A patient has meperidine, 75 mg every 3—4 hours prn, ordered for postoperative pain. Before administering this narcotic, the nurse should: Position in a semi-Fowler's position to minimize respiratory effects. Assess the type, location, and intensity of discomfort. Evaluate whether the pain is real. Try other measures to relieve discomfort, such as position change. Before administering any narcotic, the nurse should assess the type, location, and intensity of pain, as well as factors that seem to precipitate or relieve it. Meperidine, like morphine, has hypotensive and respiratory depressant effects. Positioning in anticipation of respiratory changes is not indicated (Answer 1). Pain and discomfort are subjective symptoms that are always real to the patient (Answer 3). Based on the information gained in Answer 2, it is then possible to decide whether the patient needs supportive measures (such as back rub or position change as in Answer 4), the bedpan, and/or the administration of a narcotic. Choose the first step in the nursing process—assess. Neostigmine bromide (Prostigmin), 0.5 mg subcutaneously stat, is ordered by a patient's physician to relieve urinary retention. The nurse knows that this drug is classified as: A cholinergic. An anticholinesterase. An anticholinergic. A beta blocker. Neostigmine bromide (Prostigmin) is an anticholinesterase. It enhances bladder tone and contraction, enabling complete emptying of the bladder. It is also used in the treatment of myasthenia gravis. Bethanecol chloride (Urecholine) is an example of a cholinergic drug (Answer 1), also used to treat postoperative urinary retention. Atropine is an example of an anticholinergic drug (Answer 3), which would act to inhibit initiation of urination. Beta blockers (Answer 4) such as propranolol do not affect the bladder. Know expected effects of common drug classifications. The nurse explains to a patient that although salicylates are given to relieve pain in rheumatoid arthritis, they also function as an: Analgesic. Anti-inflammatory. Anticholinergic. Antiadrenergic. Salicylates, particularly acetylsalicylic acid (aspirin), are given in divided doses after each meal and at bedtime for their analgesic (reduced pain), anti-inflammatory (reduced swelling), and antipyretic (reduced fever) effects. Answer 1 is incorrect because relief of pain was already described in the question. Answers 3 and 4 are incorrect because salicylates neither inhibit nor stimulate the autonomic nervous system synapses. Consider why the drug relieves pain— decreased inflammation. Drug therapy goals for a patient include strengthening cardiac contraction and increasing glomerular filtration rate. Which medication would the nurse prepare to accomplish both goals? Epinephrine. Digoxin. Furosemide (Lasix). Hydralazine. Digoxin increases the force and velocity of cardiac contraction and slows the heart rate by delaying conduction through the atrioventricular node. The hemodynamic effects of its action include increased cardiac output, decreased right atrial and venous pressures, decreased left ventricular filling pressure, and increased excretion of sodium and water. Epinephrine (Answer 1) increases the force of cardiac contractions but also increases heart rate, which in this case would increase cardiac embarrassment. Furosemide (Lasix) (Answer 3) is a rapidly acting diuretic that enhances excretion of sodium and water. However, although its use is indicated to reduce fluid volume during the acute phase of pulmonary edema, it has no known direct effects on the cardiac musculature. Hydralazine (Answer 4) is a peripheral vasodilator used in hypertensive therapy. It is not indicated in this situation. Know the expected therapeutic effects. Would increased or decreased heart rate improve cardiac output and renal blood flow? Which outcome is the best indicator that digoxin has been effective? Increased systolic and diastolic pressures. Unlabored respirations and increased urinary output. Decreased pulse rate and increased urinary output. Increased blood pressure and decreased pulse rate. The best indicator that digoxin has been effective in strengthening cardiac contraction and increasing glomerular filtration is a decrease in heart rate (vagal effect) and increased urinary output. As a result of these drug effects, cardiac output is improved, raising blood pressure and decreasing pulmonary congestion. Answers 1,2, and 4 are only partially correct. Look for one expected effect (increased urinary output) to help eliminate two other options. Patient teaching includes the early side effects of theophylline administration, which are: Tachycardia and palpitations. Anorexia, nausea, and vomiting. Restlessness and tremors. Headache and insomnia. Theophylline relaxes bronchial smooth muscles, which helps relieve the wheezing and coughing associated with bronchospasm. Side effects are rare, but the earliest signs of overdose are usually anorexia, nausea, and vomiting. Tachycardia (Answer 1), restlessness and tremors (Answer 3), headache and insomnia (Answer 4), are side effects associated with bronchodilators. Know expected outcomes of drug therapy—desired and untoward effects. Based on the peak action of furosemide (Lasix) PO, the nurse will evaluate the drug's effects in: 30-60 minutes. 1-2 hours. 3-4 hours. 6-8 hours. Furosemide is a rapidly acting diuretic with a peak action in 1-2 hours and a duration of 6-8 hours. The peak time is too rapid for Answer 1 and too long for Answers 3 and 4. Notice the time overlap—the option that includes both is better. The nurse administers sodium polystyrene sulfonate (Kayexalate) knowing that the drug reduces hyperkalemia by: Exchanging sodium ions for potassium ions in the GI tract, thereby increasing potassium excretion in the feces. Inhibiting potassium absorption sites in the GI tract. Promoting diarrhea, thereby decreasing potassium absorption from the gut. Altering the effects of aldosterone in the kidney tubules. Sodium polystyrene sulfonate (Kayexalate) is a cation-exchange resin. As it passes along the intestine or is retained in the colon after enema administration, sodium ions are par¬tially released and replaced by potassium ions, allowing for fecal excretion of potassium ions. This drug is extremely unpalatable and may be administered in syrup, chilled, or mixed in the diet, and if necessary, administered directly into the stomach per nasogastric tube. Side effects of administra¬tion include anorexia, nausea, vomiting, constipation,hypokalemia, hypocalcemia, and sodium retention. Answers 2,3, and 4 are not actions of sodium polystyrene sulfonate. Know the common therapies for increased K+—ion exchange; also glucose and insulin, sorbitol. Focus on the options that include increasing K+ excretion rather than decreasing K+ absorption (Answers 2 and 3). The nurse knows that the best time to give oral iron preparations is: With meals, to decrease gastric upset. 