1418 Unit 11 Additional Drug Classes
75.9 Activated charcoal is effective at adsorbing Adverse Effects: Vomiting may occur when given by
(binding) most poisons if administered within rapid ingestion and at high doses. Constipation and diar-
60 minutes of ingestion. rhea have also been reported.
Activated charcoal has been used as an adsorbent for acute Contraindications/Precautions: Activated charcoal
poisoning for almost 200 years. Activated charcoal is the is not effective for poisonings by cyanide, mineral acids,
only FDA-approved poison-adsorbent drug. Although caustic alkalis, organic solvents, iron, ethanol, or methanol
activated charcoal is effective in the treatment of many poi- ingestion. This drug should not be used in patients at a
sons, it is not beneficial when given to individuals with decreased level of consciousness or with a diminished gag
lithium, iron, or cyanide poisoning or strong acid or alkali reflex due to the risk of pulmonary aspiration. Activated
ingestion. charcoal also should not be used in individuals with cen-
tral nervous system depression, coma, or gastrointestinal
PROTOTYPE DRUG Activated Charcoal (CharcoAid) (GI) obstruction.
Classification Therapeutic: Antidote Drug Interactions: Activated charcoal will decrease
Pharmacologic: Adsorbent drug absorption of all other oral medications. Oral medication
should not be given for at least 2 hours after administration
Therapeutic Effect and Uses: Activated charcoal of activated charcoal. Herbal/Food: Milk and dairy prod-
consists of organic material such as coal, wood, or veg- ucts may decrease the effectiveness of activated charcoal.
etables that have been carbonized, reduced, and dried to
a charcoal-like substance. It is then activated by exposing Pregnancy: Category C.
it to steam, carbon dioxide, or other oxidizing chemicals
at extremely high temperatures. The activation drives off Nursing Responsibilities: Key nursing implications
impurities and reduces the particle size so that the surface for patients receiving activated charcoal are included in
area of the charcoal is very large. the Nursing Practice Application for Patients Receiving
Pharmacotherapy for Poisoning or Overdose.
This drug effectively adsorbs toxins in the intestinal
tract, thus preventing their systemic absorption. Adsorp- Drugs Similar to Activated Charcoal
tion is the process of a drug physically binding to the char- (CharcoAid)
coal. As a general-purpose emergency antidote, it is used in
the treatment of poisonings from most drugs and chemi- Activated charcoal is the only drug in this class.
cals. To be most effective, the charcoal should be adminis-
tered within 1 hour of oral ingestion. Normally, a single 75.10 Ion trapping with forced diuresis may be
dose is administered, although some poisons benefit from helpful for some poisonings.
multiple doses. The general dosage is 5 to 10 times the esti-
mated weight of the poison ingested. One procedure that is occasionally used in acute poisoning
is ion trapping through forced diuresis. Because most drugs
Activated charcoal can also be used off-label to adsorb are either weak acids or weak bases, changing the urine pH
intestinal gases in the treatment of dyspepsia, flatulence, can be used to enhance the elimination of some drugs. For
and distention. It is sometimes used topically as a deodor- example, if the urine is made alkaline, the acidic drugs are
ant for foul-smelling wounds and ulcers. trapped in the renal tubules and their elimination in urine
is increased. The opposite effect applies for alkaline drugs.
Mechanism of Action: Activated charcoal (carbon) is
a chemically inert, odorless, tasteless, fine black powder. Forced alkaline diuresis may be used to increase the
It acts by binding (adsorbing) toxic substances, thereby excretion of acidic drugs like salicylates and phenobarbital,
inhibiting their gastric absorption, enterohepatic circula- and forced acid diuresis has been used to eliminate amphet-
tion, and bioavailability. amines, quinine, and strychnine. When forced alkaline
diuresis is employed, a diuretic such as furosemide along
Pharmacokinetics: with IV sodium bicarbonate will make the urine more alka-
line. Forced alkaline diuresis is specifically recommended
Route(s) PO or via nasogastric tube when rhabdomyolysis (the rapid breakdown of skeletal
muscle tissue) occurs.
Absorption Not absorbed
Ascorbic acid is used for forced acid diuresis. In past
Distribution Not distributed systemically decades, ammonium chloride was used for forced acid diure-
sis; however, due to its toxicity its use has greatly diminished.
Primary metabolism Not metabolized Research studies indicate that ion trapping through forced
diuresis produces only a slight increase in the renal clearance
Primary excretion Fecal of the drug and is rarely done in practice.
Onset of action Rapid
Duration of action Unknown
Chapter 75 Emergency Preparedness: Bioterrorism and Management of Poisoning 1419
75.11 Chelating agents are capable of forming Pharmacokinetics:
bonds with heavy metals.
Route(s) IV/IM
Human exposure to metals has risen dramatically in the
past 50 years as a result of an increase in the use of heavy Absorption Rapidly absorbed
metals in industrial processes and products. Chelation
therapy is the use of drugs to detoxify poisonous metals Distribution Distributed to extracellular fluid;
such as mercury, arsenic, and lead by converting them to a
chemically inert form that can be easily excreted. The com- does not enter the cerebrospinal
pound formed by a chelating drug and a metal is called a
chelate. Chelating drugs are most frequently administered fluid
intravenously or intramuscularly depending on the agent
and the type of poisoning. Chelation was introduced dur- Primary metabolism Not metabolized
ing World War I originally as an antidote to arsenic-based
poison gas. Primary excretion Chelated lead is excreted in
The mechanism of action of chelation therapies urine; 50% is excreted in 1 h
involves the chelating drug “latching onto” and removing
positively charged metals from the body. Once the amino Onset of action Peak chelation: 24–48 h
acid binds with the metal or poison, it can be eliminated
from the body by the kidneys. Two chelating drugs are Duration of action Half-life: 20–60 min IV, 90 min IM
described in this chapter. Many times both medications are
given to the individual who is experiencing heavy metal Adverse Effects: Calcium EDTA may produce renal
poisoning. damage such as proteinuria and microscopic hematuria.
Treatment-induced nephrotoxicity is dose dependent and
PROTOTYPE DRUG Edetate Calcium Disodium may be reduced by ensuring adequate diuresis before
(Calcium EDTA) therapy begins. Patients should be monitored for cardiac
rhythm irregularities and other electrocardiogram (ECG)
Classification Therapeutic: Drug for heavy metal changes during IV therapy. Additional cardiovascular
poisoning effects include hypotension and thrombophlebitis.
Pharmacologic: Chelating drug Many patients experience febrile reaction (excessive
thirst, fever, chills, severe myalgia, arthralgia, GI distress) or
Therapeutic Effects and Uses: Approved in 1953, histamine-like reactions (flushing, throbbing headache,
edetate calcium disodium is a chelating drug that binds sweating, sneezing, nasal congestion, lacrimation, postural
with heavy metals such as lead to form a soluble complex hypotension, tachycardia). Black Box Warning: Patients with
that can be excreted by the kidneys, thereby ridding the lead encephalopathy and cerebral edema may experience a
body of the poisonous substance. Although usually used lethal increase in intracranial pressure if the drug is given by
for acute poisoning, this drug can also remove lead that IV infusion. The IM route is preferred for these patients.
is stored in fat, bone, or other locations. Edetate calcium
disodium is administered by the IV or intramuscular (IM) Contraindications/Precautions: Edetate calcium
routes. This drug is generally used in combination with disodium is contraindicated in patients with severe kidney
dimercaprol (BAL) in the treatment of lead encephalopa- disease, anuria, or oliguria. IV administration is contrain-
thy or when the blood lead level exceeds 100 mcg/dL. dicated in patients with lead encephalopathy because of a
possible increase in intracranial pressure.
