complex.
A patient who has developed opioid tolerance will experience which
a. Decreased analgesic effect
c. Increased euphoria
d. Increased respiratory depression
Patients who develop tolerance to opioids will develop
tolerance to its analgesic, euphoric, and sedative effects and will
also develop tolerance to respiratory depression. Very little
tolerance develops to constipation.
A nurse is administering morphine sulfate to a postoperative patient.
Which are appropriate routine nursing actions when giving this drug?
(Select all that apply.)
a. Counting respirations before and
after giving the medication
b. Encouraging physical activity and
offering increased fluids
c. Monitoring the patient's blood
pressure closely for hypertension
d. Palpating the patient's
lower abdomen every 4 to 6 hours
e. Requesting an order for
methylnaltrexone [Relistor] to prevent constipation
A, B, D
Respiratory depression, constipation, and urinary
retention are common adverse effects of opioid analgesics. It is
important to count respirations before giving the drug and
periodically thereafter to make sure that respiratory depression has
not occurred. Increased physical activity, increased fluid intake, and
increased fiber help alleviate constipation. It is important to assess
the patient's abdomen and palpate the bladder to make sure that
urinary retention has not occurred. Patients taking morphine often
experience hypotension, not hypertension. Methylnaltrexone is given as
a last resort to treat constipation, because it blocks mu receptors in
Which side effects of opioid analgesics can have therapeutic
benefits? (Select all that apply.)
a. Biliary colic
c. Suppression of bowel motility
B, C, E
Individual effects of morphine may be beneficial,
detrimental, or both. Cough suppression is usually beneficial;
suppression of bowel motility and vasodilation can be either
beneficial or detrimental. Biliary colic and urinary retention are
always detrimental side effects.
A patient taking fluoxetine [Prozac] complains of decreased sexual
interest. A prescriber orders a "drug holiday." What
teaching by the nurse would best describe a drug holiday?
"Cut the tablet in half anytime to reduce the
b. "Discontinue the drug for 1
c. "Don't take the medication on Friday and
d. "Take the drug every other day."
Sexual dysfunction may be managed by having the patient take a
drug holiday, which involves discontinuing medication on Fridays and
Saturdays. Cutting the tablet in half anytime to reduce the dosage is
an inappropriate way to manage drug administration effectively. In
addition, it does not describe a drug holiday. The patient should not
take the drug every other day, nor should it be discontinued for a
week at a time, because this would diminish the therapeutic levels of
the drug, thereby minimizing the therapeutic effects. In addition,
neither of those options describe a drug holiday.
A patient whose spouse has died recently reports feeling down most of
each day for the past 2 months. On further questioning, the nurse
learns that the patient has quit participating in church and social
activities, has difficulty falling asleep, and has lost 5 pounds. The
patient reports feeling tired and confused all the time but does not
have suicidal thoughts. What does the nurse suspect?
a. Grief and
c. Major depression
d. Situational depression
This patient has symptoms of major depression, which include
depressed mood, loss of pleasure in usual activities, insomnia, weight
loss, and feelings of fatigue. For a diagnosis of major depression,
these symptoms must be present most of the day, nearly every day, for
at least 2 weeks. Grief and sadness and situational depression are
common responses to the death of a loved one, but this patient's
symptoms go beyond this normal response. This patient does not show
signs of hypomania.
A patient is diagnosed with major depression with severe symptoms and
begins taking an antidepressant medication. Three weeks after
beginning therapy, the patient tells the nurse that the drug is not
working. The nurse will counsel this patient to ask the provider
a. adding a second medication to complement this
b. changing the medication to one in a different drug
c. increasing the dose of this medication.
nondrug therapies to augment the medication.
Patients with severe depression benefit more from a
combination of drug therapy and psychotherapy than from either
component alone, so this patient should ask the provider about nondrug
therapies. Once a drug has been selected for treatment, it must be
used for 4 to 8 weeks before its efficacy can be assessed. Until a
drug has been used at least 1 month without success, it should not be
considered a failure. Adding a second medication, changing to a
different medication, and increasing the dose of this medication
should all be reserved until the current drug is deemed to have failed
after at least 4 weeks.
A young adult patient has been taking an antidepressant medication
for several weeks and reports having increased thoughts of suicide.
The nurse questions further and learns that the patient has attempted
suicide more than once in the past. The patient identifies a concrete
plan for committing suicide. The nurse will contact the provider to
a. changing the medication to another drug
b. discontinuing the medication immediately.
hospitalizing the patient for closer monitoring.
more frequent clinic visits for this patient.
Patients with depression often think of suicide, and during
treatment with antidepressants, these thoughts often increase for a
time. Patients whose risk of suicide is especially high should be
hospitalized. All antidepressants carry this risk, so changing
medication is not recommended. Discontinuing the medication is not
recommended. More frequent clinic visits are recommended for patients
with a low to moderate risk of suicide.
A patient has been taking fluoxetine [Prozac] for 2 years and reports
feeling cured of depression. The nurse learns that the patient is
sleeping well, participates in usual activities, and feels upbeat and
energetic most of the time. The patient's weight has returned to
normal. The patient reports last having symptoms of depression at
least 9 months ago. What will the nurse tell this patient?
Indefinite drug therapy is necessary to maintain remission.
Discuss gradual withdrawal of the medication with the
c. Stop the drug while remaining alert for the return
d. Take a drug holiday to see whether symptoms recur.
Abrupt discontinuation of selective serotonin reuptake
inhibitors (SSRIs) can cause a withdrawal syndrome, so these drugs
should be withdrawn gradually. After symptoms are in remission,
treatment should continue for 4 to 9 months to prevent relapse; these
drugs are not taken indefinitely. It is incorrect to counsel the
patient to stop taking the drug without tapering it. Drug holidays are
used to minimize sexual dysfunction side effects, not to monitor symptoms.
A patient has been taking an SSRI antidepressant for major depression
and reports having headaches and jaw pain. What will the nurse tell
a. This represents an irreversible extrapyramidal
b. Discuss discontinuing the antidepressant with the
c. Discuss these symptoms with a dentist.
stress-relieving methods and relaxation techniques.
Bruxism is a side effect of SSRIs and can result in headache
and jaw pain. Patients who experience these signs should be evaluated
for bruxism by a dentist, who can determine whether the patient may
benefit from use of a mouth guard. Headache and jaw pain are not signs
of extrapyramidal side effects. Discontinuing the antidepressant is
not indicated, because depression may return. Stress-relieving methods
and relaxation techniques are not recommended, because these symptoms
occur during sleep.
A patient who has been taking a monoamine oxidase inhibitor (MAOI)
for depression for several months tells the provider that the
medication has not helped with symptoms. The provider plans to switch
the patient to an SSRI. The nurse will teach this patient to:
start taking the SSRI and stop the MAOI when symptoms improve.
start taking the SSRI and then gradually withdraw the MAOI.
stop taking the MAOI and wait 5 weeks before starting the
d. stop taking the MAOI 2 weeks before starting the SSRI.
MAOIs increase 5-HT availability, thus greatly increasing the
risk of serotonin syndrome. MAOIs should be withdrawn at least 14 days
before an SSRI is started. An SSRI should never be given at the same
time as an MAOI. It is not necessary to wait 5 weeks before starting
A neonate is born to a patient who reports taking venlafaxine
[Effexor XR]. The nurse caring for the infant will observe the infant
a. irritability, tremor, and respiratory distress.
poor appetite and disturbed sleeping patterns.
d. sustained mydriasis.
Use of venlafaxine late in pregnancy can result in a neonatal
withdrawal syndrome characterized by irritability, abnormal crying,
tremor, respiratory distress, and possibly seizures. Poor appetite and
disturbed sleep are not part of this withdrawal syndrome. Serotonin
syndrome is not likely. Sustained mydriasis occurs as an adverse
effect in patients taking the drug.
A provider has indicated that a serotonin/norepinephrine reuptake
inhibitor (SNRI) will be prescribed for a patient who is experiencing
major depression. When conducting a pretreatment health history, the
nurse learns that the patient has a recent history of alcohol abuse.
Which SNRI would be contraindicated for this patient?
b. Duloxetine [Cymbalta]
d. Venlafaxine [Effexor SR]
Duloxetine can cause elevation of serum transaminases,
indicating liver disease. Patients with existing liver disease or
alcohol abuse should not receive this drug. This side effect is not
likely with desvenlafaxine or venlafaxine. Escitalopram is an SSRI.
A nurse is teaching a group of nursing students about tricyclic
antidepressants (TCAs). Which statement by a student indicates a need
for further teaching?
a. "TCAs block receptors for
histamine, acetylcholine, and norepinephrine."
block the uptake of norepinephrine and 5-HT."
have many side effects, but none of them are serious."
"TCAs have other uses than for depression."
TCAs can adversely affect cardiac function, and these effects
can be serious in patients with preexisting cardiac impairment. TCAs
do block receptors for histamine, acetylcholine, and norepinephrine;
they do block the uptake of norepinephrine and 5-HT; and they do have
other uses besides depression.
An older adult patient who is to begin taking imipramine [Tofranil]
asks the nurse when the drug should be taken. The nurse will instruct
the patient to:
a. divide the daily dose into two equal doses 12
b. take the entire dose at bedtime to minimize
c. take the medication once daily in the late
d. take the medication once daily in the morning.
For many patients, taking the entire dose of a TCA at bedtime
is advantageous for facilitating adherence, minimizing daytime
sedation, and promoting sleep. However, older adult patients are at
greater risk for cardiotoxicity and may experience intolerable effects
on the heart if the entire dose is taken at once; therefore,
twice-daily dosing is recommended in the elderly.
A patient who has fibromyalgia is diagnosed with major depression.
The provider orders a TCA. The nurse will teach this patient
a. avoid foods containing tyrosine.
b. consume alcohol
c. sit or lie down when feeling
d. take the medication in the morning.
Orthostatic hypotension can occur with TCAs. Patients should
be advised to sit or lie down if they feel lightheaded to prevent
falls. Foods containing tyrosine cause adverse effects in patients
taking MAOIs. Patients taking TCAs should be counseled to avoid all
alcohol. Because TCAs cause sedation, the medication should be taken
A patient taking an MAOI is seen in the clinic with a blood pressure
of 170/96 mm Hg. What will the nurse ask this patient?
any antihypertensive medications are used
b. Whether the patient
drinks grapefruit juice
c. To list all foods eaten that
d. Whether SSRIs are taken in addition to the MAOI
Patients taking an MAOI should be counseled to follow strict
dietary restrictions and to avoid all foods containing tyramine.
Patients who consume such foods when taking an MAOI experience a
hypertensive episode. Antihypertensive medications, given with an
MAOI, will result in hypotension. Grapefruit juice does not alter the
metabolism of an MAOI. SSRIs and MAOIs, when administered together,
cause a serotonin syndrome
A patient who has been taking an SSRI tells the nurse that the drug
has caused reduced sexual performance, weight gain, and sedation. The
nurse will suggest that the patient ask the provider about using which
a. Bupropion [Wellbutrin]
c. Isocarboxazid [Marplan]
d. Trazodone [Oleptro]
Bupropion does not cause weight gain, sexual dysfunction, or
sedation, so it may be a useful adjunct to or substitute for an SSRI
when those side effects become intolerable. Imipramine causes
sedation. Isocarboxazid is an MAOI and is not used unless other drugs
are ineffective. Trazodone causes sedation.
A first-time parent of a 6-week-old infant tells the nurse that she
feels anxious and sad, cries a lot, and has difficulty sleeping. What
will the nurse do?
a. Ask her to complete the Edinburgh Postnatal
b. Reassure her that the "baby blues"
are normal after childbirth.
c. Suggest that she get more sleep
and try to increase her activity.
d. Suggest that she talk to her
provider about using an SSRI.
Women who experience depressive symptoms after childbirth can
be screened using a quick test: the Edinburgh Postnatal Depression
Scale, which may be administered 6 to 8 weeks after delivery.
Reassuring her that her feelings are normal does not acknowledge her
concerns; also, without objective screening, this reassurance may not
be warranted. Increased sleep and activity may help, but screening is
necessary to determine the severity of the depression. Until the
patient is diagnosed as having postpartum depression, an SSRI is not indicated.
A woman who is nursing a newborn develops postpartum depression and
her provider orders sertraline [Zoloft] to treat her symptoms. The
patient is concerned about the safety of this medication for her
infant. What will the nurse tell her about this medication?
stop nursing while taking the medication
b. To expect symptoms of
colic and poor weight gain in the baby
c. That sertraline is
safer than other antidepressants for nursing mothers
d. To ask
her provider about switching to fluoxetine [Prozac] instead
Sertraline is safer than other antidepressants for nursing
women when used to treat postpartum depression. It is not necessary
for her to stop nursing while taking the medication. Colic and poor
weight gain occur with fluoxetine, which is not safe for nursing mothers.
