PHARMACOLOGY REVIEW: Prepare for the NCLEX-RN with comprehensive Pharmacology Review. Master essential drug classes, mechanisms, side effects, and nursing considerations. Our concise, easy-to-follow guides and practice questions ensure you’re ready for exam day. Elevate your pharmacology knowledge and pass with confidence!
ANTICOAGULANTS
- Heparin
- Clopidogrel (Plavix)
- Warfarin
- Enoxaparin (Low-molecular weight heparin)
Anticoagulants are contraindicated with active bleeding (except for disseminated intravascular coagulation), bleeding disorders or blood dyscrasias, ulcers, liver, and kidney disease, and hemorrhagic brain injuries.
Heparin
Heparin
Classification: Indirect Thrombin Inhibitor: Anticoagulant
How it works:
Thrombin → converts fibrinogen to fibrin → Fibrin forms clots! Antithrombin III inhibits Thrombin. Heparin ENHANCES antithrombin III.
This stops thrombin from being activated, which therefore prevents clots from forming.
This is the intrinsic coagulation pathway
End result? SLOWS DOWN CLOTTING.
The therapeutic dose does not dissolve clots but prevents new thrombus formation.
Basic Information of HEPARIN:
- USES:
- Prevent blood clots
- Strokes
- Chronic a-fib
- Post-operatively
- Administration:
- Subcutaneous
- Intravenous
- Titration
- Patients on a heparin drip have aPTT levels drawn q4-6 hours to titrate the drip.
- Normal aPTT: 30-40 seconds
- Therapeutic aPTT: 1.5-2x normal
- If the aPTT is too long, per agency procedure, the dosage should be lowered. and if aPTT is too Short, per agency procedure, the dosage should be increased.
Important Nursing Considerations:
- Biggest side effect to monitor for = bleeding!
- Hematuria – Pink-tinged urine
- Hematemesis – bloody vomitus
- Bruising
- Antidote = protamine sulfate
- Heparin Induced Thrombocytopenia and Thrombosis (HITT)
- Complication of Heparin therapy
- Usually occurs 5-10 days after Heparin exposure
- Suspect in any patient on Heparin who has an unexplained platelet drop
- Clinical manifestations:
- Skin lesions at heparin injection sites
- Chills
- Fever
- Dyspnea
- Chest pain
- Complications – clotting!
- DVT
- PE
- Treatment:
- Discontinue ALL heparin and start a different anticoagulant!
WARFARIN:
Therapeutic class: Anticoagulant
- Indication:
- venous thrombosis
- pulmonary embolism
- A-fib
- Action:
- disrupts liver synthesis of Vitamin K dependent clotting factors
- Nursing Considerations:
- Monitor for bleeding
- Monitor PT and INR
- Prothrombin Time:
- Normal: 10-13 seconds
- International Normalized Ratio:
- Normal: <0.8-1.2
- Therapeutic INR: 2-3
- Antidote: Vitamin K
- Contraindicated during pregnancy.
ENOXAPARIN or LOW-MOLECULAR WEIGHT HEPARINS- RIVAROXABAN
Do not expel the air bubble from the pre-filled syringe or aspirate during injection.
NCLEX Question
The nurse is caring for a pregnant client who is at 16 weeks’ gestation. She developed a pulmonary embolism and was initiated on heparin therapy two days ago. She is getting ready to be discharged. Which of the following medications do you expect the healthcare provider to order at discharge?
A. Warfarin B. Rivaroxaban C. Apixaban D. Low Molecular Weight Heparin (LMWH)Right answer: D. LMWH (Low Molecular Weight Heparin is the drug of choice for
Let’s Solve this question…
anticoagulation in pregnancy. It does not cross the placenta and therefore does not cause fetal harm.)