1 hour before eating, to enhance absorption. 1 hour after eating, to slow absorption. At bedtime. Ideally, oral iron preparations should be taken on an empty stomach (2). However, they tend to irritate the gastric mucosa, so they should be administered with or immediately after meals to ensure patient compliance. Thus Answers 2,3, and 4 are not the best Answers. Patients may complain of constipation or loose stools. Stools will change color (dark green to black). Ferrous sulfate is apt to deposit on teeth and gums, so frequent oral hygiene is necessary, and therapy will need to continue even after hemoglobin levels return to normal, to ensure adequate iron stores in the body. Key word is best time.Answer 1 is better than Answer 3. Iron is harsh on the stomach. A patient is instructed to report the following side effect of neomycin administration: Deafness. Nausea. Diarrhea. Anaphylaxis. Toxic doses of neomycin may result in eighth cranial nerve damage much like that produced by streptomycin. Kidney damage may also occur, extending from milk albuminuria to elevation in blood urea nitrogen. Nausea (Answer 2) is common with ingestion of antibiotics, though not specific to neomycin. Erythromycin most commonly causes nausea, vomiting, and diarrhea (Answer 3). Anaphylactic reactions (Answer 4) are associated most commonly with penicillin administration. Use a process of elimination—find a specific, serious side effect that can occur. Drug would not be given in the first place with known allergic potential (because of anaphylaxis); GI upset is common to most antibiotics, and not specific to neomycin. Before administering morphine sulfate, the nurse should check: Apical and radial pulse. Respiratory rate. Urinary output. Skin color and turgor. Morphine strongly depresses the medullary respiratory centers. Therefore, before administering the narcotic, the nurse should assess the patient's respiratory rate and depth to prevent severe respiratory depression. Answers 1,3, and 4 are not affected by morphine. Know which systems (in this case, respiratory) respond to commonly used drugs—particularly pain medications. The nurse administers spironolactone (Aldactone) knowing that it is classified as: An aldosterone antagonist. A carbonic anhydrase inhibitor. A thiazide. An osmotic diuretic. Spironolactone (Aldactone) is an aldosterone inhibitor, inhibiting the effects of hyperaldosteronemia, which is common in cirrhosis. This drug safely increases sodium and water excretion but does not cause concomitant losses of potassium as do other diuretics. For this reason, potassium supplements are not generally given to the patient. An example of a carbonic anhydrase inhibitor (Answer 2) is acetazolamide (Diamox); an example of a thiazide (Answer 3) is chlorothiazide (Diuril) or hydrochlorothiazide (HydroDIURIL); and an example of an osmotic diuretic (Answer 4) is mannitol. Look for clues from the stem, such as V similarity in words—aldactone and aldosterone. Which supplement would the nurse not ordinarily administer to the patient receiving spironolactone? Vitamin B. Potassium chloride. Ascorbic acid. Calcium carbonate. Potassium chloride is not given since the patient is on spironolactone (Aldactone), which does not cause concomitant losses of potassium as do other diuretics. For this reason, potassium supplements are nor generally given to the patient. Spironolactone would not contraindicate the administration of vitamin B6 (Answer 1), ascorbic acid (Answer 3), or calcium gluconate (Answer 4). Know the expected outcome of potassium-sparing diuretics. Know drug classifications. The primary objective in giving prednisone along with aspirin for acute rheumatoid arthritis is: To inhibit the autoimmune factors associated with rheumatoid arthritis. To prevent further joint destruction. To decrease inflammation and suppress symptomatology. To increase glucose levels for tissue repair. The primary objective in giving corticosteroids is to lessen the symptoms of the disease process. Most patients initially respond well to these drugs; however, as the disease pro¬gresses, higher and higher doses are required to relieve symp¬toms. Answers 1 and 2 are incorrect because corticosteroids have no curative effects, only palliative. Many of the side effects of corticosteroid administration are due to the effects of these drugs on glucose metabolism (Answer 4), such as Cushing-like syndrome. Look for an option that will improve an "itis"—inflammation. The nurse would recognize prednisone toxicity if which of the following occurred? Tinnitus. Exfoliative dermatitis. Glucosuria. Nausea and vomiting. Side effects of prednisone therapy mimic the manifestations of Cushing's syndrome (moon facies, abnormal fat deposits, purple striae, hyperglycemia with glucosuria, hypertension, obesity, and emotional disturbances). Side effects of other drugs used in the management of rheumatoid arthritis include tinnitus (Answer 1), from aspirin; nausea, vomiting (Answer 4), headaches, and vertigo with indomethacin (Indocin) administration; and dermatitis ranging from erythema to exfoliative dermatitis (Answer 2) with gold salts therapy. Know the untoward effects of excessive steroids on the body. Propantheline bromide (Pro-Banthine) is given to patients with cholelithiasis and cholecystitis because it: Reduces gastric secretions and intestinal hypermobility. Decreases bile secretion by the liver and gallbladder. Slows the emptying of the stomach, thereby reducing chyme in the duodenum. Inhibits contraction of the gallbladder and the bile duct. Although the primary use of propantheline bromide in many clinical situations involving the gastrointestinal tract is to reduce gastric secretions and intestinal hypermotility, it is used in gallbladder disease because of its antispasmodic effects an the gallbladder and bile duct. Answer 1 is therefore correct, but not the best choice. Answers 2 and 3 are incorrect because propantheline bromide does not reduce bile secretions; its calming effect on gastric motility does not reduce the amount of chyme entering the duodenum. Look for an option that alleviates and explains a possible cause of gallbladder pain. The nurse would most likely give papaverine HCl for relief of gallbladder pain rather than morphine SO,, because: Morphine depresses gallbladder contractions, thereby decreasing bile secretions. Opiates tend to mask symptoms in patients with acute abdomen. Morphine tends to increase contractions of the sphincter of Oddi, thereby increasing intraductal pressures. Morphine relaxes smooth