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Feuer NCLEX RN/LPN

PHARMACOLOGY REVIEW

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Presented by :

Professor Elizabeth A Berro MA RN PNP CHSE

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GOAL

REVIEW AND APPLY KNOWLEDGE REGARDING DRUG THERAPY



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Review Topics

1. Nurses Role in Medication Administration

2. Basic Pharmacology

3. Common Drugs

4. IV Therapy

5. Calculations

Nurses Role in Medication Administration

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The Nurse’s Role in Medication Administration

✦ How does the drug work? - mechanism of action

✦ Therapeutic Response?- Purpose

✦ What effect and when?- Efficacy

✦ Adverse Effects?- Harmful drug responses

✦ Common Side Effects?- Expected responses

✦ Toxic Side Effects?- Emergency responses

✦ Allergic Responses?- Recognition and Response

✦ Idiosyncratic Reactions?- Recognition and Response

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Stevens Johnson Syndrome

NSAIDS, Allopurinol, Phenytoin, Carbamazepine,

barbiturates, anticonvulsants, and sulfa antibiotics



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THE 7 RIGHTS

✦ Right client - Two methods of ID

✦ Right drug - (3 times- retrieve, take med, return)16% of errors

✦ Right dose - 41% of errors

✦ Right documentation

✦ Right route -16% of errors

✦ Right time

✦ Right to refuse treatment - (client’s Bill of Rights)

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THE JOINT COMMISSION'S “DO NOT USE” LIST: BRIEF REVIEW



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REVIEW QUESTION

A client presents to an urgent care center.

Vital signs include respiratory rate 15.

heart rate 68, blood pressure -126/74.

The client is complaining of hives and pruritus after taking an antibiotic.

The spouse states that the client does not have any allergies.

Which action should be taken first by the nurse?

Obtain equipment needed for allergy testing.

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REVIEW QUESTION

A client complains of dry mouth after starting a new medication that has

anticholinergic side effects. Which action by the nurse is most appropriate?

1. Instruct the client to stop the medication and notify their primary care provider.

2. Assess the client’s serum drug level.

3. Assess the client’s skin turgor.

4. Instruct the client to suck on hard candy.



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REVIEW QUESTION

A nurse is caring for an adult client with Congestive Heart Failure.

Which of the following findings would indicate a therapeutic response from a

dosage of intravenous furosemide?

1. Change from atrial fibrillation to NSR, 6 hours after administration.

2. Serum potassium decreased to 3.2 mEq/L 4 hours after administration.

3. Urine specific gravity 1.040, 2 hours after administration.

4. Respiratory rate decreased to 18, 30 minutes after administration.

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REVIEW QUESTION

A nurse is caring for a client on a medication regimen including Rifampin. The

client reports a reddish discoloration of his urine.

The nurse’s best response is which of the following?

1. Increase your fluid intake to at least 32 ounces of water per day.

2. Obtain a urine analysis, culture and sensitivity.

3. Inform the client that other body fluids may also become discolored.

4. Discontinue the medication and assess the urine for clots or mucous plugs



Basic Pharmacology

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Basic Pharmacology

What’s the Goal of Drug Therapy?

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Brief Review of Pharmacokinetics “How Drugs Move”

✦ Absorption - administration site to blood stream

✦ Distribution - moves to site of action

✦ Metabolism - detoxification of medication

✦ Excretion - elimination from the body

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Pharmacokinetics

✦ Critical Concentration -The amount of a drug that is needed to cause a

therapeutic effect

✦ Loading Dose - A higher dose than that usually used for treatment

✦ Dynamic Equilibrium - The actual concentration that a drug reaches in

the body

✦ Peak/ Trough - Peak Highest blood level. If too high?

✦ Trough - Lowest blood level. If too low?



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Distribution

✦ Moving drug from the bloodstream to the tissues

✦ Depends on blood flow, protein binding, solubility

T/F: A malnourished client receiving a highly protein bound drug has an increased risk of toxicity.

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Protein Bound Drugs

Coumadin, Dilantin, propanolol, rifampin, amitriptyline

✦ Loading Dose

✦ Drug Interactions



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Metabolism: Short half-life vs. Long half –life

✦ Half-life is the time it takes for the amount of drug in the body to

decrease to one-half.

✦ Short half-life -

✦ Medications leave the body quickly.

✦ Short dosing interval

✦ Long half –life

✦ Medications leave the body more slowly- 24+ hr.

✦ Greater risk for medication accumulation and toxicity

✦ Longer dosing intervals, meds take longer to reach steady state

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Narrow Therapeutic Index

✦ Toxic effects

✦ Serum levels

✦ Examples:



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Review Question

A client is started on a Fluoroquinolone which is known to displace warfarin (Coumadin) from its protein binding site. The nurse anticipates which of the following?

1. The client will need an increase in the Coumadin.

2.The client will need a decrease in the Coumadin.

3.The client will continue on the prescribed amount of Coumadin.

4.The client will have to have the Coumadin discontinued until the antibiotic is completed.

Methods of Medication Administration

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Oral

✦ Liquids: Solutions, Elixirs, Suspensions, Syrups

✦ Measure at eye level

✦ HOB elevated

✦ Tablets, capsules, caplets

✦ Do not crush: long acting (LA), Extended release (XR), Slow release

(SR), enteric or sublingual

✦ Give with 4 Ounces (120mL)

✦ Sublingual, buccal, lozenge/ troche

✦ Avoid first–pass metabolism

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Rectal Administration

✦ Suppository - solid glycerin form (refrigerate)

✦ Enema - Solution

✦ Insert past anal sphincter 2 inches

✦ Deep breaths to decrease sphincter tone

✦ Maintain medication for 30 minutes

✦ Left lateral (Sims)



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Cutaneous Via Skin/Modified Skin Surface

✦ Skin: Ointments, creams, powders : use gloves, thin layer, apply to

area with minimal hair, rotate sites, write date & time of

administration

✦ Inhalation: MDI difficult timing, may use spacer, teach technique

✦ Ear (otic): solutions at body temp, side lying & ear up adults pinna up

& back

✦ Eye: (optic) in conjunctiva sac , pressure on Nasolacrimal duct to

prevent systemic absorption

✦ Vaginal: Douches warmed, suppositories up 3-4”

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Parenteral Administration

✦ “By some other means than through the GI tract”



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Intradermal/Transdermal

✦ Administered just into the dermis 26 -27 G, ½ to 5/8” long, tuberculin

syringe 1mL

✦ T/F: Use 0.2ml or less volume

✦ Clean site with ETOH

✦ Non hairy site (forearm, scapula)

✦ Needle bevel up, 10-15 degree angle

✦ Don’t rub site

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Subcutaneous

✦ Slow absorption

✦ Rotate sites

✦ Common sites

✦ 23-25G, ½ to 5/8th” needle

✦ Limit volume 1ml

✦ Pinch skin insert at 45-90 degree angle

✦ No aspiration required

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Intramuscular

✦ IM Sites

✦ Deltoid

✦ Dorsogluteal

✦ Ventrogluteal

✦ Vastus lateralis

✦ Rectus femoris

✦ Note needle length, 1.5” adult, 1” child or frail adult, 2” obese adult

✦ 19 - 22 gauge needle depending on ________

✦ T/F: Limit to 3ml

✦ Max: Depends on muscle mass

✦ Dart like motion, 90 degree angle, note blood return



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Identify this injection site



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Identify this injection site

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The vastus lateralis is the muscle for IM injection in children under 2 years of age



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Acromion Process

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Z Track IM

✦ Prevent backflow of med into subcutaneous tissue

✦ Give irritating / staining meds deep IM

✦ Iron/Vistaril / Vitamin B12 preparations

✦ Replace needle

✦ T/F: Ventrogluteal preferred site

✦ Displace skin laterally & inject

✦ Wait 10 seconds for drug dispersal

✦ Withdraw and then release tissue to trap medicationSee correct answer and rationale on the last page of this book.



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Intravenous

✦ Most rapid effect

✦ IV PUSH

✦ 1mL/min (unless specified)

✦ LPN’s NOT ALLOWED

✦ Flush catheter before and after infusion

✦ Always check compatibility

✦ Continuous IV - infuse at constant rate

✦ Maintains a therapeutic drug level

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REVIEW QUESTION

Which of the following is true regarding parenteral drugs?

1. They bypass the first-pass effect.

2. They decrease blood flow to the stomach.

3. They are altered by the presence of food in the stomach.

4. They exert their effects while circulating in the bloodstream.



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REVIEW QUESTION

When administering medication by IV bolus (push), occlude the IV line by

performing which of the following techniques?

1. folding the tubing just above the injection port.

2. clamping the tubing just above the insertion site.

3. pinching the tubing just above the injection port.

4. pinching the tubing at least 2 inches above the injection port.

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REVIEW QUESTION

In which of the following situations would you administer an intramuscular

medication with the Z-track method?