SUBSTANCES TO AVOID WITH ANTI-COAGULANTS:
1. Allopurinol
2. Cimetidine
3. Corticosteroids
4. Green Leafy Vegetables and other foods high in vitamin K
5. NSAIDS
6. Oral hypoglycemic agents
7. Phenytoin
8. Salicylates
9. Sulfonamides
10. Herbs like Ginkgo and Ginseng
ANTICONVULSANTS
- Anticonvulsants:
- Phenytoin (Dilantin)
- Carbamazepine
- Divalproex
- Gabapentin
- Lamotrigine
- Levetiracetam (Keppra)
Phenytoin:
- Therapeutic class: Anticonvulsant
- Indication:
- Seizures Action: blocks sustained high frequency repetitive firing of action potentials
- Nursing Considerations:
- Therapeutic level: 10-20 mcg/mL
- Side effect: Gingival hyperplasia: Reddened gums that bleed easily
- Regular dental check-ups
- Use soft bristle toothbrush
- Antacids can reduce the effect of phenytoin and should be avoided.
Phenytoin must be given slowly to prevent hypotension and cardiac dysrhythmias. Also, it may decrease the effectiveness of some birth control pills and may cause teratogenic effects, if taken pregnancy.
NCLEX Question
The nurse is educating a patient who is taking phenytoin. To make sure
phenytoin does not fail, which over-the-counter medication should the nurse
advise the patient not to take at the same time?
A. Acetaminophen B. Ibuprofen C. Calcium Carbonate D. RanitidineRight Answer: C (Calcium Carbonate (Tums) should not be taken at the same time as Phenytoin
Let’s try this question
because taking them together can decrease the effects of phenytoin. Antacids containing
calcium carbonate reduce the bioavailability of phenytoin by reducing the rate of absorption
and amount of intake. If the patient needs both phenytoin and calcium carbonate, they
should be administered at least 2-3 hours apart.)
ANTIDEPRESSANTS:
ANTIDEPRESSANTS CLASSIFICATION
- Antidepressants
- SSRIs Fluoxetine
- Sertraline
- Escitalopram
- Citalopram
- TCAs
- Amitriptyline
- Nortriptyline
- Protriptyline
- MAOIs
- Tranylcypromine
- Isocarboxazid
- Phenelzine
- selegiline
RULES OF ANTIDEPRESSANT medications:
1. Slow onset and Slow
2. Increased risk of Suicide
First few weeks: Suicidal thoughts increased
3. Never mix SSRIs
4. Educate client to not discontinue medication abruptly.
5. Initiate safety precautions and contact physician if dizziness occurs
- SSRIs: SELECTIVE SEROTONIN REUPTAKE INHIBITORS
- Fluoxetine, Sertraline, Escitalopram, Citalopram
- Indication: Depression
- Action: Prevent reuptake of serotonin increasing the availability of serotonin in the body.
- Nursing Considerations:
- Monitor for serotonin syndrome
- Hypertension, confusion, anxiety, tremors, ataxia, sweating.
- Suicide precautions important for 2-3 weeks
- When the patient’s mood starts to improve, they are an increased risk for suicide
- Why?
- They now have the energy to follow through with a plan.
- Why?
- TCA’s: TRICYCLIC ANTIDEPRESSANTS
- Amitriptyline, Nortriptyline, Protriptyline
- Indication: Depression
- Action: Prevents the reuptake of norepinephrine and serotonin increasing these neurotransmitters in the body.
- Nursing Considerations:
- Monitor for anticholinergic side effects
- Dry mouth, constipation, urinary retention
- Monoamine Oxidase Inhibitors (MAOIs)
- Tranylcypromine, isocarboxazid, phenelzine, selegiline
- Indication: Depression
- Action: blocks monoamine oxidase enzymes to increase the levels of ALL neurotransmitters (dopamine, norepinephrine, epinephrine, serotonin)
- Nursing Considerations:
- Avoid foods that are high in tyramine.
- Aged cheeses
- Wine
- Pickled meats
- Avoid foods that are high in tyramine.
