1. Prepare to administer protamine sulfate
2. Continue with the current prescription
3. Prepare to administer Vitamin K
4. Call the healthcare provider to increase the dose
An INR within the range of 2 to 3 is considered the level for warfarin therapy. For a level of 1.2, the nurse would contact the healthcare provider to discuss an order for an increase dose. International Normalized Ratio is a standard reference range used to establish consistency in reporting PT levels that accounts for normal variations seen in lab testing. INR leads to a better consensus of therapeutic management and ensures that evaluation of test results are based on common standards.
1. Respiratory rate and level of consciousness
2. Blood pressure and heart rate
3. Interactions with foods and other prescribed drugs
4 Oxygen saturation and bowel sounds
The primary purpose of administering opioid analgesics is pain relief. SE placing the client at greatest risk are respiratory depression and reduced LOC (option 1). Blood pressure and heart rate could decrease because of diminished sympathetic nervous system stimulation, but not priority over resp. rate and LOC. Concerns about drug interactions are pre-administration concerns (option 3) History of drug abuse and past experiences with pain management are also pre-admin issues (option 4)
1.Vegetable beef soup, macaroni and cheese, and a dinner roll
2. Beef ravioli, spinach souffle, and Italian bread
3. Baked white fish, mashed potatoes, and carrot-raisin salad
4.Roasted chicken breast, brown rice and stewed tomatoes
Furosemide is frequently ordered with digoxin in the treatment of heart failure and furosemide depletes potassium stores because it is a potassium-wasting diuretic. Hypokalemia makes the client more susceptible to digitalis toxicity. Baked fish, potatoes, and carrots/raisins are the best choices because all three foods are high in potassium and low in sodium (option 3). Options 1,2, and 4 have higher sodium and fat intake which are not appropriate for heart failure.
1.Avoid individuals with colds or other infections.
2.Maintain nutritional status with supplements.
3.Plan for periods of rest to prevent fatigue.
4.Use a soft-bristled toothbrush and an electric razor.
1.This is good information to teach, but it is not based on the laboratory values. The client’s WBC and absolute neutrophil counts are within normal range.
2.This is good information to teach, but it is not based on laboratory values. The client may develop mouth ulcers as a result of chemotherapy administration, and the nurse should discuss methods of maintaining nutrition for this reason but not because of the laboratory values.
3.This is good information to teach, but it is not based on the laboratory values. Fatigue related to cancer and its treatment is real and should be addressed, and an Hgb and Hct of around 8 and 24 could cause fatigue, but the client’s levels do not indicate this.
1. When administering medication via a MDI, avoid shaking the canister before discharging the medication.
2. Medication is ordered in two “puffs”; press on the canister twice in succession to discharge the medication.
3. There should be a tight seal around the mouthpiece of the inhaler before discharging the medication.
4. There should be a 2- to 3-inch space (or spacer device) between the inhaler and the open mouth of the child.
Rationale: Children often have difficulty learning to depress and inhale their medications at the same time, and holding the MDI 2 to 3 inches away from the mouth or utilizing a “spacer” (an attachable device that provides space and contains the medication in a confined area) improves the effects of the medication. Shaking the MDI canister well before use supplies a better delievery of the aerosolized medication. When using two “puffs” of medication, waiting one minute between puffs allows for better absorption of the inhaled medication.
When using inhaled medications via an MDI the client should be instructed that wrapping the lips tightly around the mouthpiece consolidates the medication in the buccal cavity and decreases the effectiveness of inhaled medications. (Ohman, 2010)
1. Include leafy green vegetables in daily diet.
2. Include whole-grain bread in daily diet.
3. Include raisins in diet three times per week
4. Use adequate sources of vitamin C in diet
Vitamin C helps to enhance the absorption of iron supplements as well as dietary iron (option 4). Leafy green vegetables, whole-grain breads, and raisins are high in iron, but would not enhance the absorption of the medication.
1. Tachycardia and hypertension
2. Urinary retention, hesitancy, and constipation
3. Pain resembling pattern associated with cholecystitis
4. Pain resembling renal colic
Anticholinergic drugs stimulate the parasympathetic system and tachycardia and hypertension indicate sympathetic system stimulation. Cholinergic agonists, not anticholinergics, cause biliary tract contractions (option 3). Renal colic is also more commonly associated with agonists rather than anticholinergics (option 4)
1.The ventricular rate is increasing
2.The absent pulse is now palpable
3.The number of premature ventricular contractions is decreasing
4.The fine ventricular fibrillation changes to coarse ventricular fibrillation
Amiodarone is used for the treatment of premature ventricular contractions, ventricular tachycardia with a pulse, atrial fibrillation, and atrial flutter. Amiodarone is not used as initial therapy for a pulseless dysrhythmia
1.Cyanocobalamin (vitamin B12) to a client with pernicious anemia.