The off-label uses of edetate calcium disodium include
the treatment of poisoning from other heavy metals such as Drug Interactions: No clinically significant interac-
chromium, manganese, nickel, zinc, and possibly vana- tions have been identified. Herbal/Food: None known.
dium, and removal of radioactive and nuclear fission prod-
ucts such as plutonium, yttrium, and uranium. However, Pregnancy: Category C.
this drug is not effective in treating poisoning from arsenic,
gold, or mercury. Nursing Responsibilities: Key nursing implica-
tions for patients receiving edetate calcium disodium are
Mechanism of Action: As a chelating drug, Calcium included in the Nursing Practice Application for Patients
EDTA combines with metals to form stable, nonioniz- Receiving Pharmacotherapy for Poisoning or Overdose.
ing soluble complexes that can be readily excreted by the
kidneys. Action is dependent on the ability of the heavy PROTOTYPE DRUG Dimercaprol (BAL in Oil)
metal to displace the weakly bound calcium in the drug
molecules. Classification Therapeutic: Antidote
Pharmacologic: Chelating drug
Therapeutic Effects and Uses: Given by the IM
route, dimercaprol is a chelating drug that neutralizes the
effects of various heavy metals such as arsenic, gold, and
mercury. The drug forms stable, nontoxic intermediates
with these metals so they are more easily excreted in the
1420 Unit 11 Additional Drug Classes
urine and bile. Dimercaprol is also used as an adjunct to nausea, vomiting, fatigue, restlessness, apprehension,
EDTA in the treatment of lead encephalopathy. Off-label headache, burning sensation of the mouth, throat, and
uses include chromium dermatitis and ocular and derma- eyes, lacrimation, blepharospasm, salivation, tingling of
tologic manifestations of arsenic poisoning. Some studies extremities, a feeling of constriction in the chest muscle,
indicate that dimercaprol may be used as an adjunct to diffuse pain and muscle spasm, hypertension (systolic and
penicillamine to increase the rate of copper excretion in diastolic), and tachycardia. Most patients report pain at the
Wilson’s disease. Wilson’s disease is a rare genetic disorder injection site.
in which copper builds up in the liver and is released into
other parts of the body. Contraindications/Precautions: Dimercaprol is
contraindicated in individuals with hepatic insufficiency
Mechanism of Action: Dimercaprol forms ring com- (with the exception of postarsenic jaundice); severe kidney
plexes with some heavy metals, such as arsenic, gold, and disease; or poisoning due to cadmium, iron, selenium, or
mercury, preventing or reversing the binding of metallic uranium. Because dimercaprol is formulated in peanut oil,
cations to body proteins. patients with a hypersensitivity to peanut products should
not receive this drug. This drug should be used cautiously
Pharmacokinetics: in patients with hypertension, oliguria, G6PD deficiency,
and preexisting chronic kidney disease (CKD).
Route(s) IM only
Drug Interactions: Dimercaprol should not be given
Absorption Well absorbed when iron, cadmium, selenium, or uranium poisoning
is suspected. When this drug is given in the presence of
Distribution Distributed mainly in intracel- these poisonings, it forms toxic complexes. Herbal/Food:
Unknown.
lular spaces, including the brain;
Pregnancy: Category C.
highest concentration is in the
Nursing Responsibilities: Key nursing implications
liver and kidneys for patients receiving dimercaprol are included in the
Nursing Practice Application for Patients Receiving Phar-
Primary metabolism Unknown macotherapy for Poisoning or Overdose.
Primary excretion Urine and feces
Onset of action Peak: 30–60 min
Duration of action Half-life: unknown
Adverse Effects: About 50% of patients who receive
high therapeutic doses have minor reactions, including
CONNECTIONS: NURSING PRACTICE APPLICATION
Patients Receiving Pharmacotherapy for Poisoning or Overdose
Assessment
Baseline assessment prior to administration:
• Obtain a complete health history including musculoskeletal, GI, cardiovascular, neurologic, endocrine, hepatic, or kidney disease.
• Obtain a drug history including allergies, current prescription and over-the-counter (OTC) drugs, herbal preparations, alcohol use, and smoking. Be
alert to possible drug interactions.
• Obtain baseline weight, vital signs, and assessment of cardiopulmonary status.
• Evaluate appropriate laboratory findings (e.g., hepatic and renal function studies, complete blood count [CBC], and urinalysis).
• Assess the patient’s ability to receive and understand instructions. Include family and caregivers as needed.
Assessment throughout administration and care:
• Assess for desired therapeutic effects (e.g., cardiopulmonary status is maintained, symptoms related to poison or drug overdose are diminishing, level
of consciousness is maintained or improving).
• Continue monitoring vital signs and urine output.
• Continue to monitor hepatic and renal studies, CBC, urinalysis, and other drug-specific laboratory values.
• Assess for and promptly report adverse effects: worsening respiratory distress, decreasing level of consciousness, agitation, confusion, vomiting,
diminished urine output, or dysrhythmias.
Implementation
Interventions and (Rationales) Patient-Centered Care
Ensuring therapeutic effects: • Explain the purpose and expected outcome of antidotes administered
• Administer antidotes, activated charcoal, or chelating agents as to the patient, family, or caregiver.
appropriate for drug overdose or poisoning once the substance is • When no antidote exists for the poisonous substance, inform the
identified. (Commonly known antidotes include acetylcysteine for patient, family, or caregiver what supportive care will be provided.
acetaminophen, flumazenil for benzodiazepines, sodium bicarbonate
for cyclic antidepressants, amyl nitrate for cyanide, naloxone for
opioids, and osmotic diuretics for methanol and ethylene glycol.)
Chapter 75 Emergency Preparedness: Bioterrorism and Management of Poisoning 1421
CONNECTIONS: NURSING PRACTICE APPLICATION (continued)
Implementation
Interventions and (Rationales) Patient-Centered Care
Minimizing adverse effects: • Instruct the patient to notify the healthcare provider if difficulty
• Maintain airway and provide supplemental oxygen as needed. (Patients breathing or swallowing occurs.
with an overdose or poisoning may be unable to maintain a patent
airway, leading to respiratory arrest and death. Intubation also protects
against possible aspiration.)
• Monitor cardiopulmonary status. (Cardiac dysrhythmias and pulmonary • To allay possible anxiety, teach the patient, family, or caregiver the
edema may result from overdose of many poisons, including barbiturates, rationale for all equipment used and the need for frequent monitoring.
sedatives, hypnotics, and tranquilizers. Lifespan: Age-related physiologic
differences or undetected cardiac disease may place the older adult at
greater risk for adverse effects from Calcium EDTA.)
• Administer IV fluids as ordered. (Crystalloid solutions are used to treat • Instruct the patient, family, or caregiver to report burning, swelling, or
hypovolemia, which may occur because of compromised circulatory discomfort at the IV site.
status.)
• Continue to monitor hepatic and renal function laboratory values, CBC, • Explain to the patient, family, or caregiver the need for frequent
and electrolytes. Administer concentrated dextrose solution (D5W) as laboratory work.
ordered. (Hypoglycemia may occur due to acute poisoning or overdose
with agents such as ethanol and salicylates. Nephrotoxicity and • Instruct the patient, family, or caregiver to report symptoms of
hepatotoxicity may occur related to the poisoning or overdose or hypoglycemia such as nervousness, anxiety, hunger, shakiness,
related to adverse effects of the treatment. Lifespan: Age-related perspiration, dizziness, or lightheadedness.
physiologic differences may place older adults at greater risk for
nephrotoxicity and hepatotoxicity.)