1. When the medication is known to be irritating to tissues

2. When the client is emaciated and has very little muscle mass

3. When the medication must be absorbed quickly into the tissues

4. When the client is obese and has a deep fat layer below the muscle mass



Special Considerations

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Pediatric Considerations

✦ Dosages based on size (BSA), wt. & age

✦ Pharmacokinetics - immature kidney/liver

✦ Smaller muscle size - less volume

✦ Thinner skin - rapid absorption

✦ Lower serum protein levels

✦ Avoid mixing meds with required foods

✦ Formula, milk

✦ Document successful methods

✦ Idiosyncratic events are more common



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Geriatric Considerations

✦ Polypharmacy

✦ Simplify Schedule

✦ Assess interactions

✦ Pharmacokinetics

✦ Absorption- reduced

✦ Distribution- low albumin

✦ Metabolism- decreased

✦ Excretion- decreased

Increased risk for toxicity

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Obstetric Considerations

✦ Placenta transfer unless documented otherwise

✦ Drugs are most teratogenic in 1st trimester

✦ FDA categories: Potential Harm A-D and X

✦ A - controlled studies SAFE

✦ B - animal studies say ok

✦ C - adverse effects reported in animal fetus

✦ D - positive evidence benefit may outweigh risk

✦ X - contraindicated RISK OUTWEIGH BENEFIT



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FDA Categories- Examples

✦ A- Synthroid, folic acid

✦ B- Tylenol, hydrochlorothiazide (HCTZ), metoclopramide (Reglan),

famotidine (Pepcid), loperamide (Imodium), and insulin

✦ C- Cipro, chloramphenicol

✦ D- Aminoglycoside, tetracycline, Tegretol, Ace Inhibitors, Lithium

✦ X- Coumadin, Accutane, chemotherapy

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REVIEW QUESTION

A 22 year old client is in the 26th week of pregnancy and has developed

gestational diabetes. She is given insulin. The FDA pregnancy safety category for

this medication would be which of the following?

1. category A.

2. category B.

3. category C.

4. category X.



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REVIEW QUESTION

A nurse would consider which factor most strongly to assure safe medication

administration for a pediatric client?

A. Weight

B. Age

C. Height

D. BUN level

Major Drug Classification

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Medications Affecting the Autonomic Nervous System

Sympathetic and Parasympathetic

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Adrenergic Agents Effect Parasympathetic or Sympathetic Track

Cholinergic Adrenergic



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Adrenergic Agents

✦ Sympathomimetics /Agonist

✦ Alpha

✦ Vasoconstriction

✦ Example: phenylephrine

✦ Beta 1

✦ Increased heart rate and contractility

✦ Example: dobutamine

✦ Beta 2

✦ Bronchodilation, hyperglycemia

✦ Example: albuterol

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Adrenergic Agents

✦ Sympatholytic /Blockers

✦ Alpha blockers

✦ Vasodilation

✦ Example: phentolamine (Regitine)

✦ Beta 1 blockers

✦ Decreased heart rate and contractility

✦ Example: Esmolol (Brevibloc)

✦ Beta 1 and 2 blocker

✦ Used as antihypertensive (and to tx glaucoma)

✦ Example: nadolol (Corgard)



Cholinergic Agents

✦ Direct acting

✦ Bethanechol (urecholine)

✦ Cholinesterase Inhibitors

✦ Neostigmine, Aricept, Tensilon

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Anticholinergic Agents

✦ Atropine

✦ Benztropine (Cogentin)

✦ Glycopyrrolate (Robinul)

✦ Oxybutinin (Ditropan)

✦ Trihexyphenidyl (Artane)

✦ ANTI- SLUD, plus

✦ Dilated pupils

✦ Increased HR

✦ Bronchodilation

✦ Male sexual dysfunction

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REVIEW QUESTION

A nurse is about to administer a STAT dose of atropine sulfate to a client who is

experiencing a symptomatic cardiac dysrhythmia. During administration of this

drug, the heart rhythm should be closely monitored for which adverse effect?

1. Tachycardia

2. Bradycardia

3. Ectopic beats

4. Cardiac standstill

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REVIEW QUESTION

A client experiencing shortness of breath associated with asthma is given

epinephrine (Adrenalin). This medication is considered a nonselective adrenergic

drug because it innervates which of the following?

1. alpha adrenergic receptor sites.

2. beta adrenergic receptor sites.

3. alpha, beta1, and beta2 adrenergic receptor sites.

4. beta1 and beta2 adrenergic receptor sites.



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REVIEW QUESTION

A client experiences bradycardia due to vagal stimulation. The nurse would expect

to administer which of the following?

1. bethanechol HCl (Urecholine).

2. benztropine (Cogentin).

3. metoclopramide (Reglan).

4. atropine sulfate (Atropine).

Medications Affecting the Neurological System

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Anticonvulsants

✦ Dilantin / Phenytoin (treats any type of seizure except absence)

✦ Adverse Effects

✦ Gingival hyperplasia (dental visits)

✦ Toxic: Ataxia, sleepiness

✦ Fetal harm

✦ Interactions

✦ Alcohol decreases effect

✦ Coumadin increases effect

✦ Oral Contraceptive Pills (OCP) may not be as effective

✦ Therapeutic level 10-20 micrograms /mL

✦ IV: Never mix with other meds (NS only, give slowly 50mg /min!)

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Other Anti-seizure Medications

✦ Phenobarbital

✦ A/E: sedation or agitation

✦ Less fetal harm than Dilantin

✦ Therapeutic range: 10-40

✦ Carbamazepine / Tegretol

✦ A/E: CNS depression, decrease effectiveness of OCP and leukopenia

✦ Ethosuximide / Zarontin

✦ A/E: CNS depression and pancytopenia

✦ Increases Dilantin levels



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Other Anti-seizure Medications

✦ Valproic acid/ Depakene

✦ Comes in many forms

✦ A/E: hepatic dysfunction, GI irritant, weight gain

✦ Benzodiazepines

✦ Valium, Ativan

✦ Used for status epilepticus

✦ A/E: respiratory depression if IV administration

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Opioid Analgesics

✦ Combines with opiate receptors to alter pain perception

✦ High effectiveness

✦ Morphine Sulfate

✦ Meperidine (Demerol) - limit use to 48 hrs.-seizures

✦ Hydromorphone (Dilaudid)

✦ Fentanyl (Duragesic)

✦ Moderate effectiveness

✦ Codeine

✦ Oxycodone (Oxycontin)

✦ Oxycodone/Acetaminophen (Percocet)

✦ Propoxyphene (Darvan)

✦ Re-evaluate pain with pain scale



Controlled Substances Schedules

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✦ Risk of Abuse

✦ Sedation, confusion, euphoria

✦ Orthostatic hypotension

✦ Risk for falls

✦ N/V

✦ Minimize movement

✦ Constipation

✦ Fluid and fiber

✦ Itching

✦ Antihistamine

✦ Urinary retention

✦ Straight catheter

✦ Respiratory depression

✦ Hold medication for

RR<12/minute

✦ Biliary colic with morphine sulfate

✦ Tolerance: needs more for same

effect with time

✦ Withdrawal: abstinence symptoms

with abrupt discontinuation

Opioid Analgesics Adverse Effects

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Opioids Agonist-Antagonist Effects

✦ Buprenorphine (Buprenex)

✦ Butorphanol (Stadol)

✦ Nalbuphine (Nubain)

✦ Pentazocine (Talwin)

✦ Used for moderate pain

✦ Less potential for abuse and

respiratory depression

✦ These drugs can precipitate

withdrawal in a client who is

physically dependent on a pure

opioid agonist

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Opioid Antagonist: Narcan

✦ IV, IM, SQ, nasal

✦ State of overdose (Heroin, Morphine…) to state of withdrawal

✦ May require additional doses Q 1-2 hours

✦ Others

✦ Nalmefene (Revex): long acting

✦ Naltrexone (ReVia): alcohol abuse, dependence treatment (not emergency)



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Non-Opioid - Acetaminophen

✦ Acetaminophen

✦ A non-opioid drug that has both analgesic and antipyretic effects

✦ Little to no anti-inflammatory effects

✦ If client is taking warfarin instruct to observe for s/s of bleeding- (Coumadin)

metabolism is slowed by acetaminophen= risk of bleeding)

✦ In the event of a Tylenol overdose, administer weight-based dosage of the

antidote= ACETYLCYSTEINE (Mucomyst)

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Non-Opioid - NSAIDS

✦ Antipyretic, anti-inflammatory, analgesia

✦ Salicylates: Also have antiplatelet activity

✦ Inhibits platelet aggregation

✦ Useful both prophylactically and following an MI

✦ “Ulcerogenic”

✦ A/E: Dyspepsia, heartburn, epigastric distress, nausea

✦ Aspirin Induced gastric ulcer

✦ Perforation

✦ GI bleeding*

✦ Mucosal lesions* (erosions or ulcerations)

✦ Reyes Syndrome in children who have had a viral illness (chicken pox or influenza)

✦ Tinnitus and hearing loss (most common sign of acute toxicity)- Salicylism



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NSAIDS

✦ indomethacin (Indocin)