muscles, thereby increasing bile production. Morphine sulfate causes spasms of the sphincter of Oddi, thereby increasing intraductal pressures and abdominal pain. Papaverine and meperidine, both synthetic opiates, as well as nitroglycerin, may be administered to relieve pain associated with gallbladder disease. Answer 1 is incorrect because the effect of morphine is to increase spasms in the gallbladder. Answer 2, though correct, is not the best Answer Opiates are withheld when a patient has an acute abdomen and the diagnosis is unknown or tentative. In this case, the patient has an established history of gallbladder disease and specific symptomatology. Answer 4 is incorrect, in that although morphine does relax vascular smooth muscle, this effect does not increase bile synthesis in the liver. Look for options that are opposites— increase or decrease contractions. Which would likely cause pain? The nurse can anticipate side effects of hydrochlorothiazide because it is classified as: An aldosterone inhibitor. A carbonic anhydrase inhibitor A potassium-sparing drug. A potassium-wasting drug. Hydrochlorothiazide is a thiazide diuretic that promotes the excretion of water, sodium, and chloride by inhibiting the reabsorption of sodium ions in the distal ascending limb of the loop of Henle and in the distal convoluted tubule of the nephron. Natriuresis promotes the secondary loss of potassium, so this drug is classified as potassium wasting. Spironolactone is an example of an aldosterone inhibitor and is a potassium-sparing diuretic (Answers 1,3). Acetazolemide (Diamox) is the most frequently employed carbonic anhydrase inhibitor (Answer 2). Know the common side effects of frequently used diuretics. Potassium is usually lost (wasted). Focus on two contradictory options. You know potassium is involved; decide whether it is spared or wasted. The nurse knows that hydrochlorothiazide exerts its primary effect on: The proximal and distal tubules of the kidney. The distal convoluted tubule of the kidney only. The distal ascending loop of Henle and the distal tubule of the kidney. The descending loop of Henle and the proximal tubule of the kidney. Hydrochlorothiazide is a thiazide diuretic that promotes the excretion of water, sodium, and chloride by inhibiting the reabsorption of sodium ions in the distal ascending limb of the loop of Henle and in the distal convoluted tubule of the nephron. Natriuresis promotes the secondary loss of potassium, so this drug is classified as potassium wasting. Answer 1 describes the effect of the carbonic anhydrase inhibitors, e.g., acetazolemide (Diamox). Answer 2 would be the effect of the potassium-sparing diuretics such as spironolactone (Aldactone). Answer 4 is the site for the osmotic diuretics, e.g., mannitol, urea. Picture a functional nephron unit from a physiology book—know the action point for the most common diuretics. Assessment for the side effects of hydrochlorothiazide includes signs of: Hypernatremia. Hyperkalemia. Hypochloremia. Hypouricemia. Thiazide diuretics promote the excretion of sodium, chloride, bicarbonate, and potassium. However, chloride excretion tends to be proportionately greater than bicarbonate excretion, so therapy may result in hypochloremic alkalosis. Hyponatremia, not hypernatremia (Answer 1), occurs. Hypokalemia, not hyperkalemia (Answer 2), may develop, especially with brisk diuresis. Supplemental KC1 therapy and/or increased dietary intake of potassium is indicated with thiazide therapy. Answer 4 is incorrect because it says hypouricemia and hyperuricemia result, which may precipitate frank gout. When potassium loss (hypokalemia) is not a choice, think what else goes with K+ to balance the shift (CI). A 2-year-old child (diagnosis: meningitis) is to be sedated with phenobarbital, 18 mg PO q6h. The label reads "20 mg per 5 mL." How much phenobarbital should the nurse administer to this child? 4mL. 4.3 mL. 4.5 mL. 4.8 mL. The formula for finding the correct Answer is Dose desired/Dose on hand = it/Amount on hand. 18/20 = x/5 20x= 18(5) x = 18(5)/20 x = 4.5 mL The age of the patient is a distractor. Know the formula; the dose on hand is 5 mL. A patient's CSF culture is positive for Haemophilus influenzae meningitis. To protect other members of the patient's family who have been exposed to meningitis, the nurse should explain that they may be given: Amoxicillin/clavulanate potassium (Augmentin). Sulfisoxazole. Rifampin. Immune serum globulin. Rifampin is the drug of choice for the prophylactic treatment of Haemophilus influenzae meningitis. The usual dose is 20 mg/kg/day in a single dose for 4 days. Amoxicillin/clavulanate potassium (Augmentin) (Answer 1) sulfisoxazole (Answer 2) and immune serum globulin (Answer 4) are not the drugs of choice to prevent H. influenzae meningitis. Use the process of elimination—the stem says prevent; two options are treatment for infections, and one option has minimal effect in many situations (immune globulin). Select a broad-spectrum antibiotic for prophylaxis. The nurse is to administer pancreatin to a child with cystic fibrosis. To evaluate the effect of this medication, the nurse should know that the primary purpose of this medication is to increase the absorption of: Glucose. Vitamin C. Sodium chloride. Fats. Pancreatin (Viokase) is an exocrine pancreatic supplement used as a digestive aid in cystic fibrosis; its primary use is to promote the absorption of fats. Pancreatin has no effect on the absorption of glucose (Answer 1), vitamin C (Answer 2), or sodium chloride (Answer 3). Know the digestive problem (fat) with cystic fibrosis. The nurse about to administer medication to a 5-year-old patient notes that the child has no ID bracelet. The best way for the nurse to identify this patient would be to ask: The child, "Is your name?" The adult visiting, "The child's name is?" The other children in the room what the child's name is. Another staff nurse to identify this child. The only acceptable way to identify a 5-year-old patient is to have a parent or another staff member identify the patient. Answer 1 is incorrect because most 5-year-old children, under the age of reason, cannot legally be held accountable for self-identification. Answer 2 is incorrect unless the nurse is sure this adult is this patient's patent. Also, it would be better to ask, "What is the child's name?" Answer 3 is also incorrect; children cannot legally be held accountable for identifying other children. Look for the person with the legal responsibility—parent or, if not present, staff. Elixir of digoxin (Lanoxin) is available with 0.05 mg of the drug in 1 mL of solution. How much of this elixir should the nurse administer if the physician's order reads "0.125 mg PO bid"? 