• Monitor urinary output. (Observe for changes in urine character and color. • Instruct the patient, family, or caregiver to report any diminished urine
Myoglobin may be present if rhabdomyolysis occurs as a result of output or changes in urine appearance.
overdose, causing a cola-colored or rust-brown appearance to the urine.)
• If ordered, insert a nasogastric tube, aspirate fluid for analysis, and • To allay possible anxiety, teach the patient, family, or caregiver the
perform gastric lavage. (Aspiration and lavage removes drugs that may rationale for the nasogastric tube and procedure.
remain in the stomach, preventing further absorption. Aspirate may be
sent to the laboratory for analysis of the drugs ingested to provide
identification for appropriate treatment.)
• Continue administration of activated charcoal, chelating agents, or • Explain the purpose and expected outcome of activated charcoal,
antidotes as ordered. (Activated charcoal absorbs drugs from gastric chelating agent, or antidote if administered.
content to prevent systemic absorption. Chelating agents bind heavy
metal toxins to remove them from the body.) • Inform the patient, family, or caregiver that stools may become
temporarily black if activated charcoal has been used.
• Prepare the patient for dialysis procedures as ordered. (Peritoneal • Explain the rationale for peritoneal dialysis or hemodialysis to the
dialysis or hemodialysis removes poisons from the system and is used patient, family, or caregiver.
when levels are potentially lethal; otherwise the toxin may be metabolized
to a more lethal substance.)
• Assess for suicidal ideation and refer to a mental health professional as • When suicidal ideation is present and poisoning is self-inflicted, explain
appropriate. (A psychiatric consultation should be ordered for patients the reason for referral to a mental health professional.
who demonstrate suicidal ideations or behaviors.)
• Assess learning needs and provide education related to poisoning and • Instruct the patient, family, or caregiver on the importance of
overdose. (Poisoning may often be prevented by personal and public maintaining a safe environment to prevent recurrence of unintentional
education efforts.) poisonings.
Patient understanding of drug therapy: • The patient, family, or caregiver should be able to state the reason for
• Use opportunities during administration of medications and during the drug, appropriate dose and scheduling, what adverse effects to
observe for and when to report them, and the anticipated length of the
assessments to discuss the rationale for the drug therapy, desired medication therapy.
therapeutic outcomes, commonly observed adverse effects, and any
necessary monitoring or precautions. (Using time during nursing care
helps to optimize and reinforce key teaching areas.)
Understanding Chapter 75
Key Concepts Summary 75.2 Bioterrorism is the intentional release of a virus or
microorganism to cause human harm.
75.1 Emergency preparedness has become an essential
competency for all healthcare professionals.
1422 Unit 11 Additional Drug Classes 75.8 The general management of poisoning includes
contacting the poison control center or emergency
75.3 Nurses may have the first opportunity to medical services as soon as possible.
recognize and initiate a response to bioterrorism.
75.9 Activated charcoal is effective at adsorbing
75.4 The Strategic National Stockpile has large (binding) most poisons if administered within
quantities of medicine to protect the public if a 60 minutes of ingestion.
health emergency arises.
75.10 Ion trapping with forced diuresis may be helpful
75.5 Highly infectious bacteria or viruses could be for some poisonings.
used as bioterrorist threats.
75.11 Chelating agents are capable of forming bonds
75.6 There are 13 categories of toxic chemicals that with heavy metals.
could cause mass casualties if released into the
environment.
75.7 Ionizing radiation produces immediate and long-
term effects on human tissue.
CASE STUDY: Making the Patient Connection
Remember the ED nurse “Carol a series of staff education meetings to discuss bioterrorism
Boler” at the beginning of the threats.
chapter? Now read the remainder
of the case study. Based on the Critical Thinking Questions
information presented within
this chapter, respond to the criti- 1. When discussing the bioterrorism threat with a group
cal thinking questions that of staff nurses, which information regarding smallpox
follow. should be included?
As an ED nurse in a busy urban hospital, Carol Boler par- 2. Identify the nursing assessments and interventions
ticipates in frequent emergency practice drills to be pre- that the nurse should initiate when a patient is
pared for mass casualty events and acts of bioterrorism. exposed to anthrax.
Although there have been no incidents yet, she knows that
with a military base nearby, there is a chance that such an 3. Discuss the mode of transmission and symptoms
incident could occur. She is working with unit staff to plan associated with Y. pestis exposure.
Answers to Critical Thinking Questions are available on the
faculty resources site. Please consult with your instructor.
Additional Case Study 2. What recommendations should you give to the group
about the use of ipecac syrup?
As a school nurse, you have been asked to speak to a group
of mothers about unintentional poisonings in young Answers to Additional Case Study questions are available on
children. the faculty resources site. Please consult with your instructor.
1. Outline the information you need to present to this
audience.
Chapter Review 2. The patient is exhibiting the symptoms of Yersinia
pestis exposure. Which pharmacologic therapy would
1. The patient is suspected of having been exposed to most likely be used in the treatment of this patient?
ionizing radiation. Which nursing intervention would
have the greatest priority? 1. Doxycycline
2. Trivalent botulinum antitoxin
1. Provide supportive care for nausea, vomiting, and 3. Ribavirin
diarrhea. 4. Atropine sulfate
2. Limit the patient’s exposure to ultraviolet light.
3. Avoid contamination of self through limited
exposure to the patient.
4. Administer antiradiation medications as indicated.
Chapter 75 Emergency Preparedness: Bioterrorism and Management of Poisoning 1423
3. The nurse has received a telephone call from an anx- 5. The nurse knows that the mechanism of action for
ious mother of an 18-month-old child. In a panicked chelating therapy is:
voice, the mother states, “I just discovered that my
baby has swallowed an unknown amount of house- 1. Removal of positively charged metals.
hold cleanser.” Which instruction would be appropri- 2. Deactivation of chemical reaction.
ate for the nurse to give? 3. Increased liver metabolism.
4. Decreased glomerular filtration.
1. “Consult the package instructions for information
concerning poisoning.” 6. Which of the preadministration assessment parame-
ters would the nurse consider before administering
2. “Force your child to vomit using a mixture of edetate calcium disodium (Calcium EDTA) to a
warm water and raw eggs.” patient?
3. “Call 911 to take your child immediately to the 1. Bowel sounds
nearest emergency department or healthcare 2. Urinary output
agency.” 3. Visual acuity
4. Skin turgor
4. “If your child develops seizures or difficulty
breathing, call the healthcare provider.” See Answers to Chapter Review in Appendix A.
4. Activated charcoal is ordered for a patient who unin-
tentionally overdosed on prescription medications.
The nurse would question the order for activated
charcoal for the patient with which condition?
1. Acute hepatitis and cirrhosis
2. Chronic kidney disease
3. Decreased level of consciousness
4. Anxiety and nervousness
References Edgewood Chemical Biological Center. (n.d.). Biological
and chemical agent quick reference tables. Retrieved from
Centers for Disease Control and Prevention. (n.d.). http://www.ecbc.army.mil/hld/ip/bca_qr.htm
Emergency preparedness & response: CDC bioterrorism
agents/diseases. Retrieved from https://fas.org/ Madrid, P. B., Chopra, S., Manger, I. D., Gilfillan, L.,
biosecurity/resource/documents/CDC_Bioterrorism_ Keepers, T. R., Shurtleff, A. C., . . . Tanga, M. J. (2013). A
Agents.pdf systematic screen of FDA-approved drugs for inhibitors
of biological threat agents. PLoS One, 8, e60579.
Centers for Disease Control and Prevention. (2017). doi:10.1371/journal.pone.0060579
Anthrax vaccine. Retrieved from https://www.cdc.gov/
vaccines/hcp/vis/vis-statements/anthrax.html Streatfield, S. J., Kushnir, N., & Yusibov, V. (2015). Plant-
produced candidate countermeasures against emerging
Dean, S. N., & van Hoek, M. L. (2015). Screen of FDA- and reemerging infections and bioterror agents. Plant
approved drug library identifies maprotiline, an Biotechnology Journal, 13, 1136–1159. doi:10.1111/
antibiofilm and antivirulence compound with QseC pbi.12475
sensor-kinase dependent activity in Francisella novicida.
Virulence, 6, 487–503. doi:10.1080/21505594.2015.1046029 U.S. Nuclear Regulatory Commission. (2014). Backgrounder
on the Three Mile Island accident. Retrieved from http://
Dowell, D., Hagerich, T. M., & Chou, R. (2016). CDC www.nrc.gov/reading-rm/doc-collections/fact-
guideline for prescribing opioids for chronic pain— sheets/3mile-isle.html
United States, 2016. MMWR Recommendation and
Reports, 65(No. RR-1), 1–49.
Selected Bibliography Adalja, A. A., Toner, E., & Inglesby, T. V. (2015). Clinical
management of potential bioterrorism-related
Aaseth, J., Skaug, M. A., Cao, Y., & Andersen, O. (2015). conditions. New England Journal of Medicine, 372,
Chelation in metal intoxication—principles and 954–962. doi:10.1056/NEJMra1409755
paradigms. Journal of Trace Elements in Medicine and
Biology, 31, 260–266. doi:10.1016/j.jtemb.2014.10.001
1424 Unit 11 Additional Drug Classes
Andersen, O., & Aaseth, J. (2016). A review of pitfalls and Veenema, T. G., Griffin, A., Gable, A. R., MacIntyre, L.,
progress in chelation treatment of metal poisonings. Simons, R. N., Couig, M. P., . . . Larson, E. (2016).
Journal of Trace Elements in Medicine and Biology, 38, Nurses as leaders in disaster preparedness and
74–80. doi:10.1016/j.jtemb.2016.03.013 response—a call to action. Journal of Nursing Scholarship,
48, 187–200. doi:10.1111/jnu.12198
Cao, Y., Skaug, M. A., Andersen, O., & Aaseth, J. (2014).
Chelation therapy in intoxications with mercury, lead Villarreal, J., Kahn, C. A., Dunford, J. V., Patel, E., & Clark,
and copper. Journal of Trace Elements in Medicine and R. F. (2015). A retrospective review of the prehospital
Biology, 31, 188–192. doi:10.1016/j.jtemb.2014.04.010 use of activated charcoal. The American Journal of
Emergency Medicine, 33, 56–59. doi:10.1016/j.
Moore, B. L., Geller, R. J., & Clark, C. (2015). Hospital ajem.2014.10.019
preparedness for chemical and radiological disasters.
Emergency Medicine Clinics of North America, 33, 37–49. Wilkinson, A. M., & Matzo, M. (2015). Nursing education
doi:10.1016/j.emc.2014.09.005 for disaster preparedness and response. The Journal of
Continuing Education in Nursing, 46(2), 65–73.
Stokowski, L. A. (2015). Ready, willing and able: Preparing doi:10.3928/00220124-20150126-01
nurses to respond to disasters. Retrieved from http://
www.medscape.com/viewarticle/579888_8
Appendix A
Answers to Chapter Review
Chapter 1 Chapter 2
1 Answer: 3 Rationale: Indications are the conditions for 1 Answer: 2 Rationale: The FDA requires that drug manufactur-
which a particular drug is approved. Options 1, 2, and 4 are incor- ers demonstrate both the safety and effectiveness of pharmaceutical
rect. A description of how a drug works on its target organs and products. Options 1, 3, and 4 are incorrect. All drugs have potential
cells is called the mechanism of action. The dosage is the amount reactions and adverse effects. Many factors determine the cost of a
of the drug that is given. The conditions whereby the drug should drug, and newly approved drugs may be the most expensive and
be avoided are contraindications. Cognitive Level: Applying; Cli- not fully covered by healthcare insurance plans. Not all drugs have
ent Need: Safe and Effective Care Environment; Nursing Process: been tested in diverse populations, and women, minority ethnic
Implementation groups, children, and older adults are often underrepresented in
2 Answer: 3 Rationale: Like the original reference product drug research studies. Cognitive Level: Applying; Client Need: Safe
drug, biosimilars are derived from living cells, such as yeast or bac- and Effective Care Environment; Nursing Process: Implementation
teria. They are not exact, duplicate copies of the original medica- 2 Answer: 2 Rationale: Phase 2 of the clinical investigation
tion, but have comparable effectiveness and safety. Options 1, 2, relies on studying patients with the disease to be treated. Options
and 4 are incorrect. Because it is not an exact duplicate copy of the 1, 3, and 4 are incorrect. Phase 1 studies use small groups of
original drug, it cannot be considered a generic drug. It is not in a healthy participants. Phase 3 studies use large numbers of partici-
different therapeutic or chemical class because it differs little from pants with the condition being treated by the drug. Phase 4 is con-
the reference product. It must still be evaluated by the FDA, and sidered postmarketing surveillance after the drug has been
demonstrate that the biosimilar differs very little from the approved approved. Cognitive Level: Applying; Client Need: Safe and
reference product, before it is approved. Cognitive Level: Applying; Effective Care Environment; Nursing Process: Implementation
Client Need: Physiological Integrity; Nursing Process: Assessment 3 Answer: 2 Rationale: Most drug testing occurs using adult,
3 Answer: 1, 2, 4 Rationale: Monitoring patient response to white, non-Hispanic men, which may limit the generalization of
drug therapy, teaching the patient about self-administration and the results to other populations. Options 1, 3, and 4 are incorrect.
how to monitor drug effects, and verifying drugs currently being Drug testing is seldom performed on children, women, or older
used by the patient are all key nursing responsibilities. Options 3 adults. Although many drugs are tested using animals, effective-
and 5 are incorrect. The prescribing provider weighs alternative ness in animals does not always verify that the drug will be effec-
treatment options, but may not consider all available options due tive in humans. Cognitive Level: Applying; Client Need: Safe and
to many variables such as cost or complexity of treatment. Effective Care Environment; Nursing Process: Implementation
Whereas the best option to treat a patient’s condition will be cho- 4 Answer: 4 Rationale: Telephone orders are not permissible
sen, the “ideal drug” does not exist because each patient’s out- under federal law for Schedule II controlled substances. Options 1,
comes from drug therapy will be affected by many variables. 2, and 3 are incorrect. Refill prescriptions are usually not any more
Cognitive Level: Applying; Client Need: Health Promotion and or less expensive than the original prescription. The number of lis-
Maintenance; Nursing Process: Implementation teners is irrelevant. Prescriptions are not confirmed or verified by
4 Answer: 1, 2, 3, 4 Rationale: Physiologic responses to drug the DEA. Cognitive Level: Applying; Client Need: Safe and Effec-
therapy are affected by a patient’s age, gender, race, body mass, tive Care Environment; Nursing Process: Implementation
and health status. Many diseases such as diabetes have genetic 5 Answer: 1 Rationale: The more likely a drug’s potential for
origins. Familial history of disease conditions may reflect poten- abuse and dependency, the stricter the regulation to control access
tial problems in the patient. Option 5 is incorrect because not hav- to the substance. Options 2, 3, and 4 are incorrect. The cost and
ing medical insurance is not a physiologic variable that would production difficulty do not influence the degree of regulation.
affect drug therapy. Cognitive Level: Applying; Client Need: Adverse effects and drug or food interactions do not dictate the
Physiological Integrity; Nursing Process: Evaluation level of regulatory control. The length of time taken to confirm
5 Answer: 2 Rationale: Antihypertensive indicates the thera- that a drug is effective does not affect the degree of regulation.
peutic classification of the drug by describing its usefulness in Cognitive Level: Applying; Client Need: Safe and Effective Care
lowering blood pressure. Options 1, 3, and 4 are incorrect. Beta- Environment; Nursing Process: Implementation
adrenergic antagonists, diuretics, and calcium channel blockers 6 Answer: 1, 2, 3 Rationale: Adverse drug reactions may con-
all focus on how the drug works, rather than on what therapeutic tinue to be discovered well after the FDA approval process as
effects occur. Cognitive Level: Applying; Client Need: Physiologi- larger groups of patients take the drug. Any reaction should be
cal Integrity; Nursing Process: Implementation noted in the patient’s chart, the provider notified, and an Adverse
6 Answer: 4 Rationale: Motrin and Advil are trade names for Event Report filed with the FDA when adverse reactions are
the generic drug ibuprofen. Options 1, 2, and 3 are incorrect. No noted. Options 4 and 5 are incorrect. Healthcare providers are
error is noted because “ibuprofen” is the generic name for Advil responsible for reporting adverse reactions as they occur and
and Motrin, both trade names. Each drug has only one generic should not wait for the FDA to send a recall notice. Many factors
name but may have different trade names, depending on the com- influence a patient’s reaction to medications and each patient may
pany that manufactures the drug. Cognitive Level: Applying; Cli- not have the same exact reaction to the medication. Cognitive
ent Need: Health Promotion and Maintenance; Nursing Process: Level: Applying; Client Need: Safe and Effective Care Environ-
Implementation ment; Nursing Process: Implementation
1425
1426 Appendix A Answers to Chapter Review
Chapter 3 Chapter 4
1 Answer: 2 Rationale: Although taking a larger dose of a 1 Answer: 1, 2, 3, 5 Rationale: One of the critical determinants
medication usually results in a greater therapeutic response, the of the effectiveness of drug therapy is a physical examination.
response also depends on the drug’s plasma concentration. If a Nurses will utilize assessment skills to ascertain whether the drug
toxic level is reached from too large a dose, the drug will have is being effective. In many cases, a patient’s vital signs may indi-
adverse effects instead of a better therapeutic response. Options 1, cate the effectiveness of a drug such as a decrease in body tem-
3, and 4 are incorrect because they are true statements. The liquid perature, a change in blood pressure and pulse, or improved
form of a drug will be absorbed faster than its tablet form. Food respiratory status. The effects of many drugs are monitored by
decreases the absorption rate of most drugs. Patients should diagnostic laboratory values such as white blood cell counts, cul-
always consult a healthcare provider if unexpected adverse effects tures, and various electrolyte values. Efficacy is the term that
develop. Cognitive Level: Applying; Client Need: Physiological describes the ability of a drug to produce the desired therapeutic
Integrity; Nursing Process: Evaluation effect. Option 4 is incorrect. The dosage time does not directly
2 Answer: 1 Rationale: Infants do not develop a mature micro- evaluate the effectiveness of drug therapy. Cognitive Level:
somal enzyme system until they are a year old and therefore do Applying; Client Need: Physiological Integrity; Nursing Process:
not metabolize drugs very efficiently. Options 2, 3, and 4 are incor- Implementation
rect. Pregnancy does not significantly affect drug metabolism. The
concern with pregnant patients is primarily focused on alterations 2 Answer: 1 Rationale: The therapeutic index is the ratio
in distribution due to the fetal–placental barrier. The presence of between the therapeutic dose of a drug and the toxic dose and is
kidney stones would not influence drug metabolism. Hyperten- used as a measure of the relative safety of the drug. The higher the
sion is not a factor that directly results in abnormal metabolism. therapeutic index is, the safer the drug. Options 2, 3, and 4 are
Cognitive Level: Applying; Client Need: Physiological Integrity; incorrect. A drug may be labeled “dangerous” for many reasons
Nursing Process: Implementation other than the therapeutic index, including potential for abuse.
3 Answer: 3 Rationale: Peristalsis is the wavelike muscular The higher the therapeutic index is, the less risk of drug toxicity. A
contraction of the gastrointestinal tract that propels stomach and high degree of safety does not signify the degree of effectiveness.
intestinal contents through the system. An increase in this activity Cognitive Level: Applying; Client Need: Physiological Integrity;
would decrease the time that drugs would remain in the GI sys- Nursing Process: Assessment
tem and therefore decrease absorption. Options 1, 2, and 4 are
incorrect. Excretion for most drugs occurs mostly through the kid- 3 Answer: 1 Rationale: A dose–response curve is a graphic rep-
neys, lungs, and glands. Peristalsis would not reduce excretions of resentation that shows the relation between the amount of a drug
medications. A delay in peristalsis would prolong absorption administered and the extent of response it produces. Options 2, 3,
time, and peristalsis is not involved in the distribution of drugs to and 4 are incorrect. A dose–response curve does not illustrate the
their target sites. Cognitive Level: Applying; Patient Need: Physi- toxic effects related to a drug or any specific population or graphi-
ological Integrity; Nursing Process: Evaluation cally present the duration of action of a drug. Serum drug levels
4 Answer: 3 Rationale: Inhaled drugs produce an immediate must be measured to determine the peak serum drug level. It is
therapeutic response. Options 1, 2, and 4 are incorrect. Inhaled unique to each patient and the dose–response curve only represents
medication can be used at any time during the day and is not a maximum (toxic) dose level. Cognitive Level: Applying; Client
restricted to the morning. Doses for inhaled drugs are small com- Need: Physiological Integrity; Nursing Process: Assessment
pared to orally ingested medications, and because these drugs go
directly to the lung surface area and are readily absorbed, very d4o seA. nTshwiseirn:f4o rmRaattiioonnainled:iTcahteesTtDhe50dmoeseastuhraetswthilel median toxicity
little of the substance is lost due to metabolism. Cognitive Level: produce a given
Applying; Client Need: Physiological Integrity; Nursing Process: toxicity in 50% of a group of patients. Options 1, 2, and 3 are incor-
Evaluation rect. Effectiveness, dose response, and receptor subtypes are not
5 Answer: 4 Rationale: The length of time a drug concentra- Nreeperdes: ePnhtyesdioblyogtihcealTInDt5e0glreivtye;l.NCuorgsinnigtivPeroLceevsse:l:ImApplpelmyienngt;atCiolinent
tion remains in the therapeutic range is its duration of action.
Patients with hepatic impairment do not effectively metabolize 5 Answer: 2 Rationale: Antagonists bind to receptors and
drugs, which increases the duration of action. Options 1, 2, and 3 block the effects of an endogenous chemical or another drug by
are incorrect. In patients with hepatic disease, the duration of competing with receptor binding sites or inhibiting the drug
action most likely will increase since drug metabolism is impaired. effect. As an antagonist, benztropine would block the effects of
Although the duration of action is extended, the effects of the neostigmine and the neostigmine would exhibit a lesser effect.
drug are not improved. Cognitive Level: Applying; Client Need: Options 1, 3, and 4 are incorrect. A drug that produces an effect
Physiological Integrity; Nursing Process: Evaluation after binding with a receptor is an agonist. Cognitive Level: Ana-
6 Answer: 2, 4 Rationale: A therapeutic drug level that is in lyzing; Client Need: Physiological Integrity; Nursing Process:
the acceptable range indicates that the drug is at a minimally Implementation
effective concentration but not at a toxic level. Because each
patient’s response to a drug is unique, the nurse should continue 6 Answer: 1 Rationale: Potency is a reflection of a drug’s abil-
monitoring the patient throughout the drug’s use. Options 1, 3, ity to bind to a receptor. Options 2, 3, and 4 are incorrect. Efficacy
and 5 are incorrect. Because individual patient responses to drugs and the affinity of a drug to bind to a receptor are separate vari-
can be highly variable, adverse effects, toxicities, or even no effect ables from potency. Metabolism is a function of pharmacokinetics,
may occur at levels within the therapeutic range. For that reason, not pharmacodynamics. First-pass effect is a phenomenon that
the drug dose may need to be adjusted throughout therapy. Ther- occurs during enteral absorption and does not affect drug affinity.
apeutic effectiveness of a drug depends on many factors and the Cognitive Level: Applying; Client Need: Physiological Integrity;
therapeutic range of a drug is the level between minimally effec- Nursing Process: Implementation.
tive and toxic levels. It is not an indicator of how effective a drug
will be in treating an individual condition. Cognitive Level: Chapter 5
Applying; Client Need: Physiological Integrity; Nursing Process:
Evaluation 1 Answer: 1 Rationale: Collecting additional information will
provide the prescriber with knowledge about the type and sever-
ity of the reaction to that specific drug and will assist in determin-
ing the appropriateness of the order. Options 2, 3, and 4 are
incorrect. The nurse should gather additional information from
Appendix A Answers to Chapter Review 1427
the patient or family member before notifying the prescriber. A relaying clinical findings and assessment. Cognitive Level: Apply-
medication is never administered to a patient when allergic sensi- ing; Client Need: Safe and Effective Care Environment; Nursing
tivity is suspected until further investigation into the type and Process: Implementation
severity of the reaction has been completed. Although documen- 2 Answer: 1 Rationale: Whenever a medication order is
tation of the event may be in the patient’s medical record, the unclear, the nurse should always contact the prescriber, and then
reaction may not have been documented or may have occurred have the order rewritten to prevent errors. Options 2, 3, and 4 are
after the last healthcare visit. Cognitive Level: Applying; Client incorrect. Having another nurse read the order will not necessarily
Need: Physiological Integrity; Nursing Process: Assessment ensure that the dosage is correct for the patient’s condition.
2 Answer: 1 Rationale: As the dose increases, the risk for Whereas the pharmacist or a drug guide may provide the nurse
adverse effects also increases. The patient should be closely with the usual dose for most patients, they do not take into consid-
observed for the onset of adverse effects whenever the dose of the eration the patient’s weight, disease condition, and other variables
drug is increased. Options 2, 3, and 4 are incorrect. Although that influence the drug’s pharmacokinetic and pharmacodynamic
adverse effects are sometimes noted after the first dose, they may actions. Cognitive Level: Applying; Client Need: Safe and Effective
occur at any time during drug administration. Although some Care Environment; Nursing Process: Implementation
adverse effects are common when a drug is given PO, others are 3 Answer: 2 Rationale: Pharmacies maintain records of medi-
more common when given by other routes, such as IV or IM. The cation dispensed to individuals. If a pharmacist can conduct a
timing of medication is not a factor associated with dose-related medication reconciliation by reviewing the patient’s drug history
adverse effects. Cognitive Level: Applying; Client Need: Physio- on each subsequent visit, serious potential drug–drug interactions
logical Integrity; Nursing Process: Implementation may be identified. Options 1, 3, and 4 are incorrect. Insisting on
3 Answer: 4 Rationale: Promoting adequate hydration may acquiring a trade-name drug rather than a generic does not ensure
significantly reduce the risk of renal damage produced by drug the safety of a medication. For safety reasons, drugs are dispensed
therapies. Options 1, 2, and 3 are incorrect. Avoiding direct sun- in containers that are sometimes difficult to open. Unless there is a
light is appropriate teaching for patients receiving drugs that specific reason (such as impaired hand dexterity), medications
cause photosensitivity or phototoxicity. Consuming potassium- should be stored in their original safety bottles. Information found
enriched foods will not reduce the risk of drug-induced nephro- on the internet may vary in quality and may be provided by non–
toxicity, nor will avoiding alcohol consumption. Cognitive Level: healthcare-related sources. When in doubt, the prescriber or phar-
Applying; Client Need: Physiological Integrity; Nursing Process: macist can provide the most accurate information about expected
Implementation effects. Cognitive Level: Applying; Client Need: Health Promo-
4 Answer: 3 Rationale: Urticaria or hives, with raised, itchy tion and Maintenance; Nursing Process: Implementation
areas of skin, is often a sign of an allergic reaction. Options 1, 2, 4 Answer: 3 Rationale: The nurse should always validate a
and 4 are incorrect. Angioedema is a notable swelling around the questionable order when a patient or a family member verbalizes
eyes and lips and sometimes of the hands and feet that occurs concern. Options 1, 2, and 4 are incorrect. Medications purchased
beneath the skin instead of on the surface. SJS is characterized by by a clinical agency vary in appearance depending on the manu-
a flulike period of fever, sore throat, and headache followed by the facturer. The nurse should withhold the medication and then con-
sudden development of circular lesions that cover the majority of firm that it is the correct drug as ordered before administering. If
the skin. Photosensitivity occurs when a drug renders the skin a patient questions a change in medication or procedure, the
susceptible to damage by sunlight. Cognitive Level: Applying; nurse should verify the order and obtain validation from the pre-
Client Need: Physiological Integrity; Nursing Process: Evaluation scriber. Cognitive Level: Applying; Client Need: Safe and Effec-
5 Answer: 2 Rationale: The function of the bone marrow is to tive Care Environment; Nursing Process: Implementation
produce blood cells. When drugs cause bone marrow toxicity, the 5 Answer: 1 Rationale: The nurse’s first priority is always the
condition manifests as a decrease in all blood cell types. Options patient. The nurse should first determine the patient’s baseline
1, 3, and 4 are incorrect. Muscle and bone pain are most often assessment data in order to determine if any adverse effects are
associated with muscle toxicity. Bone marrow toxicity is not occurring. Options 2, 3, and 4 are incorrect. The healthcare pro-
related to a decline in an individual’s range of motion. Liver vider should be notified of the medication error; however, it is
enzymes are not typically affected by bone marrow toxicity. Cog- also important to report the patient’s assessment data at the same
nitive Level: Applying; Client Need: Physiological Integrity; time. All healthcare agencies have reporting mechanisms for drug
Nursing Process: Evaluation errors, and the nurse is responsible for completing this process
6 Answer: 3 Rationale: The presence of right upper quadrant after assessing the patient and notifying the provider. If the
pain and anorexia are early symptoms often associated with drug- patient experiences an adverse reaction to the drug, further
induced liver damage. Options 1, 2, and 4 are incorrect. Black, assessment is needed before confirming that the drug itself, rather
“furry” tongue or infections elsewhere are not related to liver than a patient variable (e.g., allergy), was behind the reaction
damage. A sudden drop in blood pressure is orthostatic hypoten- before filing an adverse drug reaction report (see Chapter 5). Cog-
sion. Unusual and uncontrolled movements are neurologic- nitive Level: Applying; Client Need: Safe and Effective Care Envi-
related effects. Cognitive Level: Analyzing; Client Need: ronment; Nursing Process: Implementation
Physiological Integrity; Nursing Process: Evaluation 6 Answer: 3 Rationale: Returning when the patient is avail-
able ensures that the patient takes the medication and offers
Chapter 6 opportunity for the nurse to assess for effects or provide teaching
related to the medication. Options 1, 2, and 4 are incorrect. A
1 Answer: 4 Rationale: When medication orders are given via nurse must ensure that the patient takes the medication. By leav-
telephone, it is critical for the nurse to repeat the order verbatim to ing the medication at the bedside or with visitors, the nurse will
the prescriber. Options 1, 2, and 3 are incorrect. Whenever possi- not know with certainty that the patient took the medication.
ble it is best for the prescriber to write an order for medication, When a patient refuses a medication, the nurse should document
but this is not always possible. It is correct for the nurse to attempt reasons for the refusal so that appropriate follow-up may be car-
to comfort the patient using a number of nursing interventions for ried out. In this situation, the patient did not refuse the medica-
pain. However, the nurse is required to consult the prescriber tion but was not available to take it at that moment. Cognitive
when a change in the patient’s status occurs, regardless of the Level: Applying; Client Need: Safe and Effective Care Environ-
time. The nurse is responsible for contacting the prescriber and ment; Nursing Process: Implementation
1428 Appendix A Answers to Chapter Review
Chapter 7 likely to hold unrealistic expectations for herbal products. Cogni-
tive Level: Applying; Client Need: Physiological Integrity; Nurs-
1 Answer: 1 Rationale: Although CAM medications have been ing Process: Evaluation
used for thousands of years, many of these substances lack ade-
quate scientific clinical studies to verify their effectiveness. Most Chapter 8
healthcare providers are hesitant to recommend a substance that
has questionable effectiveness. Options 2, 3, and 4 are incorrect. 1 Answer: 2 Rationale: It is recommended that all drugs be
CAM has a rich history of use over thousands of years in treating avoided as much as possible during pregnancy due to the poten-
certain diseases and conditions. To imply that all alternative ther- tial effect on the fetus or infant. Options 1, 3, and 4 are incorrect.
apies are nothing more than fable is incorrect. There is no evi- Drugs that are available OTC may also be hazardous and may
dence that response to CAM therapies is related to the placebo affect the unborn fetus and nursing infant. Drugs used for treat-
effect. In many cases the CAM therapy may be less expensive than ing medical conditions such as asthma, hypertension, diabetes,
prescription medications. Cognitive Level: Applying; Client and epilepsy should be continued throughout pregnancy after
Need: Safe and Effective Care Environment; Nursing Process: review by the healthcare provider for the safety of both mother
Implementation and infant. There must be close monitoring during this time. In
2 Answer: 3 Rationale: It is best to advise the patient to take such cases the benefits may outweigh the risks. The woman
small amounts of a new supplement to determine any initial intol- should consult with her healthcare provider regarding any drugs
erance. Options 1, 2, and 4 are incorrect. Doubling dosages can be taken during pregnancy and lactation. Cognitive Level: Apply-
extremely dangerous and is seldom, if ever, advisable. There is no ing; Client Need: Physiological Integrity; Nursing Process:
indication that fluid intake should be reduced with echinacea. Implementation
Allergic reactions are possible with natural supplements. Patients 2 Answer: 4 Rationale: Drugs in category X are clearly contra-
should be taught to read the label carefully and avoid any supple- indicated because they pose serious risk to the fetus. Options 1, 2,
ment that contains any known allergy-provoking substances. and 3 are incorrect. Category A drugs are safe for the pregnant
Cognitive Level: Applying; Client Need: Physiological Integrity; woman because they demonstrate no risk of injury to the unborn
Nursing Process: Implementation fetus. Category B consists of drugs that may be given to the
3 Answer: 1 Rationale: Older adults with hepatic disease are mother during pregnancy. Drugs in category C represent those
at higher risk of developing serious drug reactions when taking whereby there is insufficient evidence that the drug is either safe
dietary supplements. Options 2, 3, and 4 are incorrect. Patients or dangerous to the fetus, and these drugs will be evaluated by
with cardiac irregularities, pneumonia, or acne may require tradi- the provider to determine if the benefit outweighs the risk. Cogni-
tional medications and should be encouraged to consult their tive Level: Applying; Client Need: Physiological Integrity; Nurs-
healthcare provider. If the patient prefers to use CAM, this can ing Process: Implementation
also be discussed with the provider at the time of the healthcare 3 Answer: 1 Rationale: Although multiple factors affect the
visit. Cognitive Level: Applying; Client Need: Physiological transfer of drugs across the placenta, highly lipid soluble drugs
Integrity; Nursing Process: Evaluation will cross the placental barrier more easily than water-soluble
4 Answer: 1, 2, 3, 5 Rationale: Dietary supplements can be drugs. Options 2, 3, and 4 are incorrect. Small molecules such as
found in almost every supermarket, pharmacy, and health food alcohol easily cross the placental barrier, whereas larger molecules
store. Due to aggressive marketing, herbal supplements are also are slower to cross. When drugs are highly protein bound, they
extremely popular. Most dietary supplements are less expensive are too large to cross the placental membrane. Cognitive Level:
than prescribed medications and are therefore more appealing to Applying; Client Need: Health Promotion and Maintenance;
individuals for whom cost is a critical issue. Older patients may Nursing Process: Implementation
also seek therapeutic alternatives for chronic health conditions. 4 Answer: 1 Rationale: Weeks 1–2 of the first trimester are
Option 4 is incorrect. Natural substances are not necessarily safer known as the preimplantation phase. Before implantation, the
than synthetic products and do not undergo the same rigorous developing embryo has not yet established a blood supply with
testing as synthetic products. Cognitive Level: Applying; Client the mother. This is sometimes called the “all-or-none” period
Need: Safe and Effective Care Environment; Nursing Process: because exposure to a teratogen either causes death of the embryo
Implementation or has no effect. Drugs are less likely to cause congenital malfor-
5 Answer: 1 Rationale: The USP verified dietary supplement mations during this period because the baby’s organ systems
mark is awarded to dietary supplements that pass verification have not yet begun to form. Options 2, 3, and 4 are incorrect
processes. The mark represents that USP has tested the supple- because the embryonic period is 3 to 8 weeks postconception.
ment to verify that the label accurately reflects the product in the During the embryonic period there is rapid development of inter-
bottle and that the supplement does not contain harmful levels of nal structures and maximum sensitivity to teratogens. Teratogenic
contaminants. Options 2, 3, and 4 are incorrect. A DEA number is drugs taken during this phase can lead to structural malformation
assigned to a healthcare provider and allows him or her to write and spontaneous abortion. The specific abnormality depends on
prescriptions for controlled substances such as a narcotic. The which organ is forming at the time of exposure. Cognitive Level:
FDA does not control herbal supplements and this code does not Analyzing; Client Need: Physiological Integrity; Nursing Process:
exist. U.S. Customs is not responsible for ensuring that herbal Planning
supplements are pure. Cognitive Level: Applying; Client Need: 5 Answer: 1, 3, 4, and 5 Rationale: OTC drugs are generally
Safe and Effective Care Environment; Nursing Process: safe when taken as directed but any drug taken by the mother
Implementation should be discussed with the healthcare provider first. Lowering
6 Answer: 4 Rationale: Changes in liver or kidney function in the dose will not alter the safety profile of an unsafe OTC drug.
the older adult may lead to changes in metabolism or excretion for Medications are found in breast milk and may be ingested by the
herbal as well as synthetic medications. Options 1, 2, and 3 are infant. The provider will review any prescription medications the
incorrect. Older adults are no more likely to have difficulty taking mother is taking and will plan for alternatives if any are unsafe
herbal medications or to spend more money on these products during breastfeeding. The form of the medication does not affect
than the younger adult population. These difficulties are patient the passage of the drug into the breast milk. Option 2 is incorrect.
specific at any age. Due to aggressive marketing campaigns by the It is true that the higher the dose, the more likely it is that the drug
herbal and dietary supplement industry, all age groups are as will enter the breast milk and the patient has understood that part
Appendix A Answers to Chapter Review 1429
of the teaching. Cognitive Level: Analyzing; Client Need: Health high potential for drug interactions. Options 1, 2, and 4 are incor-
Promotion and Maintenance; Nursing Process: Evaluation rect. Low-potency drugs, drugs with a wide therapeutic index,
6 Answer: 3 Rationale: Increased levels of progesterone cause and drugs applied to the skin are at low risk for drug interactions.
a decrease in gastric tone and intestinal motility, resulting in Cognitive Level: Applying; Client Need: Physiological Integrity;
delayed gastric emptying. This leads to extended time for drug Nursing Process: Evaluation
absorption. Options 1, 2, and 4 are incorrect. Medications may 6 Answer: 1 Rationale: Children and their parents are most
take a longer time to be absorbed and distributed, thus delaying likely to adhere if their medication regimen is simple and inex-
their onset and prolonging their duration of action. Due to the pensive. Options 2, 3, and 4 are incorrect. Patients are less likely to
changes in body fluid volume associated with pregnancy, there is adhere to the regimen if the medications are costly, they have to be
greater hemodilution, not hemoconcentration, of drugs. Of all taken over an extended period of time, or they have to be taken at
pharmacokinetic factors, drug metabolism is least affected by varying times during the day. Cognitive Level: Analyzing; Client
pregnancy. Cognitive Level: Applying; Client Need: Physiological Need: Physiological Integrity; Nursing Process: Planning
Integrity; Nursing Process: Implementation
Chapter 9 Chapter 10
1 Answer: 1, 3 Rationale: In young children, delayed gastric 1 Answer: 1, 2 Rationale: Increased gastric pH is a common
emptying causes oral medications to remain in the stomach lon- physiologic condition of aging that can affect absorption by
ger, resulting in slowed absorption and an increased risk for increasing the time it takes for oral medications to dissolve.
adverse drug reactions. Between ages 3 and 5, the liver’s meta- Decreased blood flow to the GI tract decreases the amount of
bolic rate reaches adult levels. Before age 5, extra caution and dos- absorption as well as distribution. Options 3, 4, and 5 are incor-
age adjustments may be required, particularly for drugs that are rect. GI motility slows in the older adult and increased body sur-
metabolized primarily in the liver. Options 2, 4, and 5 are incor- face area does not directly impact the area of absorption of oral
rect. Before 6 months of age, there are very small amounts of drugs. The older adult may have decreased cardiac output, but
plasma proteins, and drugs that are normally protein bound this will not affect the absorption of a drug. Cognitive Level:
remain as free drugs, increasing drug distribution and increasing Understanding; Client Need: Physiological Integrity; Nursing
the risk for adverse effects. Drug excretion through the kidneys Process: Implementation
increases with age, and standard pediatric doses may be used 2 Answer: 2 Rationale: A patient who is functioning indepen-
between 3 and 5 months of age. Cautious monitoring should be dently in all ADLs should be encouraged to take full responsibil-
continued even after this age, especially with drugs known to be ity for self-administering medications. Options 1, 3, and 4 are
nephrotoxic. The blood–brain barrier is not well developed at incorrect. Teaching the daughter to administer the insulin may
birth and drugs can easily penetrate the CNS, causing heightened become an option if the patient does not want to or cannot self-
effects. Cognitive Level: Applying; Client Need: Physiological administer the drug, but that is not noted at this time. There is no
Integrity; Nursing Process: Planning reason for recommending a home health aide if the patient is com-
2 Answer: 1 Rationale: The poison control center will have an petent in self-administering. Since the provider’s original order
exact plan of action for this child. Options 2, 3, and 4 are incorrect. was to treat the patient’s condition with insulin, there may be a
Whenever poisoning is suspected, the poison control center and reason that an oral antidiabetic medication is not appropriate for
the 911 EMS system should be called immediately. Treatment this patient or not appropriate at this time. Cognitive Level:
should begin as soon as possible. Waiting to observe the child for Applying; Client Need: Health Promotion and Maintenance;
symptoms or driving the child to the hospital delays appropriate Nursing Process: Implementation
treatment significantly. Syrup of ipecac is not to be used, espe- 3 Answer: 2 Rationale: In the older adult, renal blood flow
cially in cases where a caustic substance is suspected, because it decreases and excretion of drugs also decreases, requiring dosage
may increase damage or lead to aspiration. Cognitive Level: or frequency adjustments for many drugs. Options 1, 3, and 4 are
Applying; Client Need: Physiological Integrity; Nursing Process: incorrect. Total body fat increases rather than decreases, which
Implementation may increase storage of fat-soluble drugs. Liver function declines
3 Answer: 1 Rationale: IM injections in infants are absorbed and the amount of plasma proteins decreases. There is a decrease
slowly due to low blood flow to skeletal muscles. Options 2, 3, in total body water, and water-soluble drug concentration may
and 4 are incorrect because children experience delayed absorp- increase. Cognitive Level: Applying; Client Need: Physiological
tion and distribution of IM drugs, and IM medications may be Integrity; Nursing Process: Evaluation
absorbed slowly and erratically in children. Children have very 4 Answer: 1, 2, 3 Rationale: Excessive prescribing, multiple
weak muscle contractions that contribute to this delayed absorp- drug therapy, and increased drug sensitivity are all reasons for
tion and distribution. Cognitive Level: Analyzing; Client Need: adverse effects in older adults. As an individual ages, renal func-
Physiological Integrity; Nursing Process: Evaluation tion decreases, leading to alterations in pharmacokinetics and
4 Answer: 3 Rationale: At 3 years of age the child begins seek- pharmacodynamics. Coupled with multiple-drug therapy and
ing control and independence. Giving the patient a choice of liq- increased sensitivity, it is not unusual for adverse effects to
uid with which to combine the medicine will give the child a develop. Options 4 and 5 are incorrect. Body mass decreases as
feeling of control and independence and at the same time encour- age increases. Exercise engagement does not influence the fre-
age cooperation. Options 1, 2, and 4 are incorrect. At age 3 years quency