✦ sulindac (Clinoril)

✦ tolmetin (Tolectin)

✦ Ketorolac (Toradol)

✦ Nabumetone (Relafen)

✦ aspirin (ASA)

✦ ibuprofen (Motrin, Advil, others)

✦ ketoprofen (Orudis)

✦ naproxen (Naprosyn)

✦ oxaprozin (Daypro)

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Migraine Agents-Ergot Derivatives & Triptans

✦ Actions

✦ Prevent the dilation and inflammation of the intracranial blood vessels, thereby

relieving migraine headaches

✦ Triptans: Sumatriptan (Imitrex)

✦ A/E: tingling, chest pain, muscle pain, dysrhythmias

✦ N/I: no trigger foods, no tyramine, dark room, decrease stress



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Muscle Relaxants (Central and Direct)

✦ Indications

✦ Primarily for relief of painful musculoskeletal conditions or spasms

✦ A/E: CNS

✦ Medications: baclofen (Lioresal), Cyclobenzaprine (Flexeril), Carisoprodol (Soma),

Metaxalone (Skelaxin), Tizanidine (Zanaflex)

✦ Direct acting- Dantolene also for Malignant Hyperthermia

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Antiparkinson Agents-Dopaminergics/Anticholinergics✦ Dopaminergics increase dopamine production

✦ Levodopa (Larodopa)

✦ Levodopa- Carbidopa (Sinemet)

✦ Dopamine Agonists – activate dopamine receptors

✦ pramipexole (Mirapex)

✦ ropinirole (Requip)

✦ Amantadine: increases release of dopamine

✦ COMT Inhibitors- Inhibit the destruction of dopamine

✦ Tolcapone ( Tasmar)

✦ Entacapone (Comtan)

✦ Selegiline (Eldepryl) : MAO inhibitor

✦ Anticholinergics – decreases acetylcholine

✦ Benztropine (Cogentin)

✦ Trihexyphenidyl (Artane)



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Levodopa-Carbidopa (Sinemet)

✦ May take up to 6 months to achieve maximal effects

✦ A/E: dyskinesia (uncontrolled purposeless movements), orthostatic hypotension,

dark sweat and urine

✦ Contraindicated in clients with narrow angle glaucoma and histories of

melanoma, MAOI use

✦ Avoid supplements of pyridoxine (vitamin B6)

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Medications to Treat MS

✦ Treatment is focused on symptomatic relief and reducing frequency of exacerbations

✦ Immunomodulators

✦ Glatiramer (Copaxone)

✦ Interferon beta-1a (Avonex, Rebrif)

✦ Interferon beta-1b (Betaseron, Extavia)

✦ Natalizumab (Tysabri)

✦ Fingolimod (Glenya)

✦ Immunosuppressants

✦ Mitoxantrone (Novantrone)



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Acetylcholinesterase inhibitors- Drugs for Alzheimer's Disease

✦ Donepezil (Aricept), Tacrine (Cognex)

✦ Slows the breakdown of acetylcholine

✦ Enhance parasympathetic nervous system,

✦ Bradycardia, bronchoconstriction, N & V diarrhea, urinary incontinence, blurred

vision

✦ A/E: hepatotoxicity (Tacrine)

✦ Memantine (Namenda)

✦ Decreases glutamate

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Antidepressants A/E of all: suicidal ideations

✦ Tricyclic antidepressants (TCA)

✦ Imipramine (Tofranil), amitriptyline (Elavil)

✦ A/E: Orthostatic hypotension, bone marrow depression, anticholinergic

✦ Risk of overdose

✦ Selective Serotonin Reuptake Inhibitors (SSRI)

✦ Escitalopram ( Lexapro), Sertraline ( Zoloft)

✦ A/E: weight gain, decreased sexual desire, Stevens-Johnsons syndrome

✦ Atypical

✦ Bupropion (Wellbutrin), duloxetine ( Cymbalta)

✦ MAO inhibitors

✦ Phenelzine (Nardil)

✦ A/E- Hypertensive Crisis with Tyramine foods



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Examples of foods and beverages which contain tyramine include:

beer, ale, robust red wines, Chianti, vermouth, homemade breads, aged cheese,

sour cream, bananas, red plums, figs, raisins, avocados, fava beans, Italian broad

beans, green bean pods, eggplant, pickled herring, liver dry sausages, canned

meats, salami, yogurt, soup cubes, commercial gravies, chocolate, and soy sauce.

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Serotonin Syndrome✦ High levels of Serotonin

✦ Resulting from combining medications related to serotonin:

✦ SSRI

✦ Triptan (migraines)

✦ MAOI’s

✦ Demerol

✦ Dextromethorphan (cough medicine)

✦ Symptoms

✦ Agitation, hypertension, hallucination, nausea, muscle spasms

✦ Treatment may include:

✦ Benzodiazepines, Cyproheptadine (Periactin), a drug that blocks serotonin production, IV

Fluids, D/C medicines that caused the syndrome



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Mood Stabilizing Drugs: Lithium

✦ Used to treat bipolar disease

✦ Common side effects: metallic taste, slight tremor, diarrhea

✦ Levels must be kept below 1.5 mEq/L

✦ Level 0.6-1.2 mEq/L

✦ Toxicity increased with low sodium

✦ Draw blood levels 12 hours after night time dose

✦ Toxicity: tremor, nausea, thirst, polyuria and weakness, hypothyroidism

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Antianxiety and Sleep medications

✦ Barbiturates

✦ Thiopental, phenobarbital

✦ Respiratory depression, hypotension

✦ Benzodiazepines

✦ Alprazolam (Xanax)

✦ A/E: amnesia, respiratory depression when given IV

✦ Reversal agent: flumazenil (Romazicon)

✦ Benzo-like drugs

✦ Zolpidem (Ambien), Eszopiclone (Lunesta)

✦ Do not use with alcohol or other CNS depressants



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REVIEW QUESTION

A client currently on the anti parkinson medication Sinemet is being admitted to your

unit. Based on assessment of the medication history, the nurse understands that one

of the medications that can reduce the therapeutic effects of Sinemet is which of the

following?

1. pyridoxine

2. amantadine

3. bromocriptine

4. benztropine

84

REVIEW QUESTION

The critical care charge nurse is making patient assignments for the shift. Which patient

should the charge nurse assign to the graduate nurse who just completed the

orientation?

1. The patient with amyotrophic lateral sclerosis on a ventilator who is dying and whose family is at the bedside.

2. The patient who has a closed head injury and has increasing intracranial pressure receiving intravenous osmitrol

(Mannitol).

3. The patient with a C-5 spinal cord injury who is experiencing spinal shock and is on the vasoconstrictor

dopamine.

4. The patient with a seizure disorder who has been experiencing status epilepticus for the past 24 hours.



85

REVIEW QUESTION

A client has come into the urgent care center with severe hip pain after falling

from a ladder at work. He said he has taken several pain pills over the past few

hours but cannot remember how many he has taken. He hands you an empty

bottle of acetaminophen (Tylenol). What is the most serious toxic effect of acute

acetaminophen overdose?

1. Tachycardia

2. CNS depression

3. Hepatic necrosis

4. Nephrotic necrosis

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REVIEW QUESTION

The charge nurse has received laboratory data for clients in the medical

department. Which client would require intervention by the charge nurse?

1. The client diagnosed with a stroke who has a platelet level of 250,000 µ/L.

2. The client with a seizure disorder who has a divalproex (Depakote) level of 75 µg/mL.

3. The client with multiple sclerosis on prednisone who has a glucose level of 208 mg/dL.

4. The client receiving the anticonvulsant phenytoin (Dilantin) who has serum levels of 24 mg/dL.



87

REVIEW QUESTION

The nurse in a long-term care facility is administering medications to a group of

clients. Which medication should the nurse administer first?