2 ml.. 2.25 mL. 2.5 mL. 2.75 mL. The correct Answer is found using the following formula: Dose desired/Dose on hand = x/Amount on hand. <br> 0.125/0.05 = xl1 <br> 0.05x = 0.125(1) <br> x = 0.125(1)/0.05 <br> x = 2.5 mL Know the formula; it works every time. Use extra care with decimal points. In teaching a parent how to administer Cortisporin eye drops to an infant, the nurse would be most correct in advising the parent to place the drops: Directly onto the infant's sclera. In the inner canthus of the infant's eye In the outer canthus of the infant's eye. In the middle of the lower conjunctival sac of the infant's eye. The recommended procedure for administering eyedrops to any patient calls for the drops to be placed in the middle of the lower conjunctival sac. Placing drops directly onto the sclera (Answer 1) is irritating and less effective. Placing drops in the inner canthus of the eye (Answer 2) may lead to systemic. effects from absorption via tear ducts. Placing drops in the outer canthus of the eye (Answer 3) results in loss of medication and may also cause infection. The age or size of the patient is a distractor; correct technique for eyedrops does not change. The doctor orders ferrous sulfate (Fer-in-Sol), 0.6 mL PO tid. For maximum absorption, the nurse should plan to administer this medication: Between meals. Before meals. During meals. After meals. Maximum absorption of Fer-in-Sol occurs between meals, when hydrochloric acid is freely available in the stomach. When given before meals (Answer 2), it may cause GI upset, which will interfere with eating. When given during meals (Answer 3) or after meals (Answer 4), there is slowed absorption of the drug; however, GI upset is minimized. The stem says maximum: when is HC1 readily available? The question does not ask about avoiding GI upset. Two weeks after starting an oral iron supplement, the patient's mother tells the nurse that the child's stools are black. The nurse should advise the mother: This is a normal side effect and means the medication is working. I will notify the doctor, who will probably decrease the dosage slightly. I will need a specimen to check the stool for possible bleeding. You sound quite concerned. Would you like to talk about this further? When oral iron preparations are given correctly, the stools normally turn dark green or black. Parents of children receiving this medication should be advised that this side effect indicates the medication is being absorbed and is working well. Answers 2, 3, and 4 would only increase the parents' anxiety and lead them to believe that the stool color was abnormal. Know the expected outcome of drug therapies, particularly changes in urine or feces color. Iron and black stools = a good thing! A pregnant woman's history reveals 12 weeks of gestation, severe pruritus, dysuria, and thick creamy vaginal discharge for the past 3 days. Which assessment factor is considered predisposing to the development of monilial vaginitis? Pregnancy. Late adolescence. High-carbohydrate diet. Sickle cell anemia. Normal pregnancy alters vaginal pH and favors the growth of yeast organisms (Candida). Answer 2 is wrong because age is not a factor in the development of yeast vaginitis. Answer 3 is wrong because ingestion of large amounts of carbohydrates does not alter vaginal pH. Answer 4 is wrong because sickle cell anemia is not a predisposing factor in yeast vaginitis. Use a process of elimination. Use what you do know about risk factors of monilia in pregnant women {not age or sickle cell anemia). What alters the pH of the vagina? Health teaching for a patient with vaginal infection with Candida albicans should be planned and implemented to ensure her consistent and appropriate use of the prescribed medication. Which medication is effective in the treatment of monilial (yeast) vaginitis? Metronidazole (Flagyl) oral tablets. Nystatin (Mycostatin) vaginal suppositories. Local applications of podophyllin. Antibiotic (bacitracin) ointment. Nystatin is the drug of choice for treatment of vaginal infections caused by Candida albicans. Answer 1 is wrong because metronidazole is used in treatment of trichomonal vaginitis. Answer 3 is wrong because podophyllin is used in treating venereal warts. Answer 4 is wrong because bacitracin ointment is used in treating skin infections. Method of administration is a clue (i.e., v~ "vaginal" in the stem and "vaginal" in the option) Reviewing the results of a patient's routine prenatal lab work, the nurse notes that her VDRL is positive. To protect the fetus from congenital syphilis, the patient must receive treatment before weeks 18-20. History suggests possible allergy to penicillin. Which drug would be ordered to treat venereal disease in the penicillin-allergic patient? Streptomycin. Sulfisoxazole (Gantrisin). Chloramphenicol (Chloromycetin). Erythromycin. Erythromycin or tetracycline is commonly used in treating penicillin-allergic patients with venereal disease. Answer 1 is wrong because streptomycin is used in treating tuberculosis.Answer 2 is wrong because sulfisoxazole is most commonly used to treat urinary tract infections. Further, its use is contraindicated in pregnancy. Answer 3 is wrong because chloramphenicol is used in treating Salmonella infections and is also contraindicated during pregnancy. Match drugs listed with primary conditions for which each are used. Eliminate two of the drugs that are contraindicated during pregnancy. Recognize erythromycin as the choice when penicillin is indicated but allergy exists. Health teaching regarding uncomfortable signs and symp toms of side effects of oral antibiotic therapy includes: Tinnitus (ringing in the ears). Nausea, vomiting, and abdominal pain. Nausea and glossitis. Nausea, diarrhea, and vaginal yeast infections. Prolonged, heavy doses of oral antibiotics are irritating to the GI tract and result in nausea and diarrhea; yeast infections are common sequelae of antibiotic therapy. Answer 1 is wrong; tinnitus is a symptom of streptomycin toxicity. Answer 2 is wrong because abdominal pain is more commonly associated with sulfisoxazole therapy. Answer 3 is wrong because glossitis and stomatitis are associated with chloramphenicol therapy. Recognize commonly occurring side effects of antibiotics. Prepare patient to manage. Which medication is ordered most commonly to attempt to inhibit premature labor? Diazepam (Valium). Betamethasone. Ritodrine (Yutopar). Bromocryptine mesylate (Parlodel). Ritodrine is the drug of choice when attempting to inhibit labor. Answer 1 is wrong because diazepam is used most commonly as an anticonvulsant. Answer 2 is wrong because betamethasone is used to stimulate production of fetal pulmonary surfactant. Answer 4 is wrong because bromocryptine mesylate