- Side effect – hypertensive crisis
Mood Stabilizers: Lithium
- Lithium
- Indication: Mania
- Action: Inhibits excitatory neurotransmitters such as dopamine and glutamate and promotes GABA-mediated neurotransmission.
- Nursing Considerations:
- Do not administer with NSAIDS
- Monitor drug levels:
- Therapeutic level – 0.5-1.5mEq/L
- Encourage adequate fluid intake
- Monitor the suicidal client especially during improved mood and increased energy levels.
- Do not administer diuretics while the client is taking lithium.
- Side effects:
- Seizures, arrhythmias, fatigue, confusion, nausea, anorexia, hypothyroidism, tremors
Instruct the client taking Lithium to maintain fluid intake of 6 to 8 glasses of a water a day and an adequate salt intake to prevent lithium toxicity.
Antipsychotics: Haloperidol ● Quetiapine ● Olanzapine
- Haloperidol
- Therapeutic class: Antipsychotic
- Indication: Schizophrenia, mania, aggressive behavior, agitation
- Action: Inhibits the effects of dopamine
- Nursing Considerations:
- Monitor for extrapyramidal side effects
- Tardive dyskinesia
- Neuroleptic malignant syndrome
- Can prolong the QT interval
- Weekly EKG
- Contraindicated in pregnancy
Antihistamines:
● Diphenhydramine ● Promethazine ● Cimetidine ● Famotidine ● Ranitidine
- Diphenhydramine
- Therapeutic class: Antihistamine
- Indication: Allergy, anaphylaxis, sedation
- Action: Antagonizes effects of histamine, CNS depression
- Nursing Considerations:
- Monitor for drowsiness
- Anticholinergic effects
ANTIHYPERTENSIVES
- ACE inhibitors “pril”
- Captopril
- Enalapril
- Lisinopril
- Angiotensin II Receptor Blockers
- Losartan
- Calcium Channel Blockers “dipine”
- Amlodipine
- Diltiazem
- Nifedipine
- Verapamil
- Beta-blockers “lol”
- Atenolol
- Metoprolol
- Propranolol
- Enalapril
- Therapeutic class: ACE inhibitor
- Indication: Hypertension, CHF
- Action: Blocks conversion of angiotensin I to angiotensin II, increases renin levels and decreases aldosterone leading to vasodilation
- Nursing Considerations:
- Can cause a dry cough – should be discontinued if it does.
- Monitor BP
- Contraindicated during pregnancy
- Losartan
- Therapeutic class: Angiotensin II receptor blocker (ARB)
- Indication:
- hypertension, DM neuropathy, CHF
- Action: inhibits vasoconstrictive properties of angiotensin II
- Nursing Considerations:
- Monitor BP
- Monitor fluid levels
- Monitor renal and liver status
- Contraindicated during pregnancy
- Amlodipine
- Therapeutic class: Calcium channel blocker
- Indication:
- Hypertension
- Angina
- Action: Blocks transport of calcium into muscle cells inhibiting excitation and contraction, causes peripheral vasodilation
- Nursing Considerations:
- Avoid grapefruit
- Blocks the enzyme involved in metabolizing calcium channel blockers, causing their level to increase.
- Monitor BP – orthostatic hypotension
- Can cause gingival hyperplasia
Beta Blockers
● Propranolol ● Atenolol ● Metoprolol
- Propranolol
- Therapeutic class: antiarrhythmic
- Indication: hypertension, angina, arrhythmias, MI, cardiomyopathy, alcohol withdrawal, anxiety
- Action: blocks Beta 1 and 2 adrenergic receptors slowing the heart rate
- Nursing Considerations:
- Do not discontinue abruptly, discontinue them slowly,
- Can mask the signs of hypoglycemia; important to monitor blood sugars.
- Caution with asthma and COPD – can potentially cause bronchospasm.