1. Acetylsalicylic acid (Aspirin) to a client diagnosed with cerebrovascular disease.

2. Neostigmine (Prostigmin) to a client diagnosed with myasthenia gravis.

3. Cephalexin (Keflex) to a client diagnosed with an acute urinary tract infection.

4. Acyclovir (Zovirax) to a client diagnosed with Bell’s palsy.

Medications Affecting the Cardiovascular System

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Diuretics- Loops

✦ Loop Diuretics (high ceiling)

✦ Furosemide (Lasix), Bumetanide (Bumex)

✦ Actions: prevent reabsorption of Na and Cl (water)

✦ Uses: pulmonary edema, hypertension, heart and renal failure

✦ A/E Effects: dehydration, low electrolytes, tinnitus

✦ Can cause digoxin toxicity due to low K

N/I: monitor v/s, weights, I&O, dehydration, Digoxin Toxicity (bradycardia), low K (u waves, muscle

weakness), hearing loss

Other Diuretics

✦ Thiazide diuretics

✦ HCTZ (Hydrochlorothiazide)

✦ Chlorothiazide (Diuril)

✦ Less diuresis than loop

diuretics

✦ K sparing diuretics

✦ Spironolactone (Aldactone)

✦ Eplerenone (Inspra)

aldosterone blocker

✦ Causes K retention and Na

excretions

✦ Endocrine effects

✦ Gynecomastia, Hirsutism

90



91

92

Osmotic Diuretic

✦Mannitol - increases osmotic pressure

✦Action: decreases water reabsorption

✦Uses: acute renal failure, lowers IOP/ICP

✦Use filtered IV tubing

✦Warm solution & shake if crystals are visible

✦Caution with CHF clients



93

Carbonic Anhydrase Inhibitors

✦ Indications-Treat glaucoma

✦Examples: Acetazolamide (Diamox), Dichlorphenamide (Daranide)

✦A/E:

✦Hypokalemia

✦Metabolic acidosis

✦Electrolyte imbalances

✦Fatigue

Antihypertensives

✦ Enalapril (Vasotec)

✦ Vasodilate veins and arteries to

treat hypertension, heart

failure, prevent MI, stroke

✦ A/E: hypotension, hyperkalemia,

cough, angioedema, fetal edema

(category D), neutropenia with

captopril

✦ Losartan (Diovan)

✦ Vasodilate veins and arteries to

treat hypertension, heart

failure, prevent MI, stroke

✦ A/E: hypotension,, angioedema,

fetal edema (category D)

94

ACE Inhibitors - PRILS Angiotensin II Blockers - SARTANS

94



Calcium Channel Blocker

✦ Verapamil (Calan),

✦ Dilitiazem (Cardizem)

✦ Used for angina, hypertension

and dysrthymia

✦ A/E: flushing edema,

hypotension, bradycardia,

verapamil increases dig level

✦ Amlodipine (Norvasc)

✦ Used for angina, hypertension

✦ A/E: flushing edema,

hypotension

95

Works In Heart & blood Vessel Works In Blood Vessels ONLY

95

96

Beta Blockers

✦ Beta 1 Cardioselective

✦ Metoprolol (Lopressor), atenolol (Tenormin) cardioselective

✦ Masks hypoglycemia signs (no tachycardia/tremor)

✦ Beta 1 and 2 nonselective

✦ Propanolol (Inderal), nadolol (Corgard)

✦ A/E: risk of bronchospasm

✦ Decrease HR, myocardial contractility, decreased oxygen consumption

✦ Used for HTN, Angina and Dysrhythmias, MI, CHF



97

Vasodilators

✦Mechanism of Action

✦ Directly elicit peripheral vasodilation

✦Drug Examples: Diazoxide, Hydralazine, nitroprusside

✦ Indications: HTN: all vasodilators HTN EMERGENCIES

✦Most common A/E = EXCESSIVE HYPOTENSION

98

Cardiac Glycoside - Digoxin

✦ Digoxin narrow therapeutic index

✦ Serum level 0.5 – 2.0

✦ Increases CO & contractility & slows HR

✦ Used for heart failure and dysrhythmia (Atrial fibrillation/flutter)

✦ A/E: bradycardia, visual disturbance, N/V, bleeding

✦ Toxicity: high risk with hypokalemia

✦ N/I: hold if apical pulse < 60 bpm, or hypokalemia, IV slowly over 5 minutes, antidote - Digibind



99

Antidysrhythmics

✦ Procainamide hydrochloride (Procanbid), Quinidine sulfate (Quinidex)- PVCs, Vtach, Afib, Aflutter

✦ Lidocaine (Xylocaine), Mexiletine, Tocainide- Vfib, Vtach, PVCs

✦ Potassium channel blockers: Amiodarone (Cordarone, Pacerone), Sotalol (Betapace)- Vtach, Vfib

✦ Adenosine- PSVT- short half life- rapid bolus only

100

Hyperlipidemia Agents- Statins

✦ Atorvastatin (Lipitor)

✦ Lowers LDL

✦ Take before bed (HS)

✦ Do not stop abruptly

✦ Report muscle aches

✦ Check CK-3 (CK-MM)

✦ Pregnancy category X



101

Antianginals

✦ Nitrates

✦ Hypotension, HA, tachycardia

✦ Beta Blockers

✦ Bradycardia, bronchospasm, dizziness, hypotension

✦ Calcium Channel Blockers

✦ Hypotension, bradycardia, arrhythmias, increased digoxin levels

102

Nitroglycerin Rules

✦ When possible, avoid activities that precipitate chest pain (heavy meals, cold temps, strenuous

exercise)

✦ Take nitro sublingual q 5 minutes X 3 if no relief call 911

✦ Drink water first, should fizzle

✦ Starts working in 1-3 minutes

✦ Lasts 20-40 minutes

✦ Store in original dark bottle for 24 months

✦ Nitro paste

✦ Use gloves

✦ Keep off at night

✦ Nitro patch

✦ On in AM off in PM



103

Anticoagulant: Warfarin/Coumadin

✦ Uses:

✦ Venous thrombosis, Atrial fib

✦ Effects develop over several days and last several days after discontinuation.

✦ A/E: hemorrhage, dermatitis, red –orange colored urine

✦ What is the antidote?

104

Anticoagulant: Warfarin

✦ N/I: Monitor PT, reported as INR

✦ Goal: 2-4 X normal

✦ Use contraception, keep vitamin K foods constant

✦ Many drug interactions

✦ 734 drug interactions

✦ Bleeding precautions (electric razor, soft toothbrush)



105

Anticoagulant - Heparin

✦ Uses:

✦ DVT prophylaxis, evolving stroke,

✦ A-fib with embolism, hemodialysis, DIC, MI

✦ A/E : HEMORRHAGE, thrombocytopenia, hair loss, osteoporosis

✦ What is the antidote for overdose?

✦ Monitor aPTT,

✦ Normal, 40 seconds

✦ Goal 60-80 seconds

✦ Report sign of bleeding

✦ No IM injections, Avoid ASA, Heparin induced thrombocytopenia (HIT): monitor platelet count

✦ Enoxaparin (Lovenox)

✦ Does not require PTT monitoring

106

REVIEW QUESTION

The nurse is administering medications to clients in the cardiac critical care area.

Which client should the nurse question administering the medication?

1. A client receiving a calcium channel blocker (CCB) who is drinking a glass of grapefruit juice.

2. A client receiving a beta-adrenergic blocker who has an apical heart rate of 62 beats/min.

3. A client receiving nonsteroidal anti-inflammatory drugs (NSAIDs) who has just finished eating breakfast.

4. A client receiving an oral anticoagulant who has an International Normalized Ratio (INR) of 2.8.



107

REVIEW QUESTION

Adenosine is administered to a client experiencing an acute episode of PSVT.

When giving this medication, which of the following is important to remember?

1. The onset of action occurs in 5 minutes.

2. The medication must be given as a slow IV push.

3. Asystole may occur for a few seconds after administration.

4. The medication has a long half-life, and the duration of action is very long.

108

REVIEW QUESTION

A client in a cardiac intensive care unit is on dopamine. The B/P increases to

210/130. Which intervention should the nurse implement first?

1. Discontinue the dopamine.

2. Notify the client’s healthcare provider.

3. Anticipate administering dobutamine.

4. Assess the client’s neurological status.



Anti-Infective Medications

109

110

Antimicrobials

✦ Monitor therapeutic levels (Peak & Trough)

✦ Narrow therapeutic range (Vancomycin, Gentamicin)

✦ Prevent antimicrobial resistance

✦ Hand washing

✦ Vaccinate

✦ Culture and sensitivity (before initiation of antibiotics)

✦ Narrow spectrum / selective

✦ A superinfection (suprainfection) results from normal bacteria allowing fungal

growth.

✦ Candidiasis

✦ Pseudomembranous colitis



111

Penicillins

✦ “CILLIN”

✦ Inhibits Cell Wall Synthesis

✦ PCN G (IM, IV), Pen Vee K (oral), Procaine and Benzathine PCN (IM only)

✦ Adverse Effects: allergy (anaphylaxis), suprainfection (colitis)

✦ Penicillinase resistance penicillin

✦ Nafcillin, oxacillin, dicloxacillin

✦ Adverse effect: phlebitis, colitis

✦ Aminopenicillins

✦ Ampicillin (IV), Amoxicillin, Augmentin (Amoxicillin plus Clavulanic Acid)

✦ Adverse effect: diarrhea

Great

Broad

Spectrum!

112

Cephalosporins

✦ “CEF or CEPH”

✦ Destroys the cell wall of bacteria

✦ 1-4 generations (broader spectrum-)

✦ Cefalexin (Keflex), Cefazolin (Ancef)

✦ Cefaclor (Ceclor)

✦ Ceftazidime (Fortaz), Ceftriaxone (Rocephin)

✦ Cefepime HCL (Maxipime)

✦ Administer deep IM, IV over 30 minutes, No Alcohol

✦ A/E : pseudomembranous colitis, anaphylaxis, cross allergy to PCN, nephrotoxic, may cause

bleeding, result in disulfiram-like reaction with alcohol, decreases effectiveness of OCP

Broad

Spectrum!