A patient is brought to the emergency department after taking a
handful of TCA pills. The nurse will expect to provide what when
caring for this patient? (Select all that apply.)
b. Cholinesterase inhibitors
c. Gastric lavage
and activated charcoal
d. Sedative medications
A, B, C
Patients who overdose with a TCA should have cardiac
monitoring, because cardiac side effects can occur. Cholinesterase
inhibitors are given to counteract anticholinergic side effects.
Gastric lavage followed by activated charcoal can reduce absorption of
the TCA. Sedative drugs would only increase the sedative effects of
the TCA. Procainamide causes cardiac depression and is not recommended
to treat TCA dysrhythmias.
Which patients are candidates for MAOIs? (Select all that
a. Patients who have not responded to SSRIs and
b. Patients with atypical depression
c. Patients with
d. Patients with hypotension
with postpartum depression
A, B, C
Patients who have not responded to SSRIs or TCAs,
patients with atypical depression, and patients with bulimia nervosa
are candidates for MAOIs. MAOIs contribute to hypotension and
therefore are contraindicated in patients with hypotension. MAOIs are
not recommended for the treatment of postpartum depression.
A nurse is discussing the use of benzodiazepines as sedative-hypnotic
agents with a group of nursing students. A student asks about the
actions of these drugs in the central nervous system. The nurse makes
which correct statement?
a. "Benzodiazepines affect the
hippocampus and the cerebral cortex to cause anterograde
b. "Benzodiazepines depress neuronal
functions by acting at a single site in the brain."
"Benzodiazepines induce muscle relaxation by acting on sites
outside the central nervous system."
"Benzodiazepines promote sleep through effects on the limbic system."
All beneficial and most adverse effects of benzodiazepines
occur from depressant actions in the central nervous system (CNS); the
various effects depend on the site of action. Anterograde amnesia is
the result of effects in the hippocampus and the cerebral cortex.
Benzodiazepines act at multiple sites in the CNS. Muscle relaxant
effects are the result of actions on supraspinal motor areas in the
CNS. Benzodiazepines promote sleep through effects on cortical areas
and on the sleep-wakefulness "clock."
A patient who has been using secobarbital for several months to treat
insomnia tells the nurse that the prescriber has said the prescription
will be changed to temazepam [Restoril] because it is safer. The
patient asks why this agent is safer. The nurse is correct in telling
the patient that temazepam:
a. does not depress the central
b. shows no respiratory depression, even in toxic
c. mimics the actions of a central nervous system
d. potentiates endogenous
gamma-aminobutyric acid (GABA) producing a finite CNS depression.
Benzodiazepines potentiate the actions of GABA, and because
the amount of GABA in the CNS is finite, these drugs' depressive
effect on the CNS is limited. Benzodiazepines depress the CNS but not
to the extent that barbiturates do. Benzodiazepines are weak
respiratory depressants at therapeutic doses and moderate respiratory
depressants at toxic doses. Barbiturates mimic GABA; therefore,
because they produce CNS depression, this effect is limited only by
the amount of barbiturate administered.
A hospitalized patient who is given one dose of flurazepam continues
to show drowsiness the next day. A nursing student asks the nurse the
reason for this, because the drug's half-life is only 2 to 3 hours.
Which response by the nurse is correct?
commonly cause residual effects lasting into the day after the dose is
b. "The patient is having a paradoxical
reaction to this medication."
c. "This patient must
have developed a previous tolerance to benzodiazepines."
"When this drug is metabolized, the resulting compound has
Flurazepam has a half-life of 2 to 3 hours; however, its
metabolite has a long half-life, so giving the drug results in
long-lasting effects. Barbiturates, not benzodiazepines, are commonly
associated with residual, or hangover, effects. A paradoxical reaction
to a sedative would manifest as insomnia, euphoria, and excitation,
not drowsiness. Tolerance means that the patient would need increased
amounts of a drug to get the desired effects and would not have
prolonged effects of the medication.
A patient who is experiencing alcohol withdrawal is given a
benzodiazepine. The nurse understands that this drug is effective
a. the alcohol does not interact with the
b. the benzodiazepine potentiates alcohol
c. the benzodiazepine relieves muscle spasms
d. the patient has a cross-dependence to the benzodiazepine.
Benzodiazepines are given to ease withdrawal from alcohol
because of cross-dependence with these drugs and alcohol, enabling the
benzodiazepine to suppress withdrawal symptoms. Alcohol and
benzodiazepines can potentiate one another. The benzodiazepine does
not potentiate withdrawal symptoms. Benzodiazepines relieve muscle
spasms, but this is not why they are given for alcohol withdrawal.
A patient takes temazepam [Restoril] for insomnia. The patient tells
the nurse that a recent telephone bill lists several calls to friends
that the patient does not remember making. What will the nurse
a. Ask the patient about any alcohol consumption in
conjunction with the benzodiazepine.
b. Contact the prescriber to
request an order for a benzodiazepine with a shorter duration.
Reassure the patient that this is most likely caused by a paradoxical
reaction to the benzodiazepine.
d. Tell the patient that this is
an example of anterograde amnesia, which is an expected effect of the benzodiazepine.
This patient is describing complex sleep-related behavior,
which occurs when patients carry out complex behaviors while taking
benzodiazepines but have no memory of their actions. These actions can
occur with normal doses but are more likely with excessive doses or
when benzodiazepines are combined with alcohol or other CNS
depressants, so the nurse is correct in evaluating this possibility.
The duration of the benzodiazepine does not contribute to this
phenomenon. Paradoxical effects of benzodiazepines include insomnia,
excitation, euphoria, anxiety, and rage. Anterograde amnesia occurs
when patients have impaired recall of events that occur after dosing.
A patient has been taking high doses of clorazepate [Tranxene] for
several months for an anxiety disorder. The nurse assessing the
patient observes that the patient is agitated, euphoric, and anxious.
What will the nurse do?
a. Double-check the chart to make sure
the last dose was given.
b. Request an order for a longer-acting
c. Suspect a possible paradoxical reaction to the
d. Withhold the next dose until a drug level can be drawn.
Patients taking benzodiazepines for anxiety sometimes develop
paradoxical responses to the drug, which include insomnia, excitation,
euphoria, heightened anxiety, and rage. A missed dose would trigger
withdrawal symptoms, which would include anxiety, insomnia, sweating,
tremors, and dizziness. Because this is a paradoxical reaction to the
drug, a longer-acting drug would make the symptoms worse. This is not
caused by overdose, which would manifest as drowsiness, lethargy, and
confusion, so a drug level is not warranted.
A patient in the emergency department is given intravenous diazepam
[Valium] for seizures. When the seizures stop, the nurse notes that
the patient is lethargic and confused and has a respiratory rate of 10
breaths per minute. The nurse will expect to administer which of the
a. Flumazenil [Romazicon]
c. Respiratory support
d. Toxicology testing
When benzodiazepines are administered IV, severe effects,
including profound hypotension, respiratory arrest, and cardiac
arrest, can occur. Respiration should be monitored, and the airway
must be managed if necessary. Flumazenil [Romazicon] is a competitive
benzodiazepine receptor antagonist and is used to reverse the sedative
effects but may not reverse respiratory depression. Gastric lavage
would not be effective, because the benzodiazepine has been given IV.
Without further indication of the ingestion of other drugs, toxicology
testing is not a priority.
A patient is brought to the emergency department by friends, who say
that they were at a party where alcohol and a mix of barbiturates and
benzodiazepines were all available. They tell the nurse that the
patient was among the first to arrive at the party, which started
several hours ago. The patient is nonresponsive and has pinpoint
pupils and respirations of 6 breaths per minute. After oxygen has been
administered, the nurse should prepare the patient for which
a. A central nervous system stimulant and IV
b. Activated charcoal and flumazenil [Romazicon]
Maintaining adequate oxygenation to the brain
[Narcan] and a cathartic
Because time has elapsed, enough medication is present in the
system to warrant treatment for systemic effects. A central nervous
system stimulant is contraindicated, and intravenous fluids do not
address the overdose. Although activated charcoal may assist in
absorption of medication in the gut, flumazenil will be effective only
for the benzodiazepines. Naloxone, a narcotic antagonist, is not
effective for barbiturates and benzodiazepines.
A patient who travels frequently for business reports occasional
instances of being unable to fall asleep. The patient tells the nurse
that job demands require staying up late and then getting up early for
meetings. The nurse expects that the provider will prescribe which
medication for this patient?
c. Zaleplon [Sonata]
d. Zolpidem [Ambien
Zaleplon [Sonata] works well for people who have trouble
falling asleep and, because of its short duration of action, can be
taken late at night without causing a hangover or next-day sedation
early in the morning. Zolpidem [Ambien] has a longer duration and is a
good choice for patients who have difficulty maintaining sleep.
Flurazepam has a long duration of action. Trazodone causes daytime grogginess.
A patient with a new-onset seizure disorder receives a prescription
for phenobarbital. The patient reports being concerned about the
sedative side effects of this drug. Which response by the nurse is
a. "Phenobarbital doses for seizures are
b. "This is a short-acting barbiturate,
so sedation wears off quickly."
c. "Tolerance to the
sedative effects will develop in a few weeks."
may actually experience paradoxical effects of euphoria."
Phenobarbital and mephobarbital are used for seizure disorders
and suppress seizures at doses that are nonsedative. Phenobarbital is
a long-acting barbiturate. At therapeutic doses, sedative effects do
not occur. Paradoxical drug effects are associated with
benzodiazepines and in older adults and debilitated patients with barbiturates.
A patient with a history of depression and suicidal ideation is
taking fluoxetine [Prozac]. The patient reports difficulty maintaining
sleep and is prescribed secobarbital [Seconal] as a sedative-hypnotic.
The nurse preparing this patient for discharge from the hospital
a. contact the provider to suggest an order for ramelteon
b. instruct the patient to use alcohol in
c. request an order to change to trazodone [Desyrel]
d. suggest that the patient try alternative remedies
Trazodone is an atypical antidepressant with sedative actions
and can be used to prolong sleep duration. It is useful for treating
insomnia related to antidepressants such as Prozac. Ramelteon is not a
drug of choice to treat patients who have difficulty maintaining
sleep. Patients who are depressed or at increased risk for suicide
should not take barbiturates, because overdose can readily cause
death. Alcohol is contraindicated when taking barbiturates.
Alternative remedies have not shown effectiveness in treating insomnia.
A nurse is obtaining a health history from an older adult patient in
an outpatient clinic. The patient reports chronic difficulty falling
asleep and staying asleep. The nurse knows that the best treatment for
this patient will be:
a. alternative medications.
improved sleep hygiene.
c. short-term barbiturates.
Research has shown that cognitive behavioral therapy is
superior to drug therapy for short-term and long-term management of
chronic insomnia in older adults. Alternative remedies have not been
proven effective. Barbiturates may elicit paradoxical effects in
elderly patients. Triazolam does not help to maintain sleep.
A patient complains of chronic insomnia and reports being tired of
being tired all the time. The patient is reluctant to try
pharmacologic remedies and asks the nurse what to do. What will the
a. "Eat a large meal in the evening to induce
b. "Get out of bed for a while if you
can't fall asleep."
c. "Have a glass of wine at bedtime
d. "Take a short nap early in the afternoon
Rules for sleep fitness recommend getting out of bed if unable
to fall asleep in 20 minutes and doing something relaxing and then
returning to bed when drowsy. Eating a large meal will increase
insomnia. Drinking alcohol helps some people to fall asleep but causes
fragmented sleep. Taking a nap reduces feelings of drowsiness at bedtime.
A nurse recognizes that the actions of benzodiazepines include which
findings? (Select all that apply.)
a. Sleep deprivation
Relief of general anxiety
c. Suppression of seizures and/or
d. Development of tardive dyskinesia
Increase in muscle spasms
Benzodiazepines are indicated to relieve the symptoms of
general anxiety and to suppress the central nervous system, thereby
suppressing seizures and/or seizure activity. Benzodiazepines cause
sleepiness, not sleep deprivation. Benzodiazepines do not cause
tardive dyskinesia. Benzodiazepines relax muscles; they do not
increase muscle spasms.