2.Erythropoietin (Epogen) to a client with chronic lymphocytic leukemia.
3.Filgrastim (Neupogen) to a client with a solid tissue tumor.
4.Heparin intravenously to a client with disseminated intravascular coagulation
1.Cyanocobalamin is the treatment for pernicious anemia. The nurse would not question administering this medication.
3.Stimulation of the bone marrow is not questioned in clients with solid tissue tumors. The nurse would not question administering this medication.
4.Heparin is part of the standard treatment for disseminated intravascular coagulation (DIC).
1. “I will use this medication every six hours.”
2. “If my symptoms are not better within 20 minutes I should notify my healthcare provider.”
3. “Although it will remain regular, this med may decrease my heart rate.”
4. “This drug is supposed to prevent an asthma attack, but it isn’t good for treating one.”
5. “I will take a dose of this med when I notice I am wheezing.”
Rationale: (2) This drug should begin to take effect within 20 minutes, (4) use of Salmeterol is prophylactic, (1) it is dosed every 12 hours because of the 12 hour duration, (3) although it is a beta-2 stimulant it may occasionally cause tachycardia, (5) it is not used for treatment of an acute attack. (Hogan, 2007)
1. Uticaria, itching, and flushing
2. Blood pressure = 90/50
3. Decreasing level of consciousness
4. Potassium level = 5.5 mEq/L
Unlike streptokinase, alteplase (tPA) does not cause an allergic reaction or hypotension. The greatest risk with this drug is bleeding, with intracranial bleeding the greatest concern. A decreasing level of consciousness indicates intracranial bleeding. Thrombolytic agents such as alteplase do not typically cause elevated potassium level.
1.Drowsiness
2. Tics and tremors
3. Increased pain
4. Nausea and vomiting
Naloxone (Narcan) is a medication that reverses the effects of narcotics. Although the patient's respiratory status will improve after administration of Narcan, pain will be more acute. The drug is a "pure" agonist. It blocks opioid receptor.
1.Obtaining an infusion pump for the medication.
2.Monitoring blood pressure every 4 hours.
3.Monitoring urine output hourly.
4.Obtaining serum potassium level daily
I.V. nitroglycerin infusion requires an infusion pump for precise control of the medication. Blood pressure monitoring would be done with a continuous system, and more frequently than every 4 hours. Hourly urine outputs are not always required. Obtaining serum potassium levels is not associated with nitroglycerin infusion
1.Discuss the prescription with the HCP because antibiotics do not help viral infections.
2.Teach the client to take all the antibiotics as ordered.
3.Encourage the client to seek a second opinion before taking the medication.
4.Ask the client if he or she is allergic to sulfa drugs or shellfish.
1.Antibiotics do not treat viral infections, but HCPs will frequently provide prophylactic antibiotics for clients with comorbid conditions (such as COPD) to prevent a secondary bacterial infection.
3.There is no reason for a second opinion; this is standard medical practice.
4.This is a penicillin preparation, not a sulfa medication or iodine.
1. AIDS
2. Asthma
3. COPD
4. Systemic Lupus Erythematosus
Rationale: (1) Steroids suppress the immune system and administration of these drugs is contraindicated in AIDS. (2)It is commonly used to treat asthma, (3) It may be used in COPD,(4)It is sometimes used in SLE
1.Eat lettuce and tomatoes for lunch only a few times per week.
2.Limit dietary intake of yellow wax beans to twice a week.
3.Use aspirin for minor aches and pains
4.Wear shoes that completely enclose the feet
Because of the high risk of bleeding, the client should protect the feet from injury (option 4). Lettuce and tomatoes and wax beans do not contain enough vitamin K to interact negatively with Coumadin and so they do not need to be limited (option 1). Aspirin increases the risk of bleeding and therefore should not be used while taking an anticoagulant such as warfarin.
1.Sodium phosphate
2.Calcium gluconate
3.Diltiazem (Cardizem)
4.Sodium bicarbonate
The client with tetany is suffering from hypocalcemia, which is treated by administering an I.V. preparation of calcium, such as calcium gluconate or calcium chloride. Oral calcium is then necessary until normal parathyroid function returns. Sodium phosphate is a laxative. Diltiazem is a rhythm stabilizer not effective for tetany. Sodium bicarbonate is a potent systemic antacid.