A persistent dry cough is a common compliant for those taking an ACE inhibitor, but this often subsides after a few weeks. Instruct the client to contact the PHCP if this occurs and persists.
Advise the client taking insulin that the Beta Blocker can mask early signs of hypoglycemia such as tachycardia, nervousness.
Beta-blockers are contraindicated in the client with asthma, bradycardia, severe renal or hepatic disease, hyperthyroidism, stroke
Antiarrhythmics
● Amiodarone ● Adenosine ● Procainamide ● Atropine
- Adenosine
- Therapeutic class: Antiarrhythmic
- Indication:
- SVT Action: Slows conduction through the AV node, interrupts re-entry pathways through AV node, restoring normal sinus rhythm
- Nursing Considerations:
- There will be a period of asystole after administration
- Warn the patient – it will feel like someone kicked them in the chest!
- Warn the family – they will flatline on the monitor!
- Rapid push – or it will not work.
- Use with extreme caution in asthmatics
- Atropine
- Therapeutic class: Antiarrhythmic; anticholinergic
- Indication:
- Excessive secretions, sinus bradycardia, heart block
- Action: Inhibition of acetylcholine, increasing the HR, causing bronchodilation, and decreasing secretions.
- Nursing Considerations:
- Monitor for urinary retention and constipation
- Avoid in patients with glaucoma
Cardiac glycosides
● Digoxin
- Digoxin
- Therapeutic class: Cardiac glycoside
- Indication:
- Heart failure, a-fib, a-flutter, CHF, cardiogenic shock
- Action: Increases contractility (how strong the heart pumps), and decreases the rate (how fast the heart beats). Acts on the cellular sodium-potassium ATPase, making the heart more efficient!
- Nursing Considerations:
- Monitor for toxicity
- Vision changes, blurred vision, yellow/green vision
- Toxicity
- Monitor for toxicity in any patient taking digoxin!
- Narrow therapeutic range!! → Therapeutic lab level: .5-2ng/mL
- Signs/symptoms:
- Nausea & vomiting
- Anorexia
- Vision changes – yellow/green halos
- Bradycardia → arrhythmias Monitor for these signs and symptoms and report them to the health care provider early
- Risk factors for toxicity
- Patients with hypokalemia (K<3.5) If your patient is on a loop diuretic, and digoxin, they are more likely to become toxic!
- Licorice extract acts like aldosterone (Na/water retention & K loss) → hypokalemia → Dig Toxicity. Licorice extract is in black licorice.
- Patients with hypomagnesemia (Mg<1.8)
- Patients with hypercalcemia (Ca>10.5)
- The elderly! These patients have decreased renal and liver function, making it harder for them to clear any drugs, so digoxin levels can build up and become toxic more quick
Important Nursing Consideration:
When should you HOLD your digoxin dose?
In general, if the pulse is less than 60, you should hold digoxin. This will be slightly different in different age groups. Always check your order.
ANTI-INFECTIVE DRUGS
- Aminoglycosides:
- Gentamicin ● Fluoroquinolones
- Ciprofloxacin
- Levofloxacin ● Macrolides
- Erythromycin
- Azithromycin ● Vancomycin
- ● Penicillin & Cephalosporins
- Amoxicillin
- Ampicillin
- Ancef
- ● Anti-viral
- Acyclovir
- Antifungal
- Amphotericin B
- Metronidazole
- Gentamycin
- Therapeutic class: Anti-infective; aminoglycoside
- Indication: Gram negative infections
- Action: Inhibition of bacterial protein synthesis
- Nursing Considerations:
- Monitor for tinnitus
- Do not administer with penicillin
- Ciprofloxacin
- Therapeutic class: Anti-infective; fluoroquinolone
- Indication:
- Infection
- Action: Inhibits synthesis of bacterial DNA
- Nursing Considerations:
- Can cause QT prolongation
- Decreases effects of phenytoin
- Vancomycin
- Therapeutic class: Anti-infective; glycopeptide antibiotics
- Indication:
- Infection; sepsis
- Action: kills bacteria in the intestines
- Nursing Considerations:
- Monitor for ototoxicity and nephrotoxicity
- Red-man syndrome
- Administer over at least 60 minutes; central line preferred.