Which sedative-hypnotics are useful for both difficulty falling
asleep and difficulty maintaining sleep? (Select all that
a. Eszopiclone [Lunesta]
c. Temazepam [Restoril]
e. Extended-release zolpidem [Ambien CR]
A, B, E
Eszopiclone [Lunesta], flurazepam, and extended-release
zolpidem [Ambien CR] help with difficulty falling asleep and
difficulty maintaining sleep. Temazepam is useful for maintaining
sleep only. Triazolam helps with difficulty falling asleep but does
not maintain sleep.
A patient is brought to the emergency department with shortness of
breath, a respiratory rate of 30 breaths per minute, intercostal
retractions, and frothy, pink sputum. The nurse caring for this
patient will expect to administer which drug?
b. Hydrochlorothiazide [HydroDIURIL]
d. Spironolactone [Aldactone]
Furosemide, a potent diuretic, is used when rapid or massive
mobilization of fluids is needed. This patient shows severe signs of
congestive heart failure with respiratory distress and pulmonary edema
and needs immediate mobilization of fluid. Hydrochlorothiazide and
spironolactone are not indicated for pulmonary edema, because their
diuretic effects are less rapid. Mannitol is indicated for patients
with increased intracranial pressure and must be discontinued
immediately if signs of pulmonary congestion or heart failure occur.
A patient who is taking digoxin is admitted to the hospital for
treatment of congestive heart failure. The prescriber has ordered
furosemide [Lasix]. The nurse notes an irregular heart rate of 86
beats per minute, a respiratory rate of 22 breaths per minute, and a
blood pressure of 130/82 mm Hg. The nurse auscultates crackles in both
lungs. Which laboratory value causes the nurse the most
a. Blood glucose level of 120 mg/dL
saturation of 90%
c. Potassium level of 3.5 mEq/L
level of 140 mEq/L
This patient has an irregular, rapid heartbeat that might be
caused by a dysrhythmia. This patient's serum potassium level is low,
which can trigger fatal dysrhythmias, especially in patients taking
digoxin. Furosemide contributes to loss of potassium through its
effects on the distal nephron. Potassium-sparing diuretics often are
used in conjunction with furosemide to prevent this complication. This
patient's serum glucose and sodium levels are normal and of no concern
at this point, although they can be affected by furosemide. The oxygen
saturation is somewhat low and needs to be monitored, although it may
improve with diuresis.
A patient has 2+ pitting edema of the lower extremities bilaterally.
Auscultation of the lungs reveals crackles bilaterally, and the serum
potassium level is 6 mEq/L. Which diuretic agent ordered by the
prescriber should the nurse question?
b. Furosemide [Lasix]
d. Hydrochlorothiazide [HydroDIURIL]
Spironolactone is a non-potassium-wasting diuretic; therefore,
if the patient has a serum potassium level of 6 mEq/L, indicating
hyperkalemia, an order for this drug should be questioned. Bumetanide,
furosemide, and hydrochlorothiazide are potassium-wasting diuretics
and would be appropriate to administer in a patient with hyperkalemia.
A nurse preparing to administer morning medications notes that a
patient with a history of hypertension has been prescribed
spironolactone [Aldactone]. The nurse assesses the patient and notes
dyspnea, bilateral crackles, and pitting edema in both feet. Which
intervention is appropriate?
a. Administer the medications as
b. Ask the patient about the use of salt
c. Contact the provider to request an order for
d. Request an order for furosemide [Lasix].
Spironolactone takes up to 48 hours for its effects to
develop, so it should not be used when the patient needs immediate
diuresis. This patient has shortness of breath, crackles, and edema
and needs a short-acting diuretic, such as furosemide. Asking the
patient about the use of salt substitutes is not indicated. The
patient does not need assessment of serum electrolytes.
A patient who was in a motor vehicle accident sustained a severe head
injury and is brought into the emergency department. The provider
orders intravenous mannitol [Osmitrol]. The nurse knows that this is
a. reduce intracranial pressure.
b. reduce renal
c. reduce peripheral edema.
Mannitol is an osmotic diuretic that is used to reduce
intracranial pressure by relieving cerebral edema. The presence of
mannitol in blood vessels in the brain creates an osmotic force that
draws edematous fluid from the brain into the blood. Mannitol can also
be used to increase renal perfusion. It can cause peripheral edema and
is not used to restore extracellular fluid.
A patient is taking gentamicin [Garamycin] and furosemide [Lasix].
The nurse should counsel this patient to report which symptom?
c. Ringing in the
d. Urinary retention
Patients taking furosemide should be advised that the risk of
furosemide-induced hearing loss can be increased when other ototoxic
drugs, such as gentamicin, are also taken. Patients should be told to
report tinnitus, dizziness, or hearing loss. Nocturia may be an
expected effect of furosemide. Headaches are not likely to occur with
concomitant use of gentamicin and furosemide. Urinary retention is not
an expected side effect.
An older adult patient with congestive heart failure develops
crackles in both lungs and pitting edema of all extremities. The
physician orders hydrochlorothiazide [HydroDIURIL]. Before
administering this medication, the nurse reviews the patient's chart.
Which laboratory value causes the nurse the most concern?
Elevated creatinine clearance
b. Elevated serum potassium
c. Normal blood glucose level
d. Low levels of
low-density lipoprotein (LDL) cholesterol
Hydrochlorothiazide should not be given to patients with
severe renal impairment; therefore, an elevated creatinine clearance
would cause the most concern. Thiazide diuretics are potassium-wasting
drugs and thus may actually improve the patient's potassium level.
Thiazides may elevate the serum glucose level in diabetic patients.
Thiazides increase LDL cholesterol; however, this patient's levels are
low, so this is not a risk.
A patient with chronic congestive heart failure has repeated
hospitalizations in spite of ongoing treatment with
hydrochlorothiazide [HydroDIURIL] and digoxin. The prescriber has
ordered spironolactone [Aldactone] to be added to this patient's drug
regimen, and the nurse provides education about this medication. Which
statement by the patient indicates understanding of the
a. "I can expect improvement within a few hours
after taking this drug."
b. "I need to stop taking
c. "I should use salt
substitutes to prevent toxic side effects."
should watch closely for dehydration."
Spironolactone is a potassium-sparing diuretic used to counter
the potassium-wasting effects of hydrochlorothiazides. Patients taking
potassium supplements are at risk for hyperkalemia when taking this
medication, so they should be advised to stop the supplements.
Spironolactone takes up to 48 hours to have effects. Salt substitutes
contain high levels of potassium and are contraindicated.
Spironolactone is a weak diuretic, so the risk of dehydration is not increased.
Besides having diuretic effects for patients with congestive heart
failure, thiazides are also used to treat what? (Select all that
a. Diabetes insipidus
b. Hepatic failure
Increased intracranial pressure
d. Intraocular pressure
A, B, E
Thiazide diuretics have the paradoxical effect of
reducing urine output in patients with diabetes insipidus. They can
also be used to mobilize edema associated with liver disease. They
promote tubular reabsorption of calcium, which may reduce the risk of
osteoporosis in postmenopausal women. Mannitol is used to treat edema
that causes increased intracranial pressure and intraocular pressure.
A patient who is a chronic alcoholic is admitted to the hospital.
Admission laboratory work reveals a magnesium level of 1.2 mEq/L. The
prescriber orders intravenous magnesium sulfate in a 10% solution at a
rate of 10 mL/min. What will the nurse do?
a. Administer the IV
dose as ordered and have calcium gluconate on hand.
the IV dose and make preparations for mechanical ventilation.
Hold the IV dose until the infusion rate has been clarified with the
d. Request an order for renal function tests before
administering the IV dose.
This patient has hypomagnesemia and should be given magnesium
sulfate intravenously. The percent of magnesium in solution is
correct; however, magnesium should not be infused faster than 1.5
mL/min, so the nurse is correct to question the rate of infusion.
Calcium gluconate should be available when magnesium is given, but the
nurse needs to clarify the rate of infusion first. Mechanical
ventilation is necessary with excessive magnesium. Renal function
tests are not indicated.
A patient who was injured at home is brought to the emergency
department. The nurse caring for this patient notes a respiratory rate
of 32 breaths per minute and a heart rate of 90 beats per minute. The
injuries are minor, but the patient is inconsolable and hysterical.
The nurse expects that initial management will include:
administering a gas mixture of 5% carbon dioxide (CO2).
providing 100% oxygen via nasal cannula.
c. giving sodium
d. providing sedatives to calm the patient.
The patient is at risk for respiratory alkalosis as a result
of hyperventilation, and giving the patient a gas mixture containing
CO2 will help correct the alkalosis. Administering oxygen would worsen
the problem. Sodium bicarbonate is given to correct metabolic
acidosis. Sedatives may be necessary if initial measures fail.
A child who ingested a handful of aspirin tablets from a medicine
cabinet at home is brought to the emergency department. The nurse
caring for the child notes a respiratory rate of 48 breaths per
minute. The nurse understands that this child's respiratory rate is
the result of the body's attempt to compensate for:
b. metabolic alkalosis.
d. respiratory alkalosis.
Metabolic acidosis can result from the ingestion of aspirin.
The body responds by hyperventilating to reduce CO2, which represents
volatile carbonic acid, and raise pH. This child has a rapid
respiratory rate in response to metabolic acidosis. In patients with
metabolic alkalosis, the body responds with hypoventilation in an
effort to increase the CO2 level. Patients with respiratory acidosis
usually have retention of CO2 secondary to hypoventilation, and
compensation is the result of retention of bicarbonate by the kidneys,
which is a slow process. Respiratory alkalosis is caused by
hyperventilation; treatment involves having the patient rebreathe CO2
or administering sedatives.
A patient with congestive heart failure is admitted to the hospital.
During the admission assessment, the nurse learns that the patient is
taking a thiazide diuretic. The nurse notes that the admission
electrolyte levels include a sodium level of 142 mEq/L, a chloride
level of 95 mEq/L, and a potassium level of 3 mEq/L. The prescriber
has ordered digoxin to be given immediately. What will the nurse do
a. Give the digoxin and maintain close cardiac
b. Hold the digoxin and report the laboratory values
to the provider.
c. Hold the thiazide diuretic and give the
d. Request an order for an electrocardiogram (ECG).
Potassium depletion is common with thiazide diuretics, and
hypokalemia is especially dangerous for patients receiving digoxin,
because the drug can precipitate a fatal dysrhythmia and digoxin
toxicity. The provider should be notified of the serum potassium level
so that it can be corrected before the digoxin is administered. Giving
the digoxin could produce a fatal adverse effect, so this is not an
appropriate course of action. Holding the thiazide diuretic will not
correct the potassium deficiency. An ECG is not the initial priority.
A patient collapses after running a marathon on a hot day and is
brought to the emergency department to be treated for dehydration. The
nurse will expect to provide which therapy?
hypertonic fluids given slowly over several hours
hypotonic fluids administered in stages
c. Intravenous isotonic
fluids given as a rapid bolus
d. Oral electrolyte replacement
fluids with potassium
A patient collapses after running a marathon on a hot day and is
brought to the emergency department to be treated for dehydration. The
nurse will expect to provide which therapy?
hypertonic fluids given slowly over several hours
hypotonic fluids administered in stages
c. Intravenous isotonic
fluids given as a rapid bolus
d. Oral electrolyte replacement
fluids with potassium
A nurse is caring for a child whose respirations are shallow and
marked by a prolonged expiratory phase. The nurse auscultates wheezes
and poor air movement bilaterally. The child's respiratory rate is 26
breaths per minute, and the oxygen saturation is 89%. What does the
a. Metabolic acidosis
c. Respiratory acidosis
d. Respiratory alkalosis
Respiratory acidosis results from retention of CO2 secondary
to hypoventilation caused either by depression of the medullary
respiratory center in the central nervous system (CNS) or by a
pathologic lung condition, such as asthma. This child has shallow
respirations with evidence of airway obstruction and poor ventilation.
Metabolic acidosis occurs in chronic renal failure, loss of
bicarbonate with severe diarrhea, metabolic disorders, and ingestion
of acids such as salicylates; hyperventilation is a compensatory
mechanism. Metabolic alkalosis is usually caused by excessive loss of
gastric acid or by ingestion of alkalinizing salts; hypoventilation is
a compensatory mechanism. Respiratory alkalosis is produced by
hyperventilation and can occur in any condition that increases the
respiratory rate and depth.
A nurse is caring for a postoperative patient who has a nasogastric
tube with continuous suction. The nurse notes that the patient has
shallow respirations and suspects that this patient has
a. metabolic acidosis.
c. respiratory acidosis.
d. respiratory alkalosis.
Metabolic alkalosis occurs with excessive loss of acid, such
as gastric acid, or an excessive increase in alkalinizing salts. The
body compensates for metabolic alkalosis by hypoventilating in an
attempt to retain CO2. Metabolic acidosis is usually caused by
ingestion of acids or excessive loss of bicarbonate and is compensated
by hyperventilation. Respiratory acidosis results from
hypoventilation. Respiratory alkalosis is the result of hyperventilation.