is used to inhibit lactation in non-breastfeeding mothers. Know the main use for each of the four drugs listed in order to eliminate the three that are wrong. In evaluating a patient's response to beta-mimetic therapy used to inhibit premature labor, to which sign of side effects must the nurse be alert? Maternal hypertension. Fetal bradycardia. Maternal and fetal tachycardia. Uterine hypertonia. Persistent maternal tachycardia (over 140 beats/min) is a sign of impending pulmonary edema in patients receiving beta-mimetic drugs; fetal tachycardia is a common result of ritodrine therapy. Answer 1 is wrong because ritodrine commonly results in maternal hypotension. Answer 2 is wrong because the common fetal reaction to beta-mimetics is tachycardia. Answer 4 is wrong because ritodrine is given to reduce uterine hyperirritability and threatened premature labor. Look for clues. Mimetic looks like mimic—which option mimics beta effects? Choose the option That includes mother and fetus. Know effects of drug classes generally. When a parturient is given a paracervical block, the nurse can expect: Low forceps birth. Depression of contractions, maternal hypotension, fetal bradycardia, postnatal uterine atony. Depression of contractions and fetal bradycardia. Loss of bearing-down reflex, low forceps birth. Depression of contractions and fetal bradycardia are expected effects of paracervical block. Answer 1 is incorrect because the bearing-down reflex is not affected by this anesthesia and therefore low forceps birth is usually not needed. Answer 2 is incorrect because maternal blood pressure and postnatal uterine contractility are not affected by paracervical block. Answer 4 is incorrect because the bearing-down reflex is not affected, and therefore forceps birth is usually not needed. Recognize expected effects. Eliminate choices 1 and 4 that would increase risk to the infant (forceps). Review why fetal bradycardia occurs. When a parturient is given epidural (or caudal) anesthesia, the nurse could expect: Maternal hypotension, low forceps birth, needs to remain flat in bed for several hours after birth. Loss of bearing-down reflex, depression of contractions, maternal hypotension, fetal bradycardia, low forceps birth. Loss of bearing-down reflex, depression of contractions, maternal hypotension, fetal bradycardia, low forceps birth, postnatal bladder atony, postnatal uterine atony. Depression of contractions, maternal hypotension. The medication never mixes with cerebrospinal fluid, and therefore there is no need for the woman to lie flat for several hours after receiving this form of anesthesia (Answer 1). Answers 2 and 4 are incorrect because the lists are incomplete. Choose the most complete list in this question, where Answer 3 incorporates 2 and 4. When a parturient is given saddle block (low spinal) anesthesia, the nurse can expect: Loss of bearing-down reflex, maternal hypotension, low forceps birth, need to remain flat in bed for several hours after birth. Fetal bradycardia, low forceps birth, postnatal uterine atony, need to remain flat in bed for several hours after birth. Loss of bearing-down reflex, low forceps birth, postnatal bladder atony, postnatal uterine atony. Loss of bearing-down reflex, maternal hypotension, low forceps birth, need to remain flat in bed for several hours after birth, fetal bradycardia, postnatal uterine atony, postnatal bladder atony. All of the listed effects are to be expected following spinal anesthesia: loss of bearing-down reflex, depression of contractions, maternal hypotension, fetal bradycardia, low forceps birth, postnatal bladder atony, need to remain flat in bed for several hours after birth, and postnatal uterine atony. Answers 1,2, and 3 are incorrect because the lists are incomplete. Choose the option that includes all the others. A patient is receiving tetracycline preoperatively in preparation for bowel surgery. Which common side effect should the nurse instruct the patient to expect with tetracycline? Urticaria. Urinary retention. Jaundice. Deafness. Hypersensitivity reactions (urticaria and hives) are common drug reactions. Photosensitization (exaggerated sunburn) in certain hypersensitive persons may also occur with exposure to direct or artificial sunlight during tetracycline use. Urinary retention (Answer 2) is a side effect of anticholinergic and antihistamine drugs, Jaundice (Answer 3) from drug toxicity is more common with isoniazid (1NH), acetaminophen, phenothiazines (chlorpromazine [Thorazine]), sulfonamides, and antidiabetic drugs (e.g., tolbutamide [Orinase]). Hepatotoxicity may occur with tetracycline, but it is less common. Answer 4, deafness (ototoxicity), is a major side effect of the aminoglycoside antibiotics (e.g., gentamicin, neomycin, streptomycin, tobramycin) and diuretics, such as furosemide and ethacrynic acid. This is an expected common side effect. Only one would be clinically acceptable, although annoying (rash). The following activities have been planned for a patient who is mute and autistic. In which activity will it be important for the nursing staff to take precautionary measures for a common side effect of Thorazine (chlorpromazine), which has been prescribed for this patient? Shopping in an enclosed mall after lunch. Attending the symphony on Wednesday evening. A day at the beach, if the weather permits. A morning at the art museum. The patient needs to be protected against photosensitivity and dermatitis when exposed to the sun; a sunscreen preparation should be applied to exposed parts of the skin, and the patient should wear long sleeves and cover-up clothing. Answers 1, 2, and 4 refer to indoor activities, where there is no danger of sunburn. Which Answer is not like the others? Look at patterns: three indoor activities and one outdoor. Select the one that is different. Some patients who are on phenothiazines are also given benztropine mesylate (Cogentin). The nurse administers this medication in order to: Prevent skin reactions. Increase the effectiveness of the phenothiazines. Decrease motor restlessness. Reduce extrapyramidal side effects. This is the best choice because it encompasses Answer 3. Answers 1 and 2 are definitely incorrect. When two options are correct, choose the one that covers them both. A patient has been on IM fluphenazine (Prolixin) for 3 years. This patient has recently complained of frequent sore throats and malaise. What potentially serious side effect might these symptoms indicate to the nurse? Agranulocytosis. Akathisia. Dystonia. Dyskinesia. Blood dyscrasias often are overlooked when first symptoms of possible adverse drug effects appear in the form of a minor cold. Answers 2, 3, and 4 refer to extrapyramidal tract symptoms that are not life