- Amoxicillin
- Therapeutic class: Anti-infectives; aminopenicillin
- Indication:
- Infections; skin, respiratory, endocarditis
- Action: Inhibits synthesis of bacterial cell wall leading to cell death
- Nursing Considerations:
- Monitor for rash
- Monitor kidney function
- BUN, Creatinine
Respiratory Medications
- Rescue meds
- Albuterol
- Ipratropium
- Long-term control meds
- Guaifenesin → Expectorant
- Montelukast → Leukotriene modifier
- Theophylline → Phosphodiesterase Enzyme Inhibitor
- Albuterol
- Therapeutic class: Bronchodilator; short acting beta 2 agonist
- Indication:
- Asthma, COPD
- Action: Binds to Beta2 adrenergic receptors in the airway leading to relaxation of the smooth muscles in the airways
- Nursing Considerations:
- Be very cautious when using in patients with heart disease, diabetes, glaucoma, or seizures.
- Causes tachycardia.
Theophylline toxicity is likely to occur when the serum level is higher than 20 mcg/mL. Early signs of toxicity include restlessness, nervousness, tremors, palpitations, tachycardia.
The client with a peanut allergy should not take certain Ipratropium products because they contain soy lecithin, which is in the same plant family as peanuts.
Instruct the client taking inhaled medications to drink a few sips of water before and after inhalation to prevent a cough and unpleasant taste in the mouth.
Some tuberculosis medications can cause red-orange-colored body secretions. Inform the client that this is not harmful effect but that the secretions can stain and permanent discolor items.
Ethambutol causes optic neuritis, which decreases visual acuity and the ability to discriminate between the colors red and green. This poses a potential safety hazard when a client is driving a motor vehicle.
DIURETICS
- Loop diuretics
- Bumetanide
- Furosemide
- Torsemide
- Potassium sparing diuretics
- Triamterene
- Amiloride
- Spironolactone
- Thiazide diuretics
- Chlorothiazide
- Chlorthalidone
- Hydrochlorothiazide
- Indapamide
LOOP DIURETICS:
- Loop Diuretics:
- Examples:
- Bumetanide, Furosemide, Torsemide
- Mechanism of action: Act on the loop of Henle to increase urine output by affecting sodium reabsorption within the nephron.
- Inhibits the sodium potassium chloride cotransporter causing sodium to be excreted in the urine therefore increasing diuresis.
- Uses:
- Increase urinary output, edema, CHF, blood pressure management.
- Nursing considerations:
- Monitor potassium levels
- These are the most effective of all diuretic
- Potassium Sparing Diuretics
- Examples:
- Triamterene, Amiloride, Spironolactone, Eplerenone
- Mechanism of action:
- Inhibit sodium and potassium exchange via sodium channels in the distal parts of the nephron.
- This ‘spares’ potassium!!
- Uses:
- Hypertension, edema, swelling, hypokalemia.
- Nursing considerations:
- Monitor potassium levels
- These medications are not as strong as other diuretics, so are often combined with a loop or thiazide diuretic!
THIAZIDE DIURETICS:
- Thiazide Diuretics
- Examples: Chlorothiazide, Chlorthalidone, Hydrochlorothiazide, Indapamide, Metolazone.
- Mechanism of action:
- These diuretics act on the distal convoluted tubule to inhibit the sodium-chloride cotransporter.
- This increases sodium in the filtrate causing an increased amount of water reabsorption and therefore increased urinary output.
- Uses: Hypertension, CHF
- Nursing Considerations:
- Monitor electrolyte levels
- Monitor BP
GI MEDICATIONS
GI Medications
GI MEDICATIONS..