While performing an admission assessment on a patient, the nurse
learns that the patient is taking furosemide [Lasix], digoxin, and
spironolactone [Aldactone]. A diet history reveals the use of salt
substitutes. The patient is confused and dyspneic and complains of
hand and foot tingling. Which is an appropriate nursing action for
a. Contact the provider to request orders for an
electrocardiogram and serum electrolyte levels.
b. Evaluate the
patient's urine output and request an order for intravenous
c. Hold the next dose of furosemide and request an
order for intravenous magnesium sulfate.
d. Request an order for
intravenous insulin to help this patient regulate extracellular potassium.
This patient is taking a potassium-sparing diuretic and is
ingesting dietary potassium in salt substitutes. The patient shows
signs of hyperkalemia: confusion, shortness of breath, and tingling of
the hands and feet. The cardiac effects can be fatal, especially if a
patient also is taking digoxin. The most appropriate first action
would be to obtain an ECG and serum electrolyte levels to evaluate the
extent of the patient's hyperkalemia. The patient does not need
increased potassium. Furosemide is a potassium-wasting diuretic and
would be helpful. Magnesium sulfate is not indicated. Until the
patient's status has been assessed further, intravenous insulin is not indicated.
A patient arrives in the emergency department complaining of muscle
weakness and drowsiness. The nurse notes a heart rate of 80 beats per
minute, a respiratory rate of 18 breaths per minute, and a blood
pressure of 90/50 mm Hg. The electrocardiogram reveals an abnormal
rhythm. The nurse will question the patient about which
d. Potassium supplements
Hypermagnesemia can occur when patients are taking
magnesium-containing antacids. Symptoms include muscle weakness,
sedation, hypotension, and ECG changes. Aspirin would cause metabolic
acidosis. Laxatives can contribute to hypokalemia. Potassium
supplements would cause hyperkalemia.
A patient arrives in the emergency department after becoming
dehydrated. Based on the patient's history, the provider determines
that isotonic dehydration has occurred. Which solution will the nurse
expect to infuse to treat this patient?
a. 0.45% sodium chloride
in sterile water
b. 0.9% sodium chloride in sterile water
3% sodium chloride in sterile water
d. 5% dextrose solution
Isotonic dehydration should be treated with an isotonic
solution of 0.9% NaCl in sterile water. A 0.45% solution or 5%
dextrose is used to treat hypertonic dehydration. A 3% NaCl solution
is used to treat hypotonic dehydration.
A patient is admitted to the hospital after several days of vomiting
and diarrhea. After an initial bolus of isotonic (0.9%) sodium
chloride solution, the prescriber orders dextrose 5% in normal saline
(D5NS) with 20 mEq potassium chloride to infuse at a maintenance rate.
What should the nurse review before implementing this order? (Select
all that apply.)
b. Arterial blood gas
c. Serum electrolyte levels
d. Serum glucose
e. Urine output
A, C, E
Patients receiving potassium should be monitored for
cardiovascular toxicity; an ECG before and during administration can
help monitor for this adverse effect. Serum electrolyte levels should
be reviewed to make sure the patient is not already hyperkalemic.
Because potassium is excreted via the kidneys, it is important to
determine that renal function is intact. Intravenous potassium should
never be given if the patient has not voided. Patients who are
hyperkalemic can be treated with sodium bicarbonate to increase pH and
insulin to promote uptake of potassium by cells, but it is not
necessary to evaluate the blood gas or glucose levels before
Which order for potassium (KCl) would the nurse question? (Select all
a. NS with 20 mEq KCl to start after patient
b. NS with 60 mEq KCl for a patient with a serum potassium
of 3.2 mEq/L
c. K-Dur, 1 tablet daily for a patient in diabetic
d. K-Dur, 1 tablet with a full glass of
e. Potassium chloride, 10 mEq rapid IV push
B, C, E
Patients receiving potassium should not receive
potassium in solution diluted at more than 40 mEq/L. Diabetic
ketoacidosis causes decreased cellular uptake of potassium, and
patients in whom acidosis is present should also receive sodium
bicarbonate if they need potassium. IV potassium should not be infused
faster than 10 mEq/hr. NS with 20 mEq KCl is an appropriate solution
for a patient with intact renal function. Oral potassium should be
given with a full glass of water to minimize gastrointestinal (GI) effects.
1. A nurse is reviewing the immune system with a group of nursing
students. One student asks about the difference between cell-mediated
immunity and humoral immunity. What should the nurse reply?
a. "Humoral immunity does not involve helper T cells in the
b. "Humoral immunity does not have a
role in hypersensitivity reactions."
immunity requires cytolytic T cells that attack antigens
d. "Humoral immunity uses cells produced by
B lymphocytes in the immune response."
Humoral immunity refers to immunity mediated by
antibodies, which are produced by B lymphocytes. Helper T cells have
an essential role in antibody production by B cells. The antibody
immunoglobulin E plays a role in hypersensitivity reactions. Cytolytic
T cells do not produce antibodies; they are key players in cellular immunity
2. A nurse is teaching a nursing student about a specific acquired
immunity system. Which statement by the student indicates a need for
a. "Cell-mediated immunity and humoral immunity are both
types of specific acquired immune responses."
exposure to an antigen causes a faster, more intense
c. "Immune responses occur only after
exposure to a foreign substance."
d. "The skin is a
factor in specific acquired immunity."
The skin is a physical barrier that confers natural
immunity. It is not a factor in specific acquired immunity.
Cell-mediated and humoral immunity are both types of specific acquired
immunity. In specific acquired immunity, each exposure to an antigen
evokes a more intense response more quickly. Specific acquired
immunity occurs only after initial exposure to an antigen.
3. A nurse is caring for a patient infected with the human
immunodeficiency virus (HIV). Which finding would most concern the nurse?
a. High level of macrophages
b. Low neutrophil
c. Low red blood cell (RBC) count
d. Very low helper T
The nurse understands that this patient may be vulnerable
to opportunistic infections, especially if there were an indication of
the HIV conversion to acquired immunodeficiency syndrome (AIDS). A
very low helper T lymphocyte count would most concern the nurse,
because the helper T cells are essential to the immune system, and
people with AIDS have a low or deficient count. A high level of
macrophages could indicate an inflammatory response. A low RBC count
may indicate anemia. A low neutrophil count can be caused by multiple
conditions, but a high count most likely indicates an infection.
4. Which statement is true about helper T cells?
a. They are useful but are not essential to immune
b. They do not play a role in antibody
c. They have highly specific receptors to antigens on
d. They prevent CD4 molecules from attaching to antigens.
Helper T cells have highly specific cell surface
receptors that recognize individual antigens. Helper T cells play an
essential role in several functions of the immune response. They have
an essential role in the production of antibodies by B cells. They
carry CD4 molecules on their surface and are also referred to as CD4 cells.
5. A nurse is caring for a patient who has undergone organ
transplantation. Because the sequence of amino acids in the major
histocompatibility complex (MHC) molecules of the donor is different
from that of the patient, the nurse will expect to administer which
class of drugs?
The MHC molecules from one individual are recognized as
foreign by the immune system of another individual; therefore, when an
attempt is made to transplant organs between individuals who are not
identical twins, immune rejection of the transplant is likely.
Immunosuppressants are given to counter this response. Antibiotics are
used to destroy bacteria. Antihistamines block hypersensitivity
reactions. Immune globulins are given to confer passive immunity when
specific acquired immunity has not yet developed a response.
6. A nurse is teaching a group of nursing students about antibodies.
The nurse correctly explains that which type of response is triggered
when antigens bind to antibodies on mast cells or basophils?
a. Acquired immune response
b. Autoimmune response
d. Transplant rejection
When antigens bind to antibodies on mast cells and
basophils, chemical mediators of hypersensitivity reactions are
released. Although hypersensitivity is an acquired response, mast
cells and basophils do not play a role in other acquired responses. An
autoimmune response occurs when the immune system fails to
discriminate between self and nonself. Transplant rejection occurs
when the MHC molecules of the donor are different from those of the patient.
7. A nurse is teaching a group of nursing students about
immunoglobulins. Which statement by a student indicates a need for
a. "IgD provides a first line of defense against microbes
entering the body through the lungs."
b. "IgE plays a
role in hypersensitivity reactions and responses to
c. "IgG and IgM participate in the
complement response to promote target cell lysis."
"Neonatal immunity is the result of IgG crossing the placenta."
IgD serves as a receptor for antigen recognition on B
cells, which is the only place it is found. IgE is involved in
hypersensitivity responses and responses to parasites. IgG and IgM are
involved in complement responses. IgG crosses the placenta and confers
passive immunity on the fetus.
8. A patient who breast-feeds her infant asks the nurse about the
immunity the infant receives from breast milk. What does the nurse
tell the patient about immunity through breast-feeding?
a. "The immunity protects the infant from hypersensitivity
b. "The immunity provides phagocytes to
help the infant fight infections."
c. "The immunity
results from the transfer of IgA through the breast
d. "The immunity protects the infant from
respiratory and gastrointestinal (GI) microbes."
IgA crosses breast milk and, in the GI tract, where it is
not absorbed, provides passive immunity to microbes. Infants do not
receive protection from hypersensitivity reactions through breast
milk. Phagocytes are not transmitted through breast milk. Infants are
not protected from respiratory microbes via breast milk.
9. A nurse is discussing the role of antibodies in the complement
system with a group of nursing students. Which statement by a student
a. "Antibodies activate the complement cascade by turning
on the alternative pathway."
b. "Antibodies that are
free in solution can activate the complement system."
"Antibodies flag target cells to be lysed by membrane attack
d. "Antibody receptors are nonspecific to
Lysis of target cells that have been tagged with
antibodies is the most dramatic effect of the complement system.
Antibodies activate the complement cascade by turning on the classical
pathway. C1 cannot bind with free antibodies. Antibody receptors are
specific to antigen determinants.
10. A patient has a Type IV hypersensitivity (delayed-type
hypersensitivity) response to an infection. The nurse understands that
which two types of cells are necessary for this response?
a. Antigen-presenting cells and mast cells
b. Cytolytic T
lymphocytes and target cells
c. Immunoglobulin cells and
d. Infected macrophages and CD4 helper T cells
The object of Type IV hypersensitivity (delayed-type
hypersensitivity) is to rid the body of bacteria that replicate within
macrophages. The macrophage activates the CD4 cell, which in turn
activates the macrophage. The other cells listed are not a part of
1. Which immune responses can result in harm to the body? (Select all
a. Activation of the complement system
c. IgE binding to mast cells and basophils
e. Recognition of MHC molecules as nonself
ANS: B, C, E
The autoimmune response causes the immune system to
attack the body's own cells. The hypersensitivity response, mediated
by IgE, causes the release of harmful chemical mediators. Recognition
of MHC molecules as nonself in a transplanted organ can cause organ
rejection. Activation of the complement system causes a cascade of
reactions that assist in the immune response. Opsonization is a
process that assists with phagocytosis.
1. A nurse at an immunization clinic is providing vaccines to
children. The parent of a child waiting to receive vaccines tells the
nurse that the child has an immune deficiency disorder. The nurse
understands that which vaccine should not be administered to this child?
a. Diphtheria and tetanus toxoids and acellular pertussis (DTaP)
b. Haemophilus influenzae type b (Hib) vaccine
d. Varicella virus vaccine
The varicella vaccine should be avoided by individuals
who are immunocompromised, which includes those infected with the
human immunodeficiency virus (HIV) and those who have a congenital
immunodeficiency. The DTaP vaccine, Hib vaccine, and polio injection
may be administered to immunocompromised individuals, because these
are not live vaccines.
2. A nurse is preparing to administer vaccines to a 1-year-old child.
The parents ask the nurse to give the child acetaminophen before
administering the vaccine to reduce the pain. Which response by the
nurse is correct?
a. "Children don't remember pain, so it isn't necessary to
b. "The small needles used to
inject the vaccines cause hardly any discomfort."
"You can apply a topical anesthetic when you get home to reduce
pain from the injection."
d. "Your child's immune
response may not be as effective if I give acetaminophen before the vaccine."
Giving analgesic/antipyretic medications before or
shortly after vaccines can reduce the immune response, so giving them
to prevent pain or fever is not recommended. Children do remember
pain, and it is important to provide other comfort measures and to
give the injections rapidly. Small needles cause less discomfort, and
it is important to reassure the parents about this; however, it is
more important to explain why acetaminophen is not recommended.