threatening. Which Answer is not like the others? One option is potentially life threatening (hematological system); three are not life threatening and relate to the musculoskeletal system. When nialamide (Niamid) or isocarboxazid (Marplan) is administered, what must the nurse know about the effects of these drugs? They lower the threshold for seizures. They potentiate the effects of many other drugs and common foods. They decrease muscular contractions. They commonly cause obstructive jaundice. Hypertensive crisis can be precipitated by combining this drug with common cold medications and foods high in tyramine or pressor amines (e.g., yogurt, Chianti wine, cheese, Coca-Cola, coffee). All other options are incorrect. Application of knowledge about side effects of these two drugs and the drug classification (monoamine oxidase inhibitor) will lead you to the only correct Answer. Lithium salts are frequently used to treat manic disorders. What side effect is the nurse least likely to observe? Slurred speech. Twitching and athetotic movements. Motor weakness. Tardive dyskinesia. This effect is seen in patients taking a major tranquilizer. All of the other options are likely side effects of lithium salts. Note the word "least" likely. Recall that Answer 4 is a symptom of a different drug category than lithium (Phenothiazine). A 9-month-old patient has been diagnosed with Hirschsprung’ s disease. At this time, the child is admitted to the hospital for a temporary colostomy; preoperatively, the doctor orders kanamycin. The nurse caring for this child should know that kanamycin is being given to: Increase peristalsis. Decrease amount of GI secretions. Promote passage of stool and flatus. Decrease number of intestinal flora. Kanamycin is an antibiotic that, although poorly absorbed in the GI tract, is often used as part of bowel prep before abdominal surgery. It acts as a bacteriocidal agent, thus significantly decreasing the number of intestinal flora and reducing risk of peritonitis in the postop period. Kanamycin does not increase peristalsis (Answer 1), promote passage of stool or flatus (Answer 3), or decrease amount of GI secretions (Answer 2). The age and diagnosis do not matter. Why would any patient need an antibiotic preoperatively? "Mycins" such as Kanamycin, erythromycin, streptomycin are antibiotics that decrease bacterial growth. A 22-month-old patient is admitted to the pediatric unit for observation following accidental ingestion of 17 children's acetaminophen (Tylenol) caplets. In the first 2-3 days following this child's admission, it is essential that the nurse plan to observe the child closely for signs of: Hepatic failure. Renal failure. Hyperthermia. Hemorrhage. The major toxic effect of an overdose of acetaminophen (Tylenol) is liver failure; liver function should be closely monitored during the first 2—3 days following the ingestion of acetaminophen. Renal failure (Answer 2) may occur as a late complication of acetaminophen toxicity, as may bleeding and hemorrhage (Answer 4). Hyperthermia (Answer 3) is not a major symptom of this type of ingestion; it is more common in salicylate ingestion. Know the functions of the liver, including detoxification of substances such as medications. In an acetaminophen (Tylenol) overdose situation, the nurse should have on hand the antidote to acetaminophen, which is: Acetylcysteine (Mucomyst). Potassium chloride. Aspirin. Heparin. Acetylcysteine (Mucomyst) is the antidote for acetaminophen poisoning: it serves to protect the liver, ft is usually given orally in a carbonated beverage (e.g., cola), but it can also be given via nasogastric tube. A loading dose is followed by q4h doses until a total of 18 doses have been given. KC1 (Answer 2), aspirin (Answer 3), and heparin (Answer 4) are not antidotes for acetaminophen and do not serve to protect the child's liver. Use a process of elimination. The potential adverse effects of three of the options would likely preclude use as an antidote. The doctor orders aminophylline, 100 mg via IV, for a child who is having an acute asthmatic attack. The nurse should know that the main reason the doctor ordered aminophylline is because it is a(n): Bronchodilator. Anticholinergic. Expectorant. Mucolytic agent. Aminophylline, a bronchodilator that acts as a smooth-muscle relaxant, is used to prevent and relieve symptoms of bronchial asthma. Anticholinergics (Answer 2) are used to treat muscle spasms along the GI tract. Aminophylline is neither an expectorant (Answer 3), which would assist in the removal of mucus from the respiratory tract, nor a mucolytic agent (Answer 4), which would help thin out viscid secretions. Know the drug classifications of frequently used medications. Remember that in asthma, bronchioles constrict; therefore, a bronchodilator is used. The nurse is to administer 100 mg of aminophylline IV. The ampule contains 500 mg (gr 71/2) of aminophylline in 10 mL of solution. How much solution should the nurse withdraw from the ampule? 2mL. 4mL. 6 mL. 8mL. The formula for finding the correct Answer is Dose desired/Dose on hand = x/Amount on hand.<br>100/500 = x/10<br>500x = 100(10)<br>x = 100(10)/500<br>x = 2 ml Know the formula and the Answer is easy; the dose on hand is 10 ml. While aminophylline is infusing, the nurse should plan to closely monitor the patient's: Level of consciousness. Blood pressure. Cardiac rhythm. Temperature. A transient side effect of IV aminophylline is an increase in heart rate; toxic effects include a prolonged increase in heart rate and abnormalities in cardiac rhythm. While receiving IV aminophylline, the patient should be on a cardiac monitor, and both rate and rhythm should be closely monitored and documented by the nurse. Aminophylline may also cause a transient change in the blood pressure (Answer 2), but this is not as much a concern as the patient's cardiac rhythm. Aminophylline should not affect level of consciousness (Answer 1) or temperature (Answer 4); thus there is no particular need for the nurse to monitor these specifically at this time. With two potentially correct Answers, select the more encompassing choice—change in heart function will ultimately affect BP. The words "closely monitor" in the stem usually rail for a priority Answer (cardiac is usually a priority). The nurse should know that, to prevent future asthmatic attacks, a patient will most likely receive: Theophylline. Cromolyn sodium. Prednisone. Diphenhydramine. Cromolyn sodium, an uncategorized drug used as an adjunct in the treatment of asthma, is used only after the acute attack is relieved; its primary intent is prophylaxis, i.e., to prevent future attacks. Cromolyn is used in an inhaler. It is absorbed into the systemic circulation after its