113

Vancomycin

✦ Potential life threatening infections, including MRSA

✦ Oral administration to treat colitis

✦ A/E :

✦ Ototoxicity & nephrotoxicity

✦ Red man syndrome with too rapid administration

✦ Phlebitis

✦ Infuse over 60 minutes or longer

114

Tetracyclines

✦ “CYCLINE”

✦ Broad Spectrum prevents protein synthesis

✦ Doxycycline, Tetracycline, Minocycline

✦ Treats MANY infections including: Acne, Lyme, H pylori, Anthrax

✦ A/E: superinfection, hepatotoxicity, chelating to teeth and new bone, may induce lupus

✦ Not for pregnant women, children < 8 yrs of age, avoid dairy products within 2 hours, antacids or iron,

decreases OCP effectiveness, increases sensitivity to sun

✦ Administer with meals (except tetracycline)



115

Macrolides

✦ “MYCIN”-Macrolides

✦ Erythromycin, Azithromycin, Clarithromycin

✦ Used as alternative in PCN allergies

✦ A/E: abdominal pain, hepatotoxicity, ototoxicity, phlebitis at IV site

✦ N/I: give deep IM, give on an empty stomach, increases level of theophylline and

statins may cause QT prolongation and sudden death (esp with

procainamide/quinidine)

116

Aminoglycosides

✦ “MYCIN or MICIN”

✦ Interfere with Protein Synthesis

✦ Gentamicin, Streptomycin, Tobramycin

✦ Adverse Effects:

✦ Ototoxicity (once a day dosing reduces risk)

✦ Nephrotoxicity

✦ Photosensitivity

✦ Increases neuromuscular blockers (Ca is antidote)

✦ Peak levels: 5-10

✦ How should a nurse assess for nephrotoxicity?

✦ Often given with PCN, but never mixed in same bag.

Gram -



117

Sulfonamides

✦ Bacteriostatic

✦ Bactrim (trimethoprim/sulfamethoxazole)

✦ “SULF”

✦ UTI, Ear infections, PCP infections

✦ A/E:

✦ Steven Johnson Syndrome,

✦ Photosensitivity,

✦ Pancytopenia,

✦ Phlebitis,

✦ Crystalluria (encourage fluids),

✦ Contraceptives < effective

118

Fluoroquinolones

✦ Inhibit DNA Synthesis

✦ Ciprofloxacin, Levofloxacin, Ofloxacin

✦ Gatifloxacin (Tequin), Moxifloxacin (Avelox)

✦ A/E: Dizziness, Crystalluria, photosensitivity, insomnia (decreases metabolism of

caffeine), peripheral neuropathy, may worsen Myasthenia Gravis symptoms,

✦ Cipro not for children < 18 due to risk for Achilles tendon rupture

✦ Absorption decreased with milk, yogurt, antacids, iron, zinc

✦ Anthrax

✦ Adequate fluid intake, no weight bearing with heel pain



119

Carbapenems✦ Action: Inhibit synthesis of the bacterial cell wall

✦ Broad spectrum

✦ Ertapenem (Invanz)- Prototype

✦ Imipenem (Primaxin)

✦Meropenem (Merrem IV)

✦Doripenem (Doribax)

✦ Treat community acquired pneumonia

✦ Reserved for complicated body cavity and connective tissue infections

✦Given intravenously and intramuscularly

✦ Cross-sensitivity to penicillins

✦ A/E: GI symptoms, superinfection, pseudomembranous colitis

120

Antitubercular Agents

✦ Treatment: 18 months to 2 years

✦ Traditionally mainstay of drug therapy included:

✦ 4 drugs for initial treatment:

✦ Isoniazid (INH)

✦ Rifampin

✦ Pyrazinamide

✦ Ethambutol or streptomycin sulfate

✦ Adverse effects

✦ INH: hepatotoxicity: jaundice

✦ Rifampin causes reddish orange urine



121

Antifungals

✦ Fungi (systemic or superficial)

✦ Yeast

✦ Mold

✦ Amphotericin B, (systemic infections/Highly Toxic)

✦ A/E: bone marrow depression, nephrotoxicity, phlebitis, pruritus

✦ Protect IV med from light (cover with foil)

✦ Infusion reactions occur- fever, chills, rigors 1-3 hrs after start

✦ Fluconazole (systemic or superficial)

✦ Nystatin, Miconazole (superficial)

122

Antiprotozoal Agents

✦ Amebiasis Entamoebahistolytica

✦ Contaminated food and drink

✦ Trichomoniasis

✦ Sexually transmitted disease of the vagina

✦ Pneumocystis-carinii pneumonia (PCP)

✦ Opportunistic infection in clients with AIDS

✦ Atovaquone (Mepron)

✦ Metronidazole (Flagyl, MetroGel, Noritate)

✦ Pentamidine (Pentam 300, NebuPent)

✦ Tinidazole (Tindamax)

✦ A/E: GI upset, N/V, dry mouth, metallic taste, darkening of urine, numbness of extremities, ataxia,

seizures



123

Antivirals

✦ Acyclovir, Ganciclovir

✦ Treats symptoms , minimizes transmission, prevent virus replication

✦ Herpes, influenza A, CMV retinitis

✦ A/E: nephrotoxicity (ensure hydration), dizziness, n/v/d, phlebitis

✦ Acyclovir and ganciclovir have cross-sensitivity

✦ Amantadine

✦ Influenza A (Give early) and Parkinson Disease

✦ Palivizumab (Synagis) & Ribavirin

✦ RSV

✦ Palivizumab (Synagis): Preventative monthly IM during RSV season for preemies

✦ Ribavirin inhalation via tent, pregnant women should avoid

124

HIV infection / AIDS✦ NRTI

✦ Zidovudine (AZT), one hour before meals, bone marrow suppression , risk of anemia,

neutropenia and liver toxicity

✦ NNRTI

✦ Efavirenz (Sustiva), abnormal dreams , insomnia, hyperlipidemia, Rash and Stevens

Johnson, Category D, give at bedtime

✦ Protease inhibitors

✦ Saquinavir (Invirnase): not for children, give with meals, risk of hyperglycemia, fat

redistribution, osteoporosis

✦ Integrase inhibitor: Raltegravir (Insentress)

✦ Fusion inhibitors:Enfuvirtide (T-20):SQ inj

✦ CCR5 antagonist: Maraviroc



125

REVIEW QUESTION

A client enters the emergency department with a high fever, headache, rash, and

neck ache and is diagnosed with a serious bacterial infection. The results of the

blood culture are pending. The nurse would take which of the following best

action?

1. Contact the prescriber to question the use of a broad spectrum antibiotic

2. Administer the broad-spectrum antibiotic

3. Await the culture results before beginning antibiotic therapy

4. Administer an antipyretic until culture results are obtained

126

REVIEW QUESTION

A 55 year old female has osteomyelitis and is receiving Vancomycin 750mg IV BID.

Which of the following results should prompt the nurse to hold the drug and

notify the healthcare provider?

1. Bun 19, Creatinine 0.9

2. Hemoglobin of 12.2

3. Vancomycin trough of 18

4. White blood cell count of 16.8



127

REVIEW QUESTION

A 60 year old male with heart failure and pneumonia states that he is allergic to

penicillin. A nurse receives the following orders. Which prescription should be

questioned?

1. furosemide (Lasix) 20 mg po twice a day

2. cephalexin (Keflex) 250mg po four times a day for 7 days

3. metoprolol (Lopressor) 50 mg po every 12 hours

4. levofloxacin (Levaquin) 500mg po daily

128

REVIEW QUESTION

A client is taking Cefalexin 500 mg PO every 6 hours. Which of the following

findings indicates that the medication is effective?

1. The client denies any rash or dyspnea.

2. The client’s creatinine is 1.2.

3. The client’s WBC is 8,500.

4. The client denies any diarrhea.



129

REVIEW QUESTION

A nurse notes that a client is ordered to receive a sulfonamide. The nurse is aware

that the clinical usefulness of sulfonamides is primarily in treating which of the

following?

1. fungi and viral infections.

2. leukemias and lymphomas.

3. urinary tract and ear infections.