Topical anesthetics are useful before giving the injections, not afterwards.
The parents of an infant who will be attending day care tell the
nurse that they do not want their child vaccinated against rotavirus
because an older cousin developed intussusception after receiving this
vaccine. Which response by the nurse is correct?
a. "Intussusception is much less serious than getting the
b. "It was probably just a coincidental
reaction to the vaccine."
c. "The newer vaccines for
rotavirus are not associated with intussusception."
"Your child will have herd immunity and won't need the vaccine."
The rotavirus vaccine product RotaShield was withdrawn
because of the high rate of intussusception associated with it. The
two products currently on the market—RotaTeq and Rotarix—do not carry
a risk for intussusception. Intussusception can be life threatening,
so telling parents it is less serious than the disease is incorrect.
Intussusception was not merely a coincidental reaction. Herd immunity
is not guaranteed.
A -year-old child who has been receiving high-dose systemic
glucocorticoids for several months comes to a clinic for school
immunizations, which usually include the DTaP vaccine; varicella virus
vaccine [Varivax]; the measles, mumps, and rubella virus (MMR)
vaccine; and the inactivated poliovirus vaccine (IPV). The clinic
nurse will expect to administer which vaccines to this child?
a. All four school immunizations
b. DTaP and IPV
c. DTaP, OPV, and Varivax only
d. DTaP and IPV, along
Children who are immunocompromised should not receive
live virus vaccines, including the MMR vaccine and Varivax. Children
taking high-dose systemic glucocorticoids are immunocompromised and
should not receive the vaccine until therapy is stopped and normal
glucocorticoid production returns. The oral polio vaccine (OPV)
contains live virus and is contraindicated. Immunoglobulins are not
indicated unless children are exposed to the diseases themselves.
A 1-year-old child is scheduled to receive the MMR vaccine,
pneumococcal vaccine (PCV), Varivax, and hepatitis A vaccine. The
child's parents request that the MMR vaccine not be given, saying
that, even though there is no demonstrated link with autism, they are
still concerned about toxic levels of mercury in the vaccine. Which
response by the nurse is correct?
a. "Most U.S.-made vaccines have zero to low amounts of
b. "Other vaccine preparations contain
mercury as well."
c. "Thimerosal is a nontoxic form of
d. "You can get more mercury from breast milk
and many foods on the market."
Because of concerns about mercury levels, most U.S.-made
vaccines contain either zero or very low amounts of mercury. Some
multidose vials of flu vaccine still contain thimerosal, but even that
is a very low amount. Telling parents that other vaccines contain
mercury will increase their suspicion about vaccines and further
reduce their trust. Thimerosal is a mercury-based preservative and
thus has the same toxicity as mercury. Although it is true that
mercury is found in breast milk and other foods, telling parents this
belittles their concerns about the vaccines.
The parent of a 2-month-old infant who has just received the first
dose of DTaP asks the nurse about expected reactions to the vaccine.
The nurse will respond by saying that:
a. "Mild reactions, including a low-grade fever, are
b. "Most children do not experience any
c. "Seizures are common and may require
d. "The most common
reaction is a rash that develops into itchy vesicles."
Mild reactions to the first dose of the DTaP vaccine are
common and most often are manifested by a low-grade fever,
fretfulness, drowsiness, and local reactions of swelling and redness.
At least 50% of children experience reactions. Seizures are not
common. Itchy vesicles do not appear with the DTaP vaccine.
A 1-year-old child receives the MMR vaccine. The next day the child's
parent calls the nurse to report that the child has a temperature of
103°F. What will the nurse do?
a. File an adverse event report with the Vaccine Adverse Event
Reporting System (VAERS).
b. Notify the child's provider that
thrombocytopenia is likely to occur.
c. Reassure the parent that
fever can occur with the MMR vaccine.
d. Tell the parent to take
the child to the emergency department.
The MMR vaccine can have several adverse effects,
including fever up to 103°F; this is not considered a serious effect
and does not warrant filing an adverse event report with VAERS.
Thrombocytopenia is a rare but serious side effect of the MMR vaccine
but is not associated with fever. There is no need to have the parent
take the child to the emergency department.
The parent of a child who attends day care questions the need for
Varivax. What will the nurse tell the parent?
a. "Chickenpox is not as contagious as other communicable
b. "The child will be protected by herd
immunity and does not need the vaccine."
is an uncomfortable disease, but it is not that serious."
"Varicella in adults can have serious consequences."
Varicella tends to cause more severe symptoms in adults
than in children; adults have a 10-fold greater likelihood of
hospitalization and a 20-fold increase in deaths. Chickenpox is highly
contagious. Even with herd immunity, because of the degree of
contagiousness, spread is likely. Varicella can be serious, even in children.
A clinic nurse receives a phone call from a parent who states that a
2-month-old infant has a severe cough, a low-grade fever, and a runny
nose that have lasted over a week. What will the nurse ask the parent?
a. Whether the infant has had the first set of vaccines
Whether the infant received a hepatitis B vaccine as a newborn
Whether the infant attends day care
d. Whether there is a family
history of respiratory disorders
This infant may have pertussis, for which the primary
symptoms are low-grade fever, persistent cough, and runny nose.
Infants who have not received the first set of immunizations,
including the DTaP vaccine, are especially vulnerable to this disease.
The hepatitis B vaccine does not protect against these symptoms.
Asking about day care may be important for evaluating exposure, but
differentiating between the cough of pertussis and other coughs is
best done by determining immunization status. A family history of
respiratory disorders may indicate whether the symptoms are related to
a chronic lung disease, but these do not usually manifest at 2 months
The nurse at a public health infant immunization clinic is acting as
a preceptor for a nursing student. To assess the student's
understanding of vaccinations, the nurse asks the student where the
hepatitis B vaccine (HepB) should be administered. The student would
be correct to respond that the hepatitis B vaccine should be
administered in the:
a. dorsogluteal muscle in an adult.
b. anterolateral thigh
c. ventrogluteal muscle in adolescents.
deltoid of toddlers.
The HepB vaccine should be administered in the
anterolateral thigh in infants and children. The vaccine should be
administered in the deltoid of adults and adolescents. The vaccine
should not be administered in the deltoid of toddlers, because they
have little muscle in that location.
An 11-year-old boy received all childhood immunizations before
attending school as a kindergartner. Which vaccines are recommended
for this child at his current age?
a. DTaP, MCV4, Varivax
b. PCV-23, Td, MMR
d. Tdap, Varivax, hepatitis B
At age 11, both males and females should receive a
booster of diphtheria, tetanus, and pertussis (Tdap); the Menactra
vaccine against meningitis (MCV4); and the human papilloma virus (HPV)
vaccine. A Varivax booster is not recommended at this age. The PCV-23
vaccine is indicated only in high-risk patients. The Td can be given,
but a vaccine with a pertussis component is preferred. The MMR is not
given at this age. The hepatitis B vaccine is not given at this age.
An immigrant child is in the clinic for MMR vaccination. The nurse
learns that the child has recently received an immune globulin
injection for a viral infection, currently has an upper respiratory
infection with a temperature of 100°F, and has a recent history of
thrombocytopenia, which has resolved. What does the nurse tell the
a. "The vaccine is contraindicated in this child because of
the history of thrombocytopenia."
b. "The child should
be brought back for the vaccine when the temperature is back to
c. "The child is at increased risk of
developing autism from this vaccine."
d. "The vaccine
must be postponed for 3 months after administration of the immune globulin."
The MMR vaccine should be postponed in children who have
received immunoglobulins, because the immunoglobulin contains
antibodies against the viruses in the vaccine. Thrombocytopenia is not
a contraindication to the MMR vaccine. A low-grade temperature is not
a contraindication. There is no link between receiving the MMR vaccine
and the development of autism.
An otherwise healthy child receives a varicella virus vaccine. Three
weeks later the parent calls to report that the child has a mild case
of chickenpox and wonders how this could happen after the vaccination.
What will the nurse tell the parent?
a. "A varicella-like rash can occur after the vaccine is
b. "The vaccine was probably
c. "This represents a serious vaccine
d. "Give the child aspirin to treat any
fever that may occur."
Children who receive the varicella vaccine may sometimes
develop a mild, local varicella-like rash within a month of receiving
the vaccine. This rash does not indicate that the vaccine was
ineffective, and it is not a serious side effect. Because of the
association with Reye's syndrome, children should not take aspirin or
other salicylates for 6 weeks after receiving the vaccine.
A 3-year-old child who has asthma is in the clinic for a well-child
checkup. The nurse notes that the child is up-to-date for the DTaP,
Hepatitis A, Hepatitis B, and the MMR vaccines but has only had one
each of the Hib, the Rotavirus, and the PCV13 vaccines. Which
vaccine(s) will the nurse anticipate administering to this child?
a. Hib and Rotavirus vaccines
c. PCV13 and
The PCV13 should be given to all children under the age
of 2 years and to all healthy children between ages 2 and 5 years,
especially those who have conditions such as chronic lung disease that
put them at high risk of serious pneumococcal disease. The Hib vaccine
is only given up to age 15 months. The Rotavirus vaccine is not given
after 32 weeks of age.
The public health nurse is teaching a group of parents about
immunizations. The nurse tells the parents that after receiving the
varicella virus vaccine, children should temporarily avoid close
contact with whom? (Select all that apply.)
c. Relatives older than 65 years
e. Individuals infected with HIV
ANS: A, D, E
To reduce the risk of transmission, vaccine
recipients should temporarily avoid close contact with susceptible
high-risk individuals (e.g., neonates, pregnant women, and
Which are recommended measures to help minimize pain associated with
vaccine administration? (Select all that apply.)
a. Administer acetaminophen or ibuprofen before the vaccine is
b. Apply a topical anesthetic to the injection site before
the vaccine is given.
c. Give intramuscular vaccines rapidly
d. Have the child lie down while the vaccine
e. Provide tactile stimulation as a diversion.
ANS: B, C, E
Topical anesthetics and tactile stimulation are
helpful for minimizing pain associated with vaccine administration, as
is giving IM injections rapidly without aspirating. Acetaminophen and
ibuprofen are not recommended, because they can inhibit the immune
response to the vaccine. Allowing the child to sit up helps minimize pain.
A patient has undergone liver transplantation. The provider orders
cyclosporine [Sandimmune], prednisone, and sirolimus [Rapamune]. What
will the nurse do?
a. Question the order for sirolimus.
b. Request an order
for a serum glucose level.
c. Request an order for a macrolide
d. Suggest changing the cyclosporine to tacrolimus.
Sirolimus is given to prevent rejection in renal
transplantation; it has no proof of efficacy in patients with heart,
lung, or liver transplants. A serum glucose level is not indicated;
patients taking repaglinide for diabetes should be monitored closely
while taking cyclosporine. Although antibiotic prophylaxis may be
necessary, macrolide antibiotics increase the level of cyclosporine.
Tacrolimus is more toxic than cyclosporine.
A patient with a liver transplant has been receiving cyclosporine
[Sandimmune] for 6 months. The nurse reviews this patient's laboratory
results and notes a sharp increase in the blood urea nitrogen (BUN)
and serum creatinine. Vital signs are normal, and the patient reports
no discomfort. What does the nurse suspect?
An elevation of BUN and serum creatinine is an indication of
nephrotoxicity, which occurs in 75% of patients taking cyclosporine.
Hepatotoxicity would cause elevations in liver enzymes, not the BUN
and creatinine. Infection would be associated with fever. Organ
rejection of a renal transplant would cause elevation in the BUN and
creatinine but also would cause tenderness at the graft site and fever.
A nurse provides teaching to a patient who has undergone kidney
transplantation and will begin taking cyclosporine [Sandimmune], a
glucocorticoid, and sirolimus [Rapamune]. Which statement by the
patient indicates understanding of the teaching?
a. "I should take sirolimus at the same time as the
b. "I will need to have my blood sugar
c. "I will need to take an
antibiotic to prevent lung infections."
d. "Taking this
combination of drugs lowers my risk of kidney damage."
Immunosuppressant drugs increase the risk of infections,
especially the BK virus, which can cause renal damage, and other
organisms that cause lung infections. Patients taking these drugs must
take antibiotics for the first 12 months to help prevent infection.
Sirolimus and cyclosporine should be taken 4 hours apart. Patients
with diabetes may have trouble with glucose tolerance and require
monitoring. Taking cyclosporine and sirolimus increases the risk of
A patient with a history of lung transplantation is admitted for
treatment for a respiratory infection. The patient has been taking
cyclosporine [Sandimmune], prednisone, and azathioprine [Imuran] for 8
months. The provider has ordered azithromycin [Zithromax] to treat the
infection and acetaminophen [Tylenol] as needed for fever. The nurse
will contact the provider to:
a. ask whether a different antibiotic can be used.
that the prednisone be discontinued until the infection
c. suggest increasing the dose of cyclosporine.
suggest using ibuprofen instead of acetaminophen.