● Bisacodyl ● Lactulose ● Metoclopramide ● Ondansetron
● Omeprazole ● Pantoprazole
- Ondansetron
- Therapeutic class: Antiemetic
- Indication: Nausea/vomiting
- Action: blocks effects of serotonin on vagal nerve and CNS
- Nursing Considerations:
- Administer slowly. Fast push can cause QT prolongation and VT.
- Omeprazole
- Therapeutic class: Proton-pump inhibitor
- Indication:
- GERD, ulcers
- Action: prevents the transport of H ions into the gastric lumen by binding to gastric parietal cells to decrease gastric acid production
- Nursing Considerations:
- Administer 30-60 minutes before meal
- Report black, tarry stools
NON-OPIOID ANALGESICS
Non-opioid Analgesics
- Acetaminophen
- NSAIDS
- Aspirin
- Ibuprofen
- Naproxen
- Acetaminophen
- Therapeutic class: antipyretic, non-opioid analgesic
- Indication:
- Pain, fever
- Action: Inhibit the synthesis of prostaglandins which play a role in transmission of pain signals and fever response
- Nursing Considerations:
- Max daily dose = 4g
- Monitor liver function
- Antidote = n-acetylcysteine
- NSAIDS – Non-Steroidal Anti-Inflammatory Drugs
- Examples: Aspirin, ibuprofen, ketoprofen, naproxen
- Indication:
- Pain, inflammation, fever
- Action: Block prostaglandin which causes inflammation, pain, and fever.
- Nursing Considerations:
- Can cause prolonged bleeding
- Typically avoided in trauma and surgical patients
- Can cause peptic ulcers
- Acetylsalicylic Acid (Aspirin)
- Therapeutic class: Antipyretic, non-opioid analgesic
- Indication:
- Pain – arthritis. Stroke and MI prophylaxis
- Action: Inhibits the production of prostaglandins which leads to a reduction of fever and inflammation, decreases platelet aggregation leading to a decrease in ischemic diseases
- Nursing Considerations:
- Risk of bleeding
- Don’t administer with other anticoagulants
- Discontinue 5-7 days prior to surgery
- Caution with pediatric patients
- Reye’s syndrome can occur with viral infections
- Only time it is commonly used in peds is in Kawasaki’s disease
OPIOIDS
Opioids
opioids
- Morphine ● Fentanyl ● Hydromorphone ● Methadone ● Oxycodone
MORPHINE
- Morphine
- Therapeutic class: Opioid analgesic
- Indication: Pain Action: Binds to opiate receptors in the CNS and alters perception of pain while producing a general depression of the CNS.
- Nursing Considerations:
- Common side effect: constipation
- CNS depressant
- Decreased respiration, decreased heart rate, etc.
- Monitor respiratory rate
- Antidote = Naloxone
OBSTETRIC MEDICATIONS
Obstetric Medications
- Tocolytics – slow contractions
- Terbutaline
- Magnesium-sulfate
- Indomethacin (prostaglandin inhibitor)
- Nifedipine (CCB)
- Oxytocic’s – stimulate contractions
- Oxytocin
- Ergometrine (Methergine)
- Misoprostol
- Magnesium-sulfate
- Therapeutic class: Electrolyte
- Indication:
- Hypomagnesemia, torsade de point, pre-eclampsia, preterm labor, seizures, asthma exacerbation
- Nursing Considerations:
- Monitor for hypermagnesemia
- Confusion, dizziness, weakness, decreased reflexes
- Give IV slowly
- Oxytocin
- Therapeutic class: Hormones
- Indication:
- Induction of labor; PPH
- Action: Stimulates uterine smooth muscle causing it to contract
- Nursing Considerations:
- Monitor contractions
- Monitor fetus
- Warn mother contractions will be more painful
- Monitor BP, HR, glucose.