4. ear and respiratory tract infections

Medications Affecting the Respiratory System

130



131

Anti-Asthmatic Drugs Bronchodilators- Rescue Meds

✦ Albuterol (Proventil), Levalbuterol (Xopenex)

✦ “Rescue” meds when administered via inhalation

✦ Inhaled

✦ Fastest acting/ short acting

✦ MDI or nebulized

✦ Adverse effects

✦ Tachycardia, angina, tremor

✦ Long acting (NOT RESCUE): Salmeterol (Serevent)

✦ Other rescue medications: systemic steroids and inhaled ipratropium

132

Anti-Asthmatic Drugs Bronchodilators

✦ Theophylline (PO), Aminophylline (IV)

✦ Uses: emphysema, asthma

✦ A/E: CNS stimulation, irritability, nervousness, tachycardia, hypotension

✦ N/I:

✦ Drug level 5-15 mcg/ml

✦ Toxicity

✦ Avoid caffeine

✦ Seizure risk

✦ Many drug interactions



133

Corticosteroids - Inhaled

✦ Fluticasone (Flovent)

✦ Decreases leukotrienes, histamine and prostaglandins

✦ Fixed schedule

✦ Takes 2-8 days to see effect and 4-6 weeks for maximal effect

✦ Adverse effects

✦ Oral candidiasis (rinse mouth after administration)

✦ Slows growth acceleration (but does effect adult height)

134

Mast Cell Stabilizer

✦Prevent histamine release

✦Cromolyn (Intal)

✦Four times a day administration

✦Bitter taste



135

Inhaled Anticholinergic

✦ Ipratropium (Atrovent),

Tiotropium (Spiriva)

✦ Decrease asthma attack

✦ A/E: dry mouth, bad taste

✦ Teach inhaler

✦ Don’t open or swallow capsules

✦ Taper drug for withdrawal

✦ Atrovent inhalers: contraindicated

in clients with soy and peanut

allergies

Nursing Interventions

136

Leukotriene modifiers

✦Montelukast (Singulair, Zafirlukast (Accolate)

✦Oral medication

✦ Accolate: Take on an empty stomach

✦Adverse effect: increased risk of depression and suicide



137

Mucolytics

✦ Decreases viscosity of mucus in bronchial tree = less tenacious secretions

✦ Acetylcysteine (Mucomyst)

✦ Cystic fibrosis, pneumonia, emphysema, Tylenol OD (alters Tylenol metabolism)

✦ A/E: Bronchospasm & Aspiration

✦ N/I: suction equip, rinse mouth after treatment, dilute with sterile water, drug leaves

sticky coating on face, po has a rotten egg odor dilute with fruit juice, use straw

✦ Also: Dornase alpha (Pulmozyme)

138

REVIEW QUESTION

A 14-year-old female has been treated for asthma with Salmeterol for almost 4

months. Her mother has called the clinic to report that it does not seem to work

when her daughter is experiencing acute symptoms. Which response is

appropriate?

1. It takes time for a therapeutic response to develop.

2. She is too young for this particular medication; it should be changed.

3. She should take up to two puffs every 4 hours to ensure adequate blood levels.

4. Salmeterol is indicated for prevention of bronchospasms and it is not used for relief

of acute symptoms.



139

REVIEW QUESTION

A client is scheduled to receive an inhaled corticosteroid. The nurse should

instruct the client to complete which of the following?

1. Rinse his mouth after inhalation.

2. Allow 15 minutes between inhalations.

3. Use the inhaler after brushing his teeth.

4. Discontinue drug when feeling better.

REVIEW QUESTION

140

REVIEW QUESTION

A client with asthma is admitted to the hospital with shortness of breath. He was

given theophylline via intravenous (IV) fluids. The agent the client received

intravenously is which of the following?

1. theophylline (TheoDur).

2. oxytriphyline-choline theophyllinate (Choledyl).

3. aminophylline (Somophyllin).

4. dyohyline-dihydroxypropyl (Dilor).

REVIEW QUESTION



141

A nurse is teaching a client about the side effects/adverse reactions of

theophylline (Theo-Dur). Which of the following should be included in the

teaching plan?

1. headache and an aura.

2. hypertension and flushing.

3. tachycardia and palpitations.

4. diarrhea and dehydration

REVIEW QUESTION

Medications Affecting the Gastrointestinal System

142



143

Antacids-Neutralize Acid

✦ Magnesium (MOM)

✦ Avoid with renal problems, laxative effect,

✦ Aluminum: (Aluminum Hydroxide)

✦ Phosphate binder, constipation, accumulation of aluminum in serum bone & CNS (Amphogel)

✦ Na carbonate (Rolaids)

✦ Na retention, constipation

✦ Na bicarbonate

✦ Baking soda - alkalosis

✦ Calcium carbonate (Tums)

✦ Hypercalcemia, constipation, alkali syndrome

✦ (H/A, N/V)

Chew tablets well and take with 8oz of water - as a rule take other meds 1 hr. before or after

144

Histamine2 Antagonist

✦ “TIDINE”

✦ Cimetidine, Famotidine, Ranitidine, Nizatidine

✦ Block histamine2---decreases gastric acid secretion from parietal cells

✦ Uses: Short term treatment of duodenal or gastric ulcer, GERD, Zollinger-Ellison

syndrome (hypersecretory syndrome)

✦ A/E: somnolence, reversible impotence (cimetidine), diarrhea, agranulocytosis

✦ N/I: oral form with meals, antacids decrease absorption, 4-6 wks or longer, smoking

decreases effectiveness, toxic effect=confusion



145

Gastric Acid Inhibitor aka Proton Pump Inhibitor

✦ “PRAZOLE”

✦ Omeprazole, Esomeprazole, Lansoprazole

✦ Prilosec, Nexium, Prevacid, Protonix

✦ Peptic ulcer, GERD, ZES

✦ A/E: dizzy, drowsy, diarrhea

✦ N/I: may take with antacids, don’t crush capsules, may increase liver enzymes

146

Antipeptic Agents

✦ Sulcralfate (Carafate)

✦ Binds with protein and covers ulcer

✦ Promotes ulcer healing

✦ A/E: diarrhea, constipation, rash

✦ N/I: take on an empty stomach, admin antacids 1hr or > between doses of sucralfate



147

Motion Sickness: Antiemetics

✦ Anticholinergics

✦ Scopolamine (Transderm scop)

✦ A/E: orthostatic hypotension, dry

mouth, drowsiness

✦ Antihistamines - Dimenhydrinate

(dramamine),

✦ N/I: no driving, no ETOH, take

before motion sickness begins

Vistaril: anticholinergic and antihistamine

148

Antiemetics

✦ Serotonin antagonists

✦ Dolasetron (Anzemet)

✦ Ondansetron (Zofran)

✦ IV, oral patch

✦ Prophylactically

✦ Neurokinin antagonist

✦ Aprepitant (Emend)

✦ Prokinetic agent

✦ Reglan

✦ Corticosteroids

✦ Benzodiazepine (Ativan)

✦ Dopamine antagonist

✦ Antipsychotic drugs

✦ Haldol

✦ Droperidol (Inapsine)

✦ Promethazine Phenergan

✦ A/E: resp depression and

tissue damage (infiltration)



149

Antidiarrheals

✦ Absorbent: Pepto Bismol (Bismuth Subsalicylate) removes irritants

✦ A/E: impaction, salicylate toxicity

✦ N/I: use caution with ASA

✦ Lomotil (schedule V) & Imodium

✦ Inhibits peristalsis - paralytic ileus

✦ A/E: toxic megacolon, abdominal pain, urinary retention

✦ N/I: Avoid other CNS depressants, withhold in severe dehydration, prevent

dehydration

150

REVIEW QUESTION

A client took Amphojel (aluminum hydroxide). The nurse should instruct for the

client to monitor for what type of GI disturbance?

1. Nausea and vomiting

2. Anorexia

3. Diarrhea

4. Constipation



151

REVIEW QUESTION

A client is prescribed mylanta and ranitidine. Both medications are oral

medications. Which is the nurse’s best action?

1. Administer these medications at the same time because they have a synergistic effect.

2. Administer the medications 1 to 2 hours apart to prevent decrease absorption.

3. Contact the prescriber to change the ranitidine to an IV form to prevent drug interaction.

4. Contact the pharmacy to change the prescription to an enteric coated form of ranitidine

that will not irritate the gastric wall.

152

REVIEW QUESTION

The nurse is preparing to administer morning medications to clients on a medical

unit. Which medication should the nurse administer first?

1. Methylprednisolone (Solu-Medrol), a steroid, to a client diagnosed with Crohn’s disease.

2. Donepezil (Aricept), an acetylcholinesterase inhibitor, to a client with dementia.

3. Sucralfate (Carafate), a mucosal barrier agent, to a client diagnosed with ulcer disease.

4. Enoxaparin (Lovenox), an anticoagulant, to a client on bed rest after abdominal surgery.



Medications Affecting the Endocrine System

153

154

Insulin

✦ Rapid Acting

✦ Lispro (Humalog) peaks ½ - 2 ½ hr

✦ Aspart (NovoLog) peaks 1-3 hrs

✦ Glulisine peaks one hour

✦ Short Acting

✦ Regular (Humulin-R, Novolin-R) peaks 1-5 hrs

✦ Intermediate Acting

✦ NPH (Humulin-N, Novolin-N) 6-14 hours

✦ Long Acting

✦ Glargine (Lantus) doesn’t peak

✦ Detemir (Levemir) peak 6-8 hours

✦ Goal: 90 - 130 preprandial <180 postprandial



155

Nursing Implications

✦ Mixing & Premixed

✦ Clear then cloudy

✦ NPH and short or rapid acting

✦ Expiration date

✦ Keep in refrigerated after drawn up

✦ Injection site

✦ Activity, stress & diet affect glucose levels

✦ Exercise increases insulin sensitivity

✦ Stress (cortisol) raises blood glucose levels

✦ Hypoglycemic reactions

T/F: A blood sugar of 30 can be treated with glucagon or 50% Dextrose IV.