Macrolide antibiotics, such as azithromycin, can inhibit
cyclosporine metabolism, leading to increased levels of the drug. This
patient needs either a reduced dose of cyclosporine or a different
antibiotic. There is no indication for discontinuing the prednisone
during treatment. The dose of cyclosporine would need to be reduced,
because azithromycin leads to increased drug levels. There is no
contraindication to using acetaminophen.
A patient is taking cyclosporine [Sandimmune] and prednisone to
prevent organ rejection after right renal transplantation. The patient
is febrile and complains of right-sided flank pain. The nurse reviews
the patient's chart and finds that the patient's BUN and serum
creatinine are elevated. The cyclosporine trough is 150 ng/mL. What
will the nurse do?
a. Be concerned that the left kidney is failing.
the provider to order intravenous methylprednisolone.
an order for a urine culture.
d. Suspect nephrotoxicity secondary
to an elevated cyclosporine level.
The patient is showing signs of acute organ rejection, which
include pain at the graft site, fever, and elevated BUN and
creatinine; therefore, intravenous methylprednisolone is indicated.
Because the patient is having pain on the right side, along with fever
and elevated renal function test results, there is no reason to
suspect that the left kidney is failing or that an infection is
present. The cyclosporine level is within normal limits.
A patient is started on immunosuppressant drugs after kidney
transplantation and will be taking azathioprine [Imuran] as part of
the drug regimen. The patient asks the nurse why it is necessary to
have a specimen for a complete blood count drawn at the beginning of
therapy and then periodically thereafter. The nurse explains that
azathioprine can alter blood cells and tells the patient to report:
b. easy bruising.
gastrointestinal (GI) upset.
Azathioprine can cause bone marrow suppression, resulting in
neutropenia and thrombocytopenia; therefore, a CBC must be evaluated
at baseline and periodically thereafter. Patients who have low
platelet counts bruise easily, so this symptom should be reported.
Alopecia occurs with azathioprine but is not a life-threatening side
effect. Fatigue is not a common adverse effect. GI side effects occur
but are not life threatening.
A nurse is teaching a patient who is about to undergo allograft
transplantation of the liver. Which statement by the patient indicates
understanding of the post-transplant medications?
a. "Immunosuppressants help reduce the risk of
b. "I will need to have
periodic laboratory work to assess for toxicity."
will need to take immunosuppressants until all signs of organ
rejection are gone."
d. "These drugs will prevent organ rejection."
To prevent toxicity from high drug levels or organ rejection
from low levels, blood levels of immunosuppressants should be checked
periodically. Immunosuppressants do not prevent infection; they
increase the risk of infection. Patients must take immunosuppressants
for life. Immunosuppressants do not prevent organ rejection; they help
minimize the risk.
The nurse knows that which immunosuppressants are among the most effective?
a. Azathioprine [Imuran] and everolimus [Zortress]
Cyclosporine [Sandimmune] and tacrolimus [Prograf]
Methotrexate [Rheumatrex] and muromonab-CD3 [Orthoclone OKT3]
Sirolimus [Rapamune] and methylprednisolone
Cyclosporine and tacrolimus are the most effective
A nursing student asks the nurse how antibodies provide immune
suppression. The nurse responds by telling the student that antibodies:
a. block T-cell function.
b. boost immune
c. reduce proliferation of B cells.
Antibodies can be directed against components of the immune
system to suppress the immune response and block T-cell function. They
inhibit rather than boost immune responses. They do not reduce the
proliferation of B cells or suppress interferon production.
10. The nurse is preparing to administer basiliximab [Simulect] to a
patient to prevent acute rejection. By which route will the nurse
administer the drug?
Basiliximab is used to prevent acute rejection and is
The nurse is caring for a patient after recent renal transplantation.
The patient is taking sirolimus [Rapamune] to prevent transplant
rejection. What other medications would the nurse expect the patient
to be taking?
a. Rifampin and ketoconazole
b. Carbamazepine and
c. Cyclosporine and glucocorticoids
Amphotericin B and erythromycin
Sirolimus should be used in conjunction with cyclosporine and
glucocorticoids to reduce the risk of transplant rejection. Rifampin
can reduce and ketoconazole can increase therapeutic levels of
sirolimus and cyclosporine; therefore, they are not indicated for
transplant patients. Carbamazepine and phenobarbital are not
indicated, because they can reduce the therapeutic levels of sirolimus
and cyclosporine. Amphotericin B and erythromycin are not indicated,
because they can increase the therapeutic levels of sirolimus and cyclosporine.
The nurse is administering medications to a patient who is receiving
cyclosporine [Sandimmune]. Which medication, when administered
concurrently with cyclosporine, would warrant a reduction in the
dosage of cyclosporine?
a. Phenytoin [Dilantin]
d. Trimethoprim/sulfamethoxazole [Bactrim]
Concurrent use of ketoconazole would warrant a reduction in
the dosage of cyclosporine. Ketoconazole often is given concurrently
with cyclosporine so that the patient's dosage of cyclosporine, which
is costly, can be reduced. Phenytoin would cause a decrease in
cyclosporine levels. Prednisone often is given concurrently with
cyclosporine to suppress the immune response.
Trimethoprim/sulfamethoxazole reduces levels of cyclosporine in the body.
The nurse is caring for a 15-year-old patient who has undergone a
liver transplant. Which provider order will the nurse question?
a. Cyclosporine [Sandimmune] and ketoconazole [Nizoral]
Everolimus [Zortress] 1 mg twice daily
c. Prednisone 60 mg
d. Tacrolimus [Prograf] 50 mcg/kg twice daily the day after surgery
Everolimus is not approved in patients younger than 18 years
of age. Ketoconazole can decrease the metabolism of cyclosporine and
is often given concurrently to allow lower dosing and lower cost.
Prednisone and tacrolimus are commonly used, and these doses are correct.
A patient who is taking azathioprine [Imuran] to prevent rejection of
a renal transplant develops gout and the provider orders allopurinol.
The nurse will contact the provider to discuss:
a. decreasing the allopurinol dose.
b. decreasing the
c. increasing the allopurinol dose.
increasing the azathioprine dose.
Allopurinol delays conversion of mercaptopurine to inactive
products and increases the risk of azathioprine toxicity. Patients
taking the two concurrently should have an approximate 70% reduction
in the azathioprine dose. Altering the allopurinol dose is not indicated.
A pregnant patient asks the nurse if she can take antihistamines for
seasonal allergies during her pregnancy. What will the nurse tell the patient?
a. Antihistamines should be avoided unless absolutely
b. Second-generation antihistamines are safer than
c. Antihistamines should not be
taken during pregnancy but may be taken when breast-feeding.
The margin of safety for antihistamines is clearly understood for
Antihistamines are pregnancy Category C, with debate currently
occurring regarding degree of effects on the fetus. They should be
avoided unless absolutely necessary. All antihistamines have adverse
effects on the fetus. Antihistamines can be excreted in breast milk.
The margin of safety of antihistamines in pregnancy is not clear, so
these agents should be avoided unless a clear benefit of treatment
outweighs any risks
A family is preparing for travel and the parents report that their
5-year-old child has frequent motion sickness. The nurse will tell the
parents to ask the provider about which antihistamine to help prevent symptoms?
a. Desloratadine [Clarinex]
c. Hydroxyzine [Vistaril]
d. Promethazine [Phenergan]
Some antihistamines, including dimenhydrinate and
promethazine, are labeled for use in motion sickness. Promethazine,
however, is contraindicated in children under age 2 years and should
be used with caution in children older than 2 years because of the
risks for severe respiratory depression. Desloratadine and hydroxyzine
are not used for motion sickness.
A nurse is teaching a group of nursing students about antihistamines.
Which statement by a student indicates an understanding of the
mechanism of action of the antihistamines?
a. "Antihistamines block H1 receptors to prevent actions of
histamine at these sites."
b. "Antihistamines block
release of histamine from mast cells and basophils."
"H1 antagonists can bind to H1 receptors, H2 receptors, and
antihistamines are more selective than second-generation antihistamines."
Antihistamines block H1 receptors to prevent the actions of
histamine. They do not block the release of histamine. H1 antagonists
do not bind to H2 receptors; they do bind to muscarinic receptors.
Second-generation antihistamines are more selective than
A patient who has chronic allergies takes loratadine [Claritin] and
develops a severe reaction to bee stings. The patient asks the nurse
why the antihistamine did not prevent the reaction. What will the
a. "Allergy symptoms that are severe are caused by
mediators other than histamine."
b. "H1 blockers do not
prevent the release of histamine from mast cells and
c. "Second-generation H1 blockers contain
less active drug and do not work in severe reactions."
"Severe allergic reactions occur through actions on muscarinic receptors."
Severe allergic reactions with symptoms of anaphylaxis are
caused by mediators other than histamine, so the benefits of
antihistamines are limited. H1 blockers do not block the release of
histamine, but this is not why they are not effective in anaphylaxis.
Second-generation agents are as effective as first-generation agents
in allergic reactions mediated by histamine; neither is effective for
A patient tells a nurse that antihistamines help relieve cold
symptoms and wants to know why they are not recommended or prescribed
for this purpose. The nurse tells the patient that antihistamines
provide only mild relief from some cold symptoms by:
a. anticholinergic properties that decrease rhinorrhea.
blocking H1 receptors in nasal passages.
c. reducing secretions
at H2 receptor sites.
d. having sedative effects, which help
patients rest and sleep.
Histamine does not mediate cold symptoms, so antihistamines do
not provide relief through H1 blockade. Their anticholinergic effects
at muscarinic receptor sites can moderately reduce rhinorrhea, so some
patients may experience some relief of this symptom. H1-receptor sites
do not play a role in cold symptoms. H2-receptor sites do not play a
role in cold symptoms. Sedative side effects do not alleviate cold symptoms.
A patient will begin taking fexofenadine [Allegra] for hay fever. The
nurse teaching this patient will tell the patient that:
a. fexofenadine should be taken with food to prevent
gastrointestinal (GI) symptoms.
b. the medication may be taken
once or twice daily.
c. tolerance to sedation will occur in a few
d. with renal impairment, this drug should be taken every
Fexofenadine may be given 60 mg twice daily or 180 mg once
daily. Fexofenadine does not need to be given with food. Sedation is
not a common side effect of fexofenadine. There is no caution to
reduce the dosage or increase the dosing interval in patients with
renal impairment who take fexofenadine.
An 18-month-old child develops an urticarial reaction after a
transfusion. The prescriber orders intravenous promethazine
[Phenergan]. What will the nurse do?
a. Give the medication as ordered.
b. Monitor the child for
c. Question the order.
d. Request an
order to give the drug orally.
Promethazine can cause severe respiratory depression,
especially in very young patients; it is contraindicated in children
younger than 2 years. The medication should not be given as ordered.
It is not safe to give the drug and then monitor for
bronchoconstriction. The drug is not safe in this age group when given orally.
A 5-year-old child is brought to the emergency department after
ingesting diphenhydramine [Benadryl]. The child is uncoordinated and
agitated. The nurse observes that the child's face is flushed, the
temperature is 37.1oC, and the heart rate is 110 beats per minute. The
nurse will expect to:
a. administer atropine to reverse the adverse effects.
apply ice packs to stop the flushing.
c. give activated charcoal
to absorb the drug.
d. prepare to provide mechanical ventilation.
In acute toxicity, patients present with agitation, a flushed
face, tachycardia, and uncoordinated movements. There is no specific
antidote, so drug removal is the focus of treatment, starting with
activated charcoal to absorb the drug, followed by a cathartic to
enhance excretion. Atropine would cause an increase in the heart rate.
Application of ice packs is recommended for hyperthermia and not for
flushing. The child's temperature is normal. Mechanical ventilation is
not indicated with this presentation of symptoms, although
cardiovascular collapse may eventually develop.
A provider has ordered intravenous promethazine [Phenergan] for an
adult patient postoperatively to prevent nausea and vomiting (N/V).
What will the nurse do?
a. Administer the drug at a rate of 25 mg/min or more to achieve
b. Contact the provider to suggest using
dimenhydrinate [Dramamine] instead.
c. Ensure that the IV is
infusing freely through a large-bore needle.
d. Monitor the
patient closely for cardiac dysrhythmias.