STEROIDS
steroids
Steroids
● Betamethasone ● Dexamethasone ● Cortisone ● Fluticasone ● Methylprednisolone
- Methylprednisolone
- Therapeutic class: Corticosteroids
- Indication:
- Inflammation, Allergy, Autoimmune disorders
- Action: Suppress inflammation and normal immune response
- Nursing Considerations:
- Monitor for too many steroids
- Cushing’s symptoms; buffalo hump
- Side effects:
- Immunosuppression
- Hyperglycemia
- Osteoporosis
- Delayed wound healing
PRACTICE NCLEX-RN QUESTIONS:
- While working in a pediatric intensive care unit, the nurse receives orders to administer aspirin to a 12-month-old child who is febrile. The nurse knows to question this order due to the high risk of _________‘s syndrome when aspirin is administered to a child.
Answer: Reye’s
Reye’s syndrome is a very serious illness that has been associated with aspirin administration in children. It is a viral encephalopathy and usually follows a virus infection. It causes cerebral edema as well as liver disease and can be fatal. Aspirin administration should always be avoided in the pediatric population. - The nurse is answering phones in the general practice clinic and receives a call from a patient who is experiencing leg pain after starting atorvastatin. Which of the following instructions, when given by
the nurse, is the best course of action?
a. Continue taking the medication as this is an expected side effect b. Discontinue the medication and schedule an appointment for the next week c. Stretch for 20 minutes or take a warm shower d. Discontinue the medication and visit the clinic as soon as possible
Answer: D
The correct answer is D. Leg pain, and muscle aches, which occur after taking atorvastatin, may indicate a severe muscular myopathy known as rhabdomyolysis. The nurse would be most accurate to have this patient discontinue their medication and come to the clinic as soon as possible.
Choice A is incorrect. This patient should be seen in the clinic to rule out potentially fatal health problems like rhabdomyolysis.
Choice B is incorrect. While this medication should be discontinued, waiting for treatment could delay necessary treatment.
Choice C is incorrect. Stretching for 20 minutes or taking a warm shower could delay necessary treatment. - The nurse is preparing to administer a prescribed dose of lactulose 20 grams orally QID to a client with portal-systemic encephalopathy. The medication is available at 3.33 grams per 5ml oral solution. She plans to administer 30 ml per dose to the client QID. When the nurse approaches the client, the client states, I understand that I cannot take other laxatives with lactulose. After checking, the nurse should: a. Withhold the lactulose. b. Give only 3 ml lactulose instead of 30 ml. c. Give 30 ml lactulose with juice and monitor blood ammonia. d. Give 30ml lactulose and correct the client that he may take additional laxatives.
Answer: C
Choice C is correct. The client has been prescribed Lactulose for portal-systemic encephalopathy, not for constipation. The prescribed dose is 20 grams every 4 hours. Since each 5 ml has 3.33 grams in it, the accurate dosage to be administered is 30 ml every 4 hours. Lactulose does not have a palatable taste; therefore, it can be mixed with fruit juice, water, or milk to improve flavor. The nurse should monitor blood ammonia levels and watch for any side effects. Side effects include belching, flatulence, or abdominal cramping. Lactulose belongs to the class of “Osmotic Laxatives” and may be used to treat constipation. Being an osmotic laxative, it draws water into the colonic lumen and softens the stool. Lactulose is also used in hepatic (portal-systemic) encephalopathy because it inhibits intestinal ammonia production. Lactulose is metabolized by intestinal bacteria and converted to lactic acid. Because of lactic acid, the pH in the colonic lumen is reduced (acidified), and this promotes the conversion of ammonia (NH3) to ammonium (NH4+). This ionized form of the ammonia is unable to diffuse across the gut membrane into the blood, and thereby, blood ammonia levels decrease. Decreasing blood ammonia levels results in improved mental status in PSE. When used in hepatic encephalopathy, the Lactulose dose needs to be carefully adjusted so the client averages 2 to 3 loose stools per day. If other laxatives are used in conjunction, it gets challenging to determine the optimal dose of Lactulose using the above definition of 2-3 loose stools/ day. Therefore, the client should be educated not to use additional laxatives.