inhalation into the lungs. It acts on the mast cells and also inhibits the release of histamine. Theophylline (Answer 1), prednisone (Answer 3), and diphenhydramine (Answer 4) do not prevent future asthmatic attacks and have no prophylactic value. Look for a pattern: three of the options are used for acute episodes; choose the one that meets the condition of the stem (future prevention). A 15-year-old patient is admitted to the hospital with a diagnosis of infectious hepatitis (type A). To protect other members of this patient's family who have been exposed to infectious hepatitis, the nurse should explain that they may be given: Amoxicillin/clavulanate potassium (Augmentin). Sulfisoxazole. Rifampin. Immune globulin. Immune serum globulin (ISG) offers the family members some protection against type A infectious hepatitis. It contains antibodies against the organism and will aid the family members in resisting this infectious disease. Amoxicillin/ clavulanate potassium (Augmentin) (Answer 1) and sulfisoxazole (Answer 2) are antibiotics used for a variety of infections, but they would not prevent hepatitis. Rifampin (Answer 3) is used prophylactically for Haemophilus influenzae meningitis and to treat TB but would not prevent hepatitis. Know when immune globulin may be effective (infectious hepatitis) and when it is not (H. influenzae meningitis). Remember that protection for hepatitis exposure is achieved through passive immunity (i.e., immune serum globulin). A 17-month-old child has retropharyngeal abscess and is to receive ampicillin four times a day. The child weighs 15 kg (33 lb). The nurses' reference indicates that the correct dosage is 75 mg/kg/day. Which dose should the nurse give to this patient at 10 A.M.? 11 mg. 28 mg. 280 mg. 1125 mg. The nurse should give 280 mg at 10 A.M. Using the formula of 75 mg/kg/day, 75 mg (15 kg = 1125 mg per day, to be divided into 4 doses. 1125 mg divided by 4 doses = 280 mg per dose. Use basic math. Do not forget to divide the daily dose of 1125 mg by the total number of doses per day to get the amount to be given for a single dose at 10:00 A.M. A 4-year-old patient is scheduled for repair of a left undescended testicle. To administer a pentobarbital sodium (Nembutal) suppository preoperatively to this patient, in which position should the nurse place him? Prone with legs abducted. Sitting on a potty seat. Supine with foot of bed elevated. Side-lying with upper leg flexed. The recommended position to administer rectal medications to children is side-lying with the upper leg flexed. This position allows the nurse to safely and effectively administer the medication while promoting comfort for the child. If the child were to lie prone (Answer 1), the nurse could not administer the medication as safely or effectively, even if the legs were abducted; further, this position would most likely cause the child some discomfort. If the child were sitting on a potty scat (Answer 2), the nurse could not reach the rectum to insert the suppository, and it is likely the suppository would be immediately expelled. If the child were to lie supine (Answer 3), the nurse could not administer the medication comfortably for the child. Do not use "real world" experience to Answer this question (i.e., how you may have seen a mother do it!) Visualize the positions; then choose one based on patient comfort and nursing effectiveness. A 4-year-old boy appears very anxious and frightened before receiving a rectal suppository as a preoperative medication. Which statement by the nurse would be most appropriate in helping the child take this medication? Be a big kid! Everyone's waiting for you. You look so scared. Want to know a secret? This won't hurt a bit! Lie still now and I'll let you have one of your presents before you even have your operation. Take a nice, big, deep breath and then let me hear you count to five. Preschool children commonly experience fears and fantasies regarding invasive procedures. The nurse should attempt to momentarily distract the child with a simple task that can be easily accomplished while the child remains in the side-lying position. The suppository can be slipped into place while the child is counting, and then the nurse can praise the child for cooperating, while holding the bullocks together to prevent expulsion of the suppository. The nurse should not pressure the child into acting like a "big kid" (Answer 1) in such a frightening situation (use of the word "kid" is also not appropriate). The nurse should not lie, breaking a trust by saying something "won't hurt a bit" (Answer 2). The nurse should never "bribe" a child with gifts to ensure cooperation (Answer 3). Maximize patient control over the situation and use age-appropriate distraction techniques. A 4-year-old patient is scheduled for surgery. In preparing this child's preop injections, which size needle should the nurse select to administer this child's IM injection? 25 G, 5/8inch. 22 G, 1 inch. 20 G, 1 ½ inch. 18 G, 1 ½ inch. In selecting the correct needle to administer an IM injection to a young child, the nurse should always look at the child and use judgment in evaluating muscle mass and amount of subcutaneous fat. A medium-gauge needle (22 G) that is 1 inch long would be most appropriate for a young child. A % inch needle (Answer 1) would be too small, and a 1 1/2 inch (18-20 G) needle would be too long and unnecessarily large (Answers 3,4). A 23 or 25 G needle would be too thin to use on most children (Answer 1) and would be better suited for use with a newborn or an infant. Visualize the "average" size of a 4-year-old. Medium size is safe. Meperidine hydrochloride (Demerol) would be preferred over morphine sulfate for a patient with a chest tube because Demerol: Causes less nausea and vomiting. Reduces anxiety and respiratory rate more effectively. Causes less smooth muscle spasms. Causes less respiratory depression. Both drugs have depressant effects; however, morphine sulfate affects rate and depth of respirations and cough reflex, which would be undesirable following chest tube insertion. Both drugs cause nausea and vomiting (Answer 1). Morphine sulfate is used to reduce anxiety and respiratory rate (Answer 2), particularly in pulmonary edema. Demerol does cause fewer smooth muscle spasms (Answer 3); however, that is not the concern in this situation, but it would be with GI surgery such as cholecystectomy. Choose "respiratory" over GI symptoms, anxiety, or muscle spasm. Know expected effects of opioid analgesics, and what the greatest concern is for this patient situation (respiratory effectiveness). A patient with diabetes has been giving herself NPH and regular insulin daily in two separate injections. The nurse would be accurate in telling the