Promethazine can cause severe local tissue injury if it
extravasates into tissues, so the medication should be administered in
an IV that is flowing freely through a large-bore needle. The drug
should be administered at a rate of 25 mg/min or less. Dimenhydrinate
is indicated for motion sickness, not postoperative N/V. Cardiac
dysrhythmias were a concern with two antihistamines no longer on the
market, astemizole and terfenadine.
A prescriber orders hydroxyzine [Vistaril] for a patient with acute
urticaria. The nurse will include which information when teaching the
patient about this drug?
a. The drug will reduce redness and itching but not
b. This antihistamine is not likely to cause
c. The patient should avoid drinking alcohol while
taking the drug.
d. The patient should report shortness of breath
while taking the drug.
Hydroxyzine is a first-generation antihistamine and has
sedative effects, so patients should be cautioned not to consume
alcohol while taking the drug. In capillary beds, antihistamines
reduce edema, itching, and redness. This antihistamine causes
sedation. It is not associated with respiratory depression at
A patient has seasonal allergies and needs an antihistamine to
control symptoms. The patient likes to have wine with dinner
occasionally and wants to know which antihistamine will be the safest
to take. The nurse will tell the patient to discuss which medication
with the provider?
a. Cetirizine [Zyrtec]
b. Fexofenadine [Allegra]
d. Loratadine [Claritin]
Fexofenadine is the least sedating of the second-generation
antihistamines and so is the least likely to have synergistic effects
with alcohol. Cetirizine, levocetirizine, and loratadine all have
sedative side effects to some extent and thus would be less safe.
A 5-year-old child with seasonal allergies has been taking 2.5 mL of
cetirizine [Zyrtec] syrup once daily. The parents tell the nurse that
the child does not like the syrup, and they do not think that the drug
is effective. The nurse will suggest they discuss which drug with
their child's healthcare provider?
a. Cetirizine [Zyrtec] 5-mg chewable tablet once daily
Loratadine [Claritin] 10-mg chewable tablet once daily
Fexofenadine [Allegra] syrup 5 mL twice daily
[Clarinex] 5-mg rapid-disintegrating tablet once daily
The child is receiving a low dose of cetirizine and can
receive up to 5 mg per day in either a single dose or two divided
doses. Cetirizine is available in a chewable tablet, which this child
may tolerate better, so the parents should be encouraged to explore
this option with their provider. The loratadine 10-mg chewable tablet
is approved for children 6 years and older. Fexofenadine would be safe
for this child, but it is unlikely that the syrup would be any better
than the cetirizine syrup. Desloratadine is not approved for children
under the age of 12 years.
A patient is brought to the emergency department after ingesting a
handful of diphenhydramine [Benadryl] tablets. The patient has dilated
pupils, a flushed face, and tremors. The patient is agitated and has a
heart rate of 110 beats per minute. The nurse may anticipate
administering which agents? (Select all that apply.)
a. Activated charcoal
e. Second-generation H1 antagonists
A, B, D
The patient is showing signs of acute antihistamine
toxicity. Activated charcoal and cathartics are given to absorb the
drug and increase excretion. Atropine is not indicated. Lorazepam may
be administered for seizures. Second-generation antihistamines are not indicated.
Which parenteral antihistamines have sedative effects that are
classified as low to none? (Select all that apply.)
a. Cetirizine [Zyrtec]
b. Clemastine [Tavist
c. Desloratadine [Clarinex]
e. Loratadine [Claritin]
C, D, E
Desloratadine, fexofenadine, and loratadine all have
sedative effects classified as low to none. Cetirizine and clemastine
have moderate sedative effects.
A nurse is teaching a group of nursing students about cyclooxygenase
(COX) inhibitors. A student asks the nurse about characteristics of
COX-1 inhibitors. Which statement by the nurse is true?
a. "COX-1 inhibitors protect against colorectal
b. "COX-1 inhibitors protect against
myocardial infarction and stroke."
c. "COX-1 inhibitors
d. "COX-1 inhibitors suppress inflammation."
COX-1 inhibitors have beneficial effects of reducing platelet
aggregation and thus reducing the risk of myocardial infarction and
stroke. COX-2 inhibitors protect against colorectal cancer, reduce
inflammation, and reduce fever.
A patient who takes daily doses of aspirin is scheduled for surgery
next week. The nurse should advise the patient to:
a. continue to use aspirin as scheduled.
b. reduce the
aspirin dosage by half until after surgery.
c. stop using aspirin
d. stop using aspirin 3 days before surgery.
Aspirin must be withdrawn at least 1 week before surgery.
Aspirin cannot be continued as scheduled, because the risk for
bleeding is too great. An interval of 3 days is not long enough for
the bleeding effects of aspirin to be reversed. Cutting the dose in
half would not reduce the effects of bleeding associated with aspirin use.
A patient who is taking acetaminophen for pain wants to know why it
does not cause gastrointestinal upset, as do other over-the-counter
pain medications. The nurse will explain that this is most likely
because of which property of acetaminophen?
a. It does not inhibit cyclooxygenase.
b. It has minimal
effects at peripheral sites.
c. It is more similar to opioids
than to nonsteroidal anti-inflammatory drugs (NSAIDs).
d. It is
selective for cyclooxygenase-2.
The differences between the effects of acetaminophen and
aspirin are thought to result from selective inhibition of
cyclooxygenase; acetaminophen has only minimal effects on
cyclooxygenase at peripheral sites, which may explain why
acetaminophen does not have adverse GI, renal, and antiplatelet
effects. Acetaminophen is a selective COX inhibitor. It is not more
similar to opioids than NSAIDs. It is not selective for COX-2.
A patient tells the nurse that she takes aspirin for menstrual
cramps, but she does not feel that it works well. What will the nurse suggest?
a. The patient should avoid any type of COX inhibitor because of
the risk of Reye's syndrome.
b. The patient should increase the
dose to a level that suppresses inflammation.
c. The patient
should use a first-generation nonsteroidal anti-inflammatory
d. The patient should use acetaminophen
because of its selective effects on uterine smooth muscle.
Aspirin (ASA) has analgesic effects for joint pain, muscle
pain, and headache, but it is relatively ineffective against visceral
pain, including uterine smooth muscle pain, for which NSAIDs are
indicated. The risk of Reye's syndrome is associated with the use of
ASA in children to treat fever. Increasing the ASA dose to
anti-inflammatory levels is useful for rheumatic fever, tendonitis,
and bursitis. Acetaminophen is not effective for dysmenorrhea.
A patient who takes aspirin for rheumatoid arthritis is admitted to
the hospital complaining of headache and ringing in the ears. The
plasma salicylate level is 300 mcg/mL, and the urine pH is 6.0. What
will the nurse do?
a. Increase the aspirin dose to treat the patient's
b. Notify the provider of possible renal
c. Prepare to provide respiratory support, because the
patient shows signs of overdose.
d. Withhold the aspirin until
the patient's symptoms have subsided.
This patient shows signs of salicylism, which occurs when ASA
levels climb just slightly above the therapeutic level. Salicylism is
characterized by tinnitus, sweating, headache, and dizziness. Tinnitus
is an indication that the maximum acceptable dose has been achieved.
Toxicity occurs at a salicylate level of 400 mcg/mL or higher. ASA
should be withheld until the symptoms subside and then should be
resumed at a lower dose. Increasing the dose would only increase the
risk of toxicity. Signs of renal impairment include oliguria and
weight gain, which are not present in this patient. This patient has
salicylism, not salicylate toxicity, so respiratory support measures
are not indicated.
An adolescent is brought to the emergency department by a parent who
reports that the patient took a whole bottle of extended-release
acetaminophen tablets somewhere between 8 and 10 hours ago. The nurse
will anticipate administering which of the following?
a. Acetylcysteine [Mucomyst]
b. Activated charcoal
d. Respiratory support
The nurse should anticipate giving acetylcysteine, because it
is the specific antidote for acetaminophen overdose. It is 100%
effective when given within 8 to 10 hours after ingestion and may
still have some benefit after this interval. Activated charcoal is
effective only if given before the medication is absorbed, so it must
be given much sooner. Hemodialysis is not indicated. Respiratory
support is used for ASA overdose.
An older male patient with an increased risk of MI is taking
furosemide [Lasix] and low-dose aspirin. The patient is admitted to
the hospital, and the nurse notes an initial blood pressure of 140/80
mm Hg. The patient has had a 10-pound weight gain since a previous
admission 3 months earlier. The patient has voided only a small amount
of concentrated urine. The serum creatinine and blood urea nitrogen
(BUN) levels are elevated. The nurse will contact the provider to discuss:
a. adding an antihypertensive medication.
c. ordering a potassium-sparing
d. withdrawing the aspirin.
This patient shows signs of renal impairment, as evidenced by
weight gain despite the use of diuretics, decreased urine output,
hypertension, and elevated serum creatinine and BUN. ASA can cause
acute, reversible renal impairment and should be withdrawn.
Hypertensive medications do not treat the underlying cause. Serum
electrolytes are not indicated. Addition of a potassium-sparing
diuretic is not indicated.
A pregnant patient in her third trimester asks the nurse whether she
can take aspirin for headaches. Which response by the nurse is correct?
a. "Aspirin is safe during the second and third trimesters
b. "Aspirin may cause premature closure
of the ductus arteriosus in your baby."
c. "Aspirin may
induce premature labor and should be avoided in the third
d. "You should use a first-generation
nonsteroidal anti-inflammatory medication."
Aspirin poses risks to the pregnant patient and her fetus,
including premature closure of the ductus arteriosus. ASA is not safe,
especially in the third trimester, because it can cause anemia and can
contribute to postpartum hemorrhage. ASA does not induce labor but can
prolong labor by inhibiting prostaglandin synthesis. NSAIDs have
similar effects and also should be avoided.
A nurse is caring for a patient who has been taking low-dose aspirin
for several days. The nurse notes that the patient has copious amounts
of watery nasal secretions and an urticarial rash. The nurse will
contact the provider to discuss:
a. administering epinephrine.
b. changing to a
c. reducing the dose of aspirin.
giving an antihistamine.
Aspirin can cause a hypersensitivity reaction in some
patients. This may start with profuse watery rhinorrhea and progress
to generalized urticaria, bronchospasm, laryngeal edema, and shock. It
is not a true anaphylactic reaction, because it is not mediated by the
immune system. Epinephrine is the treatment of choice. Patients with
sensitivity to ASA often also have sensitivity to NSAIDs; the first
indication with this patient is to treat the potential
life-threatening effect, not to change the medication. Reduction of
the dose of ASA is not indicated, because this reaction is not dose
dependent. Antihistamines are not effective, because this is not an
A nurse is teaching a nursing student who wants to know how aspirin
and nonaspirin first-generation NSAIDs differ. Which statement by the
student indicates a need for further teaching?
a. "Unlike aspirin, first-generation NSAIDs cause
reversible inhibition of cyclooxygenase."
b. "NSAIDs do
not increase the risk of myocardial infarction and stroke; however,
unlike ASA, they do not provide protective benefits against those
c. "Unlike aspirin, first-generation
NSAIDs do not carry a risk of hypersensitivity
d. "Unlike aspirin, first-generation NSAIDs
cause little or no suppression of platelet aggregation."
Nonaspirin first-generation NSAIDs carry a risk of
hypersensitivity reactions similar to the risk posed by ASA. These
agents cause reversible COX inhibition, whereas ASA causes
irreversible COX inhibition. NSAIDs do not provide protective benefits
for myocardial infarction or stroke, as does ASA. Nonaspirin
first-generation NSAIDs do cause suppression of platelet aggregation,
but the suppression is reversible.
A nurse is providing teaching for an adult patient with arthritis who
has been instructed to take ibuprofen [Motrin] for discomfort. Which
statement by the patient indicates a need for further teaching?
a. "I may experience tinnitus with higher doses of this
b. "I may take up to 800 mg 4 times daily
c. "I should limit alcohol intake to fewer
than three drinks a day."
d. "I will take this
medication with meals to help prevent stomach upset."
NSAIDs do not cause salicylism and therefore do not cause
tinnitus with higher doses. The maximum dose for adults is 3200
mg/day, or 800 mg 4 times/day. Patients taking NSAIDs should be
cautioned to limit alcohol intake. Taking NSAIDs with meals helps
prevent GI upset.
A woman who has arthritis is breast-feeding her infant and asks the
nurse if it is safe to take NSAIDs while nursing. What will the nurse
tell this patient?
a. NSAIDs are safe to take while breast-feeding.
are not safe, even in small amounts.
c. She should take only
COX-2 inhibitors while breast-feeding.
d. She should request a
prescription for narcotic analgesics.
NSAIDs are safe and may be taken while breast-feeding. It is
not necessary to use a COX-2 inhibitor while breast-feeding. Narcotics
cross breast milk and should be used cautiously while breast-feeding.