1.Hyperkalemia
2.Digoxin toxicity
3.Fluid deficit
4.Pulmonary edema
Early symptoms of digoxin toxicity include anorexia, nausea, and vomiting. Visual disturbances can also occur, including double or blurred vision and visual halos. Hypokalemia is a common cause of digoxin toxicity because low serum potassium can enhance ectopic pacemaker activity. Although vomiting can lead to fluid deficit, given the client’s history, the vomiting is likely due to the adverse effect of digoxin toxicity. Pulmonary edema is manifested by dyspnea and coughing.
1.Ceftriaxone (Rocephin), a third generation cephalosporin, to a client who is pregnant.
2.Cephalexin (Keflex), a cephalosporin, to a client who is allergic to penicillin.
3.Trimethoprim sulfa (Bactrim), a sulfa antibiotic, to a client post-prostate surgery.
4.Nitrofurantoin (Macrodantin), a sulfa antibiotic, to a client with urinary stasis.
A cross-sensitivity exists in some clients between penicillin and the cephalosporins. The nurse should assess the type of reaction the client experienced when taking penicillin. If the client indicates any symptom of an anaphylactic reaction, the nurse would hold the medication and discuss the situation with the HCP.
1.Rocephin is in the pregnancy risk category B. No research has shown harm to the fetus in humans or animals. The nurse would not question this medication.
3.There is no reason for the nurse to question Bactrim for a client who has had prostate surgery.
4.There is no reason for the nurse to question Macrodantin for a client who has urinary stasis. Macrodantin is used to prevent or treat chronic urinary tract infections.
1. risperidone (Risperdal®)
2. clozapine (Clozaril ®)
3. haloperidol (Haldol ®)
4. ziprasidone (Geodon ®)
Haloperidol is the only medication listed with a high probability of EPS. Risperidone, clozapine, and ziprasidone are members of newer generation anti-psychotics with less potential for EPS.
1. Call the healthcare provider and discuss the reduction or withdrawal of heparin
2. Call the healthcare provider and to discuss the increasing heparin dose to achieve a therapeutic level.
Obtain vitamin K and prepare to administer it by IM injection
Observe the patient and monitor the aPTT as indicated.
1.Put air into the glargine insulin vial, and then air into the aspart insulin vial, and draw up the correct dose of aspart insulin first.
2.Roll the glargine insulin vial, then roll the aspart insulin vial. Draw up the longer-acting glargine insulin first.
3.Shake both vials of insulin before drawing up each dose in separate insulin syringes.
4.Put air into the glargine insulin vial, and draw up the correst dose in an insulin syringe; then, with a different insulin syringe, put air into the aspart vial and draw up the correct dose.
Glargine (Lantus) is a long-acting recombinant human insulin analog. Glargine should not be mixed with any other insulin product. Insulin should not be shaken; instead, if the insulin is cloudy, roll the vial or insulin pen between the palms of the hands.
1.Reduces myocardial oxygen consumption.
2.Promotes reduction in the respiratory rate.
3.Prevents ventricular remodeling.
4.Reduces blood pressure and heart rate.
5.Reduces anxiety and fear.
Morphine sulfate acts as an analgesic and sedative. It also reduces myocardial oxygen consumption, blood pressure, and heart rate. Morphine also reduces anxiety and fear due to its sedative effects and by slowing the heart rate. It can depress respirations, however, such an f may lead to hypoxia, which should be avoided in the treatment of chest pain. Angiotensin-converting enzymes- inhibitor drugs, not morphine, may help to prevent ventricular remodeling.
1.Administer the medication intramuscularly in the gluteus muscle.
2.Have the client drink a full glass of water with the pill.
3.Use a tuberculin syringe to draw up the medication.
4.Make sure the client has eaten before administering the drug.
2.There is no pill form of Rocephin, so drinking water will not affect the medication.
3.Rocephin is administered IM or IV. A tuberculin syringe is used to administer medications by the subcutaneous or intradermal route.
4.There is no pill form of the medication, so eating will not affect the medication.
1.” I know I need to restrict foods high in sugar while I’m taking lithium.”
2. “I need to come back and have my blood lithium level checked every 2 weeks.”
3. "I should take my lithium on an empty stomach for the best absorption.”
4. “I need to eat enough foods containing sodium and drink at least 2 to 3 liters of fluid daily.”
A client must consume adequate dietary sodium as well as 2,500 to 3,000 mL of fluid per day to prevent dehydration leading to lithum toxicity. Sugary foods should only be avoided if weight gain becomes a problem. Lithium levels should be checked every 1 to 2 months, not every 2 weeks. Lithium often causes stomach upset and can be taken with food for better tolerance. (Ohman, 2010)