156

✦ Sulfonylureas – Glipizide (Glucotrol)

✦ Stimulates insulin release

✦ S/E: hypoglycemia, no ETOH

✦ Meglitinides - Repaglinide (Prandin), nateglinide (Starlix)

✦ Stimulates insulin release

✦ S/E: hypoglycemia (eat within 30 minutes)

✦ Biguanides – Metformin (Glucophage)

✦ Inhibits glucose production S/E: lactic acidosis increased risk with alcohol

Oral Hypoglycemic Medications



157

Oral Hypoglycemic Medications

✦ Thiazolidinediones - Rosiglitazone (Actos), (Avandia)

✦ Increases insulin sensitivity

✦ S/E: fluid retention, hepatotoxic

✦ Gliptins- Sitagliptin (Januvia)

✦ Adverse effects: nasal inflammation

✦ Alpha-glucosidase inhibitors- Acarbose (Precose)

✦ Delays absorption of carbs

✦ Adverse effects flatulence, abdominal cramps

158

Adrenal Agents- Frequently Used Steroids

Short-acting:

Cortisone (Cortone) Hydrocortisone (Solu-Cortef)

Intermediate-acting:

Prednisone (Deltasone) Prednisolone (Solu-Medrol)

Long-acting:

Dexamethasone (Decadron) Betamethasone

(Celestone)



159

Adrenal Agents- Adverse Reactions & Side Effects

✦ Depression, euphoria

✦ Hypertension

✦ Peptic ulceration

✦ Acne, decreased wound healing, ecchymoses, hirsutism, petechiae

✦ Adrenal insufficiency

✦ High glucose

✦ Thromboembolism

✦ Muscle wasting, osteoporosis

✦ Cushingoid appearance, low K, Ca

160

Adrenal Agents-Nursing Implications

✦Instruct client regarding risk of mental changes

✦May require more insulin & potassium

✦Adrenal insufficiency S/S include N/V & hypotension

✦Give in the AM

✦With meals, diet high in Na, protein, Ca, K

✦OK to give Varicella & MMR vaccine

✦Taper when discontinuing



161

Thyroid Replacement

✦ Levothyroxine (Synthroid)

✦ Monitor T4 and TSH

✦ Take on empty stomach

✦ Do not change brands

✦ Increases Coumadin levels

✦ Adverse effects

✦ H/A, irritability, insomnia

✦ Nervousness

✦ Cardiovascular collapse

✦ Arrhythmias, tachycardia

✦ Weight loss

162

REVIEW QUESTION

The nurse is preparing to administer morning medications. Which medication

should the nurse administer first?

1. The levothyroxine (Synthroid), a thyroid hormone, to a client diagnosed with

hypothyroidism.

2. The Humulin R insulin, a pancreatic hormone, to a client diagnosed with type 2 diabetes.

3. The prednisone, a glucocorticoid, to a client

4. The tiotropium (Spiriva) inhaler, a bronchodilator, to a client diagnosed with chronic asthma.



163

A nurse is assessing a client after administering insulin. Which findings suggest

that the client is hypoglycemic? Select all that apply.

1. Tachycardia

2. Palpitations

3. Diaphoresis

4. Nausea/vomiting

5. Chills

6. Tremors

REVIEW QUESTION

164

A client received Novolin R insulin 10 units and Novolin NPH 36 units at 8 am. At

11am the client complains of palpitations and is diaphoretic. The nurse should do

the following first:

1. Call the healthcare provider and be prepared to administer additional insulin.

2. Give the client 6 ounces orange juice.

3. Administer oxygen by nasal cannula at 2LPM.

4. Check the blood sugar.

REVIEW QUESTION



165

REVIEW QUESTION

The nurse on the medical unit is preparing to administer medications. Which

medication should the nurse question administering?

1. The hormone levothyroxine (Synthroid) to the client diagnosed with hypothyroidism.

2. The metformin (Glucophage) to the type 2 diabetic who just had a CT scan with dye.

3. The Humulin N insulin to the client with type 1 diabetes who is no longer NPO.

4. The steroid prednisone to a client diagnosed with Addison’s disease.

REVIEW QUESTION

Nutritional Supplements

166



167

Electrolytes-Potassium Supplements

✦ Potassium chloride (KCL, K-Dur, K-Lor)

✦ Potassium bicarbonate (K-Electrolyte, K-lyte)

✦ PO

✦ Administer when client is upright, do not crush tablet

✦ IV

✦ Never IVP, do not exceed 10 mEq/hour

✦ A/E: confusion, weakness, arrhythmia

✦ Treatment of overdose

✦ Dextrose and insulin, sodium bicarb, calcium gluconate and Kayexalate

168

Potassium Ion Exchange Resin

✦ Sodium Polystyrene Sulfonate (Kayexalate)

✦ Exchange Na for K, Not absorbable

✦ Uses: hyperkalemia

✦ A/E: Constipation, fecal impaction

✦ Administration: PO or retention enema

✦ Daily K level, renal function & electrolytes



169

✦ Vitamin A

✦ Deficiency: night blindness

✦ Category X at high doses

✦ Vitamin D

✦ Deficiency: rickets, osteomalacia

✦ S/E: metallic state

✦ S/E flushing

✦ Vitamin K

✦ Deficiency: bleeding tendency

✦ SE flushing, hypotension, pain at injection site

✦ Vitamin B12

✦ Deficiency anemia

✦ Administered IM daily, then monthly

Vitamins

170

REVIEW QUESTION

Which of the following physician orders would the nurse question when

administering IV fluids with potassium chloride (KCl)?

1. Inject IV KCl directly into the IV tubing.

2. Check for infiltration because potassium is irritating to subcutaneous tissues.

3. Check for phlebitis because potassium is irritating to the veins.

4. Check for adequate urinary output because kidney dysfunction can cause potassium

retention that may lead to hyperkalemia.



171

REVIEW QUESTION

A client’s serum potassium level is 5.2 mEq/L. An intervention that may correct

this type of potassium imbalance is which of the following?

1. to restrict foods containing potassium.

2. to administer IV sodium bicarbonate (NaHCO3).

3. to administer insulin and glucose.

4. to administer sodium polystyrene sulfonate (Kayexalate) and sorbitol.

Herbal MedicinesNot as innocent as you think

172



173

Herbal Medicine - Echinacea

✦ Echinacea stimulates immune system, reduces bacterial growth

✦ Uses: wound-healing, may shorten cold symptoms duration

✦ Avoid herb use if pregnant - effects unknown, may contain ETOH

✦ Prolonged use > 8wks may lead to immune suppression & hepatotoxicity

174

Herbal Medicine - Garlic

✦Garlic is antithrombotic, lipid lowering, antimicrobial effects, HTN

✦Uses: HTN, antimicrobial, AID’s morbidity, vascular changes, lower lipid levels

✦N/I: note cholesterol level, hold prior to surgery, assess for bleeding with

anticoagulants



175

✦ Ginger inhibits platelet aggregation, decrease gastric acid

✦ Uses: antiemetic, motion or sea sickness, pain and swelling of rheumatoid arthritis

✦ N/I: ginger & anticoagulants enhances bleeding

✦ Monitor for bleeding

Herbal Medicine - Ginger

176

Herbal Medicine - Gingko

✦ Gingko - Arterial Vasodilation- increased tissue perfusion

✦ Uses: Cerebral & peripheral vascular disease, dementia

✦ Avoid if on anticoagulants or with seizure history



177

Herbal Medicine - Ginseng

✦Ginseng may exert opposing effects (CNS depressant/stimulant)

✦Uses: decrease fatigue, more stamina, sedative

✦N/I: Toxic: Ginseng Abuse Syndrome (diarrhea, HTN, restlessness, insomnia, skin

eruptions, depression, appetite suppression, euphoria & edema)

✦Not for prolonged use, note blood sugar

178

Herbal Medicine - St. John’s Wort

✦ St. John’s Wort (aka herbal Prozac) inhibits stress induced increase in ACTH, antiviral

effects, antidepressant

✦ Uses: mild to moderate depression, low thyroid, HIV infection, Kaposi Sarcoma

✦ N/I: evaluate for depression, many interactions, lowers many other drug levels

including: antifungal, antiviral, calcium channel blockers, dilantin, antidepressants

and immunosuppressants like cyclosporine



179

REVIEW QUESTION

A 25-year-old woman is visiting the prenatal clinic today and shares with you her

desire to go “natural” with her pregnancy. She shows you a list of herbal remedies

that she has set aside so that she can “avoid taking any drugs.” Which statement

is correct?

1. Most herbal remedies are non-toxic and safe for use during pregnancy.

2. She should read the labels carefully before use to check for cautionary warnings.

3. Products from different manufacturers are required to contain consistent amounts of herbal

constituents.