Choice A is incorrect. The client needs his prescribed dose Lactulose for his portal-systemic encephalopathy.
Choice B is incorrect. The prescribed dose is 20 grams, which is equivalent to 30 ml as per the calculation above. Administering 3ml instead of 30ml is inappropriate.
Choice D is incorrect. The client has correct understanding already. It is inappropriate to tell the client with hepatic encephalopathy to take additional laxatives while on Lactulose. Lactulose dose needs to be carefully adjusted, so the client averages 2 to 3 loose bowel movements per day. If other laxatives are used in conjunction, it gets challenging to determine the optimal dose of Lactulose. - The nurse is providing a client with discharge instructions on his newly initiated Digoxin. Which of the following statements by the client indicates he correctly understood the instructions? Select all that apply.
a. “If I note color vision changes, I will call my doctor right away.” b. “I will check my pulse before each dose and if the pulse is less than 100 bpm, I will hold Digoxin and call my doctor.” c. “I will increase my calcium intake significantly.” d. “I will make sure I get enough potassium in my daily diet.” e. “The water pills that I am on may increase the risk of side effects with Digoxin.” f. “I should avoid medications that have licorice extract.”
Answer: A, D, E, F
A is correct. One of the early side effects of Digoxin is visual aberrations such as yellowish-green color changes or halos. Therefore, if the patient notes color vision changes, they should call the doctor right away.”
B is incorrect. The first cardiac side effect of digoxin toxicity is bradycardia, but cardiac arrhythmias can follow later. It is essential to monitor for these early side effects, so the next dose of Digoxin can be held, and the physician can be notified. The patient should check their pulse before each dose and if the pulse is less than 60 bpm hold Digoxin and call the doctor.
C is incorrect. Hypercalcemia can cause digoxin toxicity, therefore the patient should not increase their calcium intake significantly.
D is correct. Because hypokalemia can cause digoxin toxicity, the patient should make sure they get enough potassium in
their daily diet.
E is correct. If the patient is on a loop diuretic such as furosemide, they increase the risk of side effects with Digoxin due to losses of potassium and subsequent hypokalemia. These patients should be monitored more closely for toxicity.
F is correct. The patient should avoid medications that have licorice extract. Licorice extract acts like the hormone aldosterone – causing sodium and water retention and growing potassium loss. Hypokalemia, in turn, precipitates digoxin
toxicity. - The nurse is doing admission documentation on a new patient. While reviewing his allergies,
he states he has a reaction called “red man’s syndrome”, but he doesn’t know which drug it is
that he’s allergic to. The nurse documents which of the following medications as the patient’s
allergy?
a. Ciprofloxacin
b. Vancomycin
c. Gentamicin
d. Amoxicillin
Answer: B
A in incorrect. Ciprofloxacin does not cause ‘red man’s syndrome’. Ciprofloxacin is a fluoroquinolone antibiotic. It can cause QT prolongation and decrease the effects of some medications, such as phenytoin.
B is correct. Vancomycin is the drug that causes the reaction known as ‘red man’s syndrome’. This is a very serious allergic reaction which the entire body itches and a red rash appears on the face, neck, and torso. It commonly occurs if the infusion is run too quickly; vancomycin should always go over at least one hour.
C is incorrect. Gentamicin does not cause ‘red man’s syndrome’. Gentamicin is an aminoglycoside antibiotic. Important side effects to monitor for include tinnitus.
D is incorrect. Amoxicillin does not cause ‘red man’s syndrome’. Amoxicillin is a penicillin antibiotic. While it can cause a rash, it is not similar to the red man syndrome rash vancomycin can cause.