A nurse is providing medication teaching for a patient who will begin
taking diclofenac [Voltaren] gel for osteoarthritis in both knees and
elbows. Which statement by the patient indicates understanding of the teaching?
a. "Because this is a topical drug, liver toxicity will not
b. "I should cover areas where the gel is
applied to protect them from sunlight."
c. "I will
apply equal amounts of gel to all affected areas."
"The topical formulation has the same toxicity as the oral formulation."
Diclofenac is available in topical and oral preparations.
Patients should be warned to protect treated areas from sunlight. Side
effects occur, such as liver toxicity, even with topical dosing.
Patients should apply smaller amounts to the upper extremities.
Systemic toxicity is lower with topical formulations.
A patient has been receiving intravenous ketorolac 30 mg every 6
hours for postoperative pain for 4 days. The patient will begin taking
oral ketorolac 10 mg every 4 to 6 hours to prepare for discharge in 1
or 2 days. The patient asks the nurse whether this drug will be
prescribed for management of pain after discharge. The nurse will
respond by telling the patient that the provider will prescribe a(n):
a. different nonsteroidal anti-inflammatory drug for home
management of pain.
b. fixed-dose opioid analgesic/nonsteroidal
c. lower dose of the oral ketorolac
for long-term pain management.
d. intranasal preparation of
ketorolac for pain management at home.
Ketorolac is not indicated for chronic or minor pain and
should not be used longer than 5 days. Patients discharged home will
be instructed to use other NSAIDs for pain. A fixed-dose opioid/NSAID
is not indicated. Low-dose ketorolac would not be used, because 5 days
would have passed. The intranasal therapy would not be indicated after
A patient who reports regular consumption of two or three alcoholic
beverages per day asks about taking acetaminophen when needed for
occasional recurrent pain. What will the nurse tell the patient?
a. "Do not take more than 2 gm of acetaminophen a
b. "Do not take more than 3 gm of acetaminophen a
c. "Do not take more than 4 gm of acetaminophen a
d. "Do not take a fixed-dose preparation with
Acetaminophen poses a risk of liver toxicity when taken
chronically or in larger doses, especially when combined with alcohol.
Patients who drink regularly should be advised to take acetaminophen
in low doses and not to exceed 2 gm per day.
A nurse is discussing glucocorticoids with a group of nursing
students. Which statement by a student indicates understanding of the
a. "Glucocorticoids have both endocrine and
b. "Patients treated for
adrenocortical insufficiency receive pharmacologic
c. "Pharmacologic effects are achieved with low
doses of glucocorticoids."
d. "Physiologic doses are
used to treat inflammatory disorders."
Glucocorticoids have applications for both endocrine and
nonendocrine disorders. Adrenocortical insufficiency requires
physiologic, or low-dose, treatment. Pharmacologic doses are used when
large doses are required, such as to suppress inflammation.
Physiologic doses are used to treat endocrine disorders.
A nurse tells a nursing student that the glucocorticoids given for
rheumatoid arthritis are nearly identical to substances produced
naturally by the body. The student remarks that the drug must be very
safe. Which response by the nurse is correct?
a. "As long as the drug is taken as prescribed, side
effects usually do not occur."
b. "By interrupting the
inflammatory process, these drugs inhibit side effects."
"Side effects can occur and are dependent on the dose and
duration of treatment."
d. "The negative feedback loop
prevents side effects."
When taken in pharmacologic doses, as for inflammatory
disorders, glucocorticoids can cause an array of serious adverse
effects. When glucocorticoids are given in pharmacologic doses, side
effects can occur even when the drugs are taken as prescribed.
Interruption of the inflammatory process causes some of the adverse
effects. The negative feedback loop does not inhibit side effects.
A clinic patient who has been taking a glucocorticoid for arthritis
for several months remarks to the nurse, "It's a good thing my
symptoms are better, because my mother has been quite ill, and I have
to take care of her." The patient's blood pressure is 100/60 mm
Hg. The nurse will report this to the provider and ask about:
a. reducing the patient's dose.
b. using every other day
c. increasing the patient's dose.
d. tapering the dose.
Because of their adrenal suppression, patients taking
glucocorticoids long term require increased doses at times of stress
and even for a time after stopping the drug until adrenal function
returns. This patient's lower blood pressure is an indication that
glucocorticoid levels may be depleted. Reducing the dose would only
exacerbate the patient's problems. Every other day dosing is used
early in glucocorticoid therapy to reduce adrenal suppression, but it
would not be useful now. Tapering of doses is used to allow adrenal
function to recover as the drug is discontinued.
A nurse is teaching a group of nursing students why glucocorticoids
are preferred over nonsteroidal anti-inflammatory drugs in the
treatment of inflammation. Which statement by a student indicates a
need for further teaching?
a. "Glucocorticoids act by multiple mechanisms and have
more anti-inflammatory effects than NSAIDs."
"Glucocorticoids have fewer side effects than nonsteroidal
c. "Glucocorticoids help
avert damage to tissues from lysosomal enzymes."
"Glucocorticoids reduce the immune component of inflammation."
Glucocorticoids have many side effects. They are used because
of their multiple mechanisms of action, including their ability to
limit tissue damage caused by the inflammatory process and suppression
of the immune component of inflammation.
A patient who is a long-distance runner has been diagnosed with
rheumatoid arthritis in both knees and will begin glucocorticoid
therapy. When teaching the patient about the medication, the nurse
will include what information?
a. "By reducing inflammation, this drug will slow the
progression of your disease."
b. "Glucocorticoids are
used as adjunctive therapy during acute flare-ups."
"Oral glucocorticoids cause less toxicity than intra-articular
d. "You may resume running when the pain
and swelling improve."
Glucocorticoids are used as adjunctive therapy to treat acute
exacerbations of rheumatoid arthritis. Glucocorticoids reduce pain and
inflammation but do not alter the course of the disease. Oral
glucocorticoids produce side effects similar to those of all
glucocorticoids, but they are absorbed more rapidly and completely
than intra-articular injections. Patients should be warned against
overactivity even though their pain has been reduced, because they can
further injure their joints.
The prescriber orders 20 mg of hydrocortisone orally once each day.
The nurse will make sure the drug is scheduled to be administered at
a. 8:00 AM
b. 12:00 PM
c. 4:00 PM
d. 9:00 PM
To allow the adrenals to recover, the hydrocortisone dose
should be administered before 9:00 AM. The other times are incorrect
for oral administration of daily hydrocortisone.
A patient is about to receive prednisone for tendonitis. The nurse
reviewing the chart would be concerned about which of the following in
the patient's medical history?
a. Asthma and allergic rhinitis
b. Gouty arthritis
d. Systemic fungal infection
Glucocorticoids are contraindicated in patients with a history
of systemic fungal infections. Glucocorticoids are used to treat
asthma, allergic rhinitis, gout, and seborrheic dermatitis.
A 60-year-old female patient is about to begin long-term therapy with
a glucocorticoid. Which of the following will be important for
minimizing the risk of osteoporosis?
a. Baseline vitamin D level
b. Calcium and vitamin D
c. Estrogen therapy
d. Skeletal x-rays before treatment
Calcium and vitamin D supplements can help minimize the
patient's risk of developing osteoporosis. A baseline vitamin D level
is not recommended. Estrogen therapy can help in postmenopausal women,
but its risks outweigh its benefits. Patients should undergo
evaluation of the bone mineral density of the lower spine, not
A patient taking high doses of a glucocorticoid develops weakness in
the muscles of the upper arms and in the legs. What will the nurse do?
a. Contact the provider to ask about reducing the dose.
Encourage the patient to restrict sodium intake.
c. Reassure the
patient that this is an expected side effect.
d. Tell the patient
to stop taking the drug.
High-dose glucocorticoid therapy can cause myopathy,
manifesting as weakness. If muscle weakness occurs, the dose should be
reduced. Reducing the sodium intake is recommended to minimize sodium
and water retention. Muscle weakness is not an expected side effect,
because it indicates myopathy. It is incorrect to tell the patient to
stop taking the drug, because a glucocorticoid must be withdrawn
slowly to allow time for recovery of adrenal function.
A patient taking a glucocorticoid for arthritis reports feeling
bloated. The nurse notes edema of the patient's hands and feet. Which
action by the nurse is correct?
a. Ask the patient about sodium intake.
b. Obtain a blood
c. Suggest the patient limit potassium
d. Tell the patient to stop taking the drug.
Because of their mineralocorticoid activity, glucocorticoids
can cause sodium and water retention and potassium loss. Asking about
the sodium intake can help the nurse evaluate this patient. Although
glucocorticoids can affect glucose tolerance, this patient does not
have signs of hyperglycemia. Patients with sodium and water retention
should be encouraged to increase their potassium intake. Telling a
patient to stop taking the drug is incorrect, because a glucocorticoid
must be withdrawn slowly to allow time for recovery of adrenal function.
A child is to begin long-term glucocorticoid therapy. The parents ask
the nurse about the effects of this drug on the child's growth. Which
response by the nurse is correct?
a. "A smaller dose may be indicated for your
b. "Ask your provider about every other day
c. "Long-acting glucocorticoid preparations
should prevent growth suppression."
glucocorticoids rarely cause growth suppression."
Growth retardation can be minimized with alternate day dosing
of glucocorticoids. Giving smaller doses does not prevent this effect
with long-term therapy. Long-acting glucocorticoids do not prevent
this effect. Oral glucocorticoids have the same side effects.
A patient who has been taking a glucocorticoid for several months
arrives in the clinic. The nurse notes that the patient's cheeks
appear full and that a prominent hump of fat is present on the upper
back. The nurse will ask the provider to order which test(s)?
a. Liver function tests
b. Serum electrolytes
Tuberculin skin test
d. Vitamin D levels
This patient shows signs of iatrogenic Cushing's syndrome,
which may include serum electrolyte disturbances; therefore, the
electrolyte levels should be monitored. Liver function tests,
tuberculin skin testing, and vitamin D levels are not indicated.
A nurse is teaching a patient who has taken glucocorticoids for over
a year about glucocorticoid withdrawal. Which statement by the patient
indicates a need for further teaching?
a. "I should reduce the dose by half each day until I stop
taking the drug."
b. "I will need to have cortisol
levels monitored during the withdrawal process."
"The withdrawal schedule may take several months."
"If I have surgery, I may need to take the drug for a while, even
after I have stopped."
Glucocorticoid therapy can suppress adrenal function, so
withdrawal should be done slowly to allow recovery of adrenal
function. Reducing the dose of a glucocorticoid by half each day is
not recommended. Patients should have their cortisol levels monitored
to determine when therapy can be stopped. The withdrawal schedule may
take several months. Patients who have stopped the drug may still
experience adrenal insufficiency in times of physiologic stress, such
A patient who has arthritis has been taking ibuprofen [Motrin] and a
glucocorticoid medication. The patient reports having tarry stools but
denies gastric pain. Which action by the nurse is correct?
a. Contact the provider to discuss ordering an antiulcer
b. Counsel the patient to use over-the-counter
c. Reassure the patient not to worry unless there is
d. Tell the patient to stop taking the
Glucocorticoid therapy, especially when combined with NSAIDs,
can increase the risk of gastric ulcer and possibly GI bleeding.
Treatment with antiulcer medications is indicated, but not with OTC
antacids, since the provider needs to be aware of this adverse effect.
Gastric pain is usually decreased because of the glucocorticoids, so
absence of gastric pain is not reassuring. The glucocorticoid should
be withdrawn slowly, not immediately.
A woman who is breastfeeding is prescribed a low pharmacologic dose
of a glucocorticoid and asks the nurse about potential effects on her
infant. What will the nurse tell her about this medication?
a. "At this dose, the concentration in your breast milk is
b. "Contact your provider to discuss lowering
c. "There will be reversible side effects
for your baby."
d. "This drug is likely to cause growth
retardation in your baby."
Women who are nursing may take physiologic or low
pharmacologic doses of glucocorticoids without achieving
concentrations in breast milk that affect the nursing infant. It is
not necessary to lower the dose. Since there are negligible levels,
there are no effects on the infant. Large pharmacologic doses can
cause growth retardation and other adverse effects in the infant.
Which disorders may be treated with glucocorticoids? (Select all that apply.)
a. Allergic rhinitis
e. Ulcerative colitis
A, D, E
Glucocorticoids are used topically for allergic rhinitis
and are given systemically for gout and ulcerative colitis. They are
not useful in anaphylactic reactions, for which epinephrine is the
drug of choice, or in bronchiolitis, which generally is induced by a
virus, not by an immune response.