4. Herbal remedies are actually drugs with unproven safety and should not be taken without medical

supervision during pregnancy.

180

REVIEW QUESTION

A client has been taking the SSRI sertraline (Zoloft) for about 4 months. At a recent

visit, she told you she has been interested in herbal therapies and wants to start

taking St. John’s Wort. Which statement below is appropriate in reply?

1. “That should be no problem.”

2. “Soon you’ll be able to stop taking the Zoloft!”

3. “Be sure to stop taking the herb if you notice a change in side effects.”

4. “Taking St. John’s Wort with Zoloft may cause severe interactions and is not

recommended.”



181

REVIEW QUESTION

If a client says that he eats large amounts of garlic for cardiovascular benefits,

which of the following drugs, if taken, would have a potential interaction with the

garlic?

1. acetaminophen (Tylenol)

2. warfarin (Coumadin)

3. digoxin (Lanoxin)

4. phenytoin (Dilantin)

Intravenous Therapy

182



183

Vascular Access

✦ Peripheral

✦ Site changes every 72 hours

✦ Increased risk for infiltration and

phlebitis

✦ Central

✦ infuses in the superior vena cava or

right atrium

✦ Non-tunneled

✦ temporary

✦ Example: Triple lumen, subclavian

line

✦ Tunneled

✦ Less risk of infection

✦ PICC line

✦ Hickman / Broviac

✦ Mediport

184

Systemic Complications

✦ Circulatory Overload: tachypnea, SOB, JVD, crackles, high BP

✦ O2, HOB up, Slow IV, Notify healthcare provider

✦ Septicemia: fever, chills, malaise, n/v, h/a

✦ D/C IV, VS, blood cultures

✦ Air Embolism: dyspnea, cyanosis, weak rapid pulse, low B/P, loss of consciousness

✦ Close source, left side position, O2, healthcare provider



185

Transfusion Reactions

✦ Transfusion types

✦ Febrile

✦ Hemolytic

✦ Hemolytic

✦ Stop transfusion IMMEDIATELY

✦ Disconnect all equipment

✦ Hang new Saline

✦ Return blood to blood bank & notify healthcare provider

✦ Complete transfusion reaction report

✦ Monitor patient and document

186

Blood Transfusion Responsibilities

✦ Verify orders, informed consent, ABO & Rh compatibility

✦ Inspect unit, explain procedure, take VS

✦ Needle Gauge & Y tubing with filter

✦ Begin administration within 30 mins of receiving, start slow

✦ Infuse no longer than 4 hrs, then change tubing

✦ FDA approved blood warming device

✦ Hang blood with NS only



187

Hyperalimentation

✦ TPN (D 15% and greater) & PPN

✦ Daily healthcare provider orders with additives

✦ Solution and tubing changed every 24 hours

✦ 22 micron in line filter

✦ Lipids below filter and no additives

✦ IV pump, monitor labs, VS, insertion site, dressing integrity, high glucose, wt & calorie

count

✦ Wean slowly, administer 20% Dextrose with administration delays

188

REVIEW QUESTION

A blood transfusion of packed RBC’s has just begun on a client when he begins to

complain of severe back pain. Which action by the nurse is a priority?

1. Question the client about his blood type and recheck the label on the transfusion bag.

2. Stop the transfusion and start a new line of NS.

3. Stop the transfusion and call the healthcare provider immediately.

4. Notify the healthcare provider and obtain an order for Tylenol.



189

A client is receiving TPN via a Hickman catheter at 100 cc/hr. The client begins to

complain of increased thirst and nausea. Which action should be performed first?

1. Stop the infusion and notify the healthcare provider.

2. Slow the infusion by 50% and notify the healthcare provider.

3. Check the client’s blood sugar.

4. Administer PRN order of Tylenol 650mg PO and reassess client in thirty minutes.

REVIEW QUESTION

190

A nurse notices a 5 inch red line extending from the IV site of a client with

dementia. The nurse should suspect that

1. The intravenous solution has infiltrated and the IV must be discontinued.

2. The infusion rate should be slowed.

3. The client has developed a phlebitis and the IV site will have to be changed.

4. The client’s airway should be checked.

REVIEW QUESTION



191

The nurse is preparing to administer two units of PRBCs to a client diagnosed with

congestive heart failure (CHF). Which HCP order should the nurse question?

1. Administer each unit over 2 hours.

2. Administer the loop diuretic furosemide (Lasix) IVP once.

3. Restrict the client’s fluids to 1000 mL per 24 hours.

4. Have a complete blood count (CBC) done the following morning.

REVIEW QUESTION

Pharmacology Math-Calculations

192



193

Methods

✦Formulas

✦Dimensional Analysis

✦Proportions

194

Review Question

A prescriber ordered 0.25 mg of digoxin and you have 0.125mg tablets. How many

tablets do you give?



195

Formula

A prescriber ordered 0.250 mg of digoxin and you have 0.125 mg tablets. How many tablets do you give?

D = 0.250mg

H = 0.125mg

V = 1 tablet

Dose Desired

Dose on HandAmount = x Vehicle

0.250

0.125Amount = x 1 = 2 tabs

196

Review Question

Order: 100 mg of phenobarbital elixir. Available: 20mg/5ml. How many mL do you

give?



197

By Formula

Desired: 100mg

On hand: 20mg

Vehicle: 5ml

100 mg of phenobarbital elixir.

Available: 20mg/5ml.

How many mLs do you give? 25mL

100mg20mg

5mLX

5 X 5

198

Conversions

✦ Within Metric System

✦ 1000mg = 1gram

✦ 1000mcg = 1mg

✦ Household

✦ 1 teaspoon = 5 mL

✦ 3 teaspoon = 1 tablespoon

✦ 1 cup = 8 ounces

✦ 16 ounces = 1 lb

✦ Between systems

✦ 2.2 lbs = 1 kg



199

Review Question

Order: 750mg of amoxicillin TID. Amoxicillin is available as 0.5 gram scored tablets.

How many tablets do you give?

First: Change grams to milligrams

X=500 mg

1000mg

1gram

X

0.5 grams=

200

750mg of amoxicillin TID. Amoxicillin is available as 500 mg scored tablets.

How many tablets do you give?

750mg

500mg

1 1/2 Tablet

Continuation…

Dose Desired


x 1 Tablet



201

Problem Using Formula

Carbenicillin 800mg IM q 6hr.

Vial states 1g/2.5ml.

How many mL should you give?0.8 X 2.5 = 2mL

800mg1000mg

(2.5mL)

Dose Desired


202

Formula 3: drops per minute

Order: 1000ml of D5W q 24hrs. Tubing delivers 10gtt per mL, calculate drops per minute

FORMULA: Volume x gtt factor

time in hr x 60 minutes

CALCULATION: 1000 mL x 10 gtt factor

24hrs x 60 min

10,000 divided 1440 = 6.94

ANSWER: 7 gtts/min



203

Calculating Dose with Formula

The client is to receive Isuprel (isoproterenol) at a rate of 4 mcg/min. The concentration

of the Isuprel is 2 mg per 500 mL of IV fluid. Find the pump setting in mL/hr.

Desired dose/min x 60min/hrConcentration/ml

0.004mg/min X 60 min/hr500mg/2mg

204

Review Question

Lidocaine drip to run at 3mg/min. Lidocaine IV comes at 2gm in 500ml of D5W.

Calculate ml/hr.

Calculation: Step 1: convert g to mg

2g = 2000mg

Step 2: 3mg/min x 60min/hr = 180

2000mg/500ml 4

Answer: 45 ml/hr

Desired dose/min x 60min/hr

Concentration/ml



205

Ratio / Proportion

A client is receiving a heparin drip at 22 ml/hr via an infusion pump. The label on

the liter bag of D5W indicates 40,000 U of heparin. How many units of heparin

does the client receive per hour?

1000ml 40,000 units

22ml x units=

1000x 880,000=

x 880units /hours=

206

Pediatric Calculation

A pediatric client is prescribed Ampicillin IVPB 700 mg every 12hours .

The child weighs 17 pounds. Is this a safe dose?

1 kg 7.7 kgs

50 mg x=

x 385 mg/day=

x 192.5 mg/dose=

Safe dose is 50-100 mg/kg/day divided 12 hours

17 pound = 7.7 kgs

1 kg 7.7 kgs

100 mg x=

x 770 mg/day=

x 385 mg/dose=



207

References

✦ Karch, A. ( 2012). Focus on nursing pharmacology. New York: Lippincott Williams & Wilkins.

✦ Lilley, L., Rainworth Collins, S. & Snyder, J. (2014). Pharmacology and the nursing process. St. Louis, MI:

Elsevier.

✦ Adams, M. & Koch, R. (2010). Pharmacology connections to nursing practice. Upper Saddle River, NJ: Pearson.

✦ Burchum, Jacqueline & Rosenthal, Laura (2016). Lehne's Pharmacology for Nursing Care, 9e 9th Edition St.

Louis, MI: Elsevier.

Documents

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