patient that: One injection, mixing the insulins, is safe, and injection sites will be used less. Her method is the best way to ensure accurate administration. It does not really make any difference if she uses one or two syringes. More mistakes are made when mixing insulins. Regular and intermediate-acting insulins are normally mixed to avoid the need to use injection sites twice as often. Rotation of sites is important, and the same site should not be used more often than every 2 to 4 weeks to avoid the development of lipodystrophies. Answer 2 may ensure accuracy; however, it is not standard practice or necessary. Although not unsafe, use of two syringes does increase the potential for lipodystrophy; therefore, it does make a difference (Answer 3). There is no evidence that more errors are made when insulin types are mixed (Answer 4). Know the "clear to cloudy" rule with V mixing insulins; therefore, one syringe is all you need. Before administering a blood transfusion, the tubing should be flushed with: 1. 5% dextrose in water. Dextran. 3. 5% dextrose, 0.5 normal saline. Lactated Ringer's. Blood and a solution containing glucose (dextrose) will result in precipitation when mixed outside the body. Saline is often the solution of choice. However, lactated Ringer's, an electrolyte-balanced solution without dextrose, is acceptable. Answers 1,2, and 3 contain glucose (dextrose). Look for patterns in the options. Three of the choices contain dextrose. Choose the one that does not. Which patient information, documented during an assessment, would be a contraindication to the patient receiving verapamil (Calan)? Epigastric pain and treatment for a peptic ulcer. Hypertension and angina on exertion. History of asthma and allergic bronchitis. Hypotension associated with bradycardia. Verapamil, a calcium channel blocker, is indicated for the management of hypertension and arrhythmia with rapid ventricular rates. Blood pressure and pulse should be taken before administration, and the medication would most likely be held or changed with persistent hypotension and bradycardia. Answers 1,2, and 3 would not be contraindications; the medication may be given to patients with these existing conditions. To narrow the choices, focus on two contradictory options: hypertension vs. hypotension. Know expected therapeutic and side effects of drug classifications. A patient is receiving heparin IV for acute thrombophlebitis The activated partial thromboplastin time (APTT) is > 110 sec. The best nursing action would be to: Stop the heparin infusion. Give protamine sulfate. Call the MD to report the APTT. Do nothing; this is the desired level. The APTT is greater than 3 times the normal level. Therapeutic levels are 1.5 to 2.3 times the normal (control) level. With a potential medical emergency, the nurse must notify the MD; care decisions are collaborative. Answers 1 and 2 are not independent nursing actions. Answer 4 is incorrect and could be life threatening for the patient. Focus on two contradictory options: "do nothing" vs. "call the MD." Know normal laboratory values and expected therapeutic levels and realize this is an "Oh! Oh!" situation. A transfusion reaction is suspected. The transfusion is stopped and the MD notified. The next appropriate nursing action would be to: Change all IV tubing to prevent additional infusion of blood cells. Keep the IV line open with saline until further orders. Arrange for the laboratory to pick up the remaining unit of blood. Collect a urine specimen from the patient. The priority is to keep the IV site open. Medications may need to be given to reverse the patient's untoward reaction to the transfusion. Answers 1,3, and 4 will eventually be done, but not before the patency of the IV is determined and maintained. Take care of the patient's safety first, then changing the equipment and laboratory tests. A patient with a history of arthritis and peptic ulcer disease is receiving misoprostol (Cytotec). Patient teaching about the drug would include: Take the medication three times a day before meals and at bedtime. Importance of using this drug when NSAIDs are also being taken by the patient. Purpose of drug is to reduce H. pylori bacteria in the stomach. Take a laxative to prevent side effect of constipation. Cytotec prevents gastric mucosal injury related to chronic NSAID therapy in high-risk patients (elderly, debilitated, or history of ulcers). The medication is taken with meals, not before (Answer 1). The drug has no effect on H. pylori(Answer 3). The drug decreases gastric acid secretion and increases production of protective mucus. A side effect of the drug is diarrhea, not constipation (Answer 4). Look for clues in the stem (a possible link between arthritis and ulcer disease). Magnesium hydroxide (Milk of Magnesia) is the routine laxative order to prevent or correct constipation. For which patient would the nurse question the order? An elderly woman with potential for fecal impaction. A patient with chronic renal failure who is admitted for shunt revision. A male patient who is recovering from total knee replacement. An older male patient who is being treated for pneumonia. Metabolism and excretion of the drug are done primarily by the kidneys. In chronic renal failure, the kidneys would be unable to regulate electrolyte balance and the patient would be at higher risk for the development of an electrolyte imbalance. Another classification of laxative should be used in the renal patient. This laxative is not contraindicated for others (Answers 1,3, and 4). Use the process of elimination. Would an electrolyte-based laxative (magnesium) adversely affect one of these patients more? A patient is admitted to the emergency department (FD) in acute distress from asthma. Theophylline and 5% dextrose are being infused IV. The patient is experiencing hypotension and an irregular pulse. The first nursing action would be to: Stop the medication and call the ED physician. Check the BP and pulse frequently while the drug infuses. Increase IV rate to reverse possible hypovolemia. Slow infusion rate and notify the ED physician. Hypotension and arrhythmias are expected side effects of too-rapid administration of theophylline or aminophylline. An infusion pump should be used for administration to ensure an accurate and safe dosage. Answer 1 is not appropriate because the drug is needed to improve breathing. Answer 2 is incorrect because it does not respond to the side effects. Answer 3 would increase the adverse drug effects. Before contacting the MD, look for a nursing action that ensures patient safety. The choice is between "stop" or "slow" before calling the MD. Choose "slow," because "stop" may stop the benefit of this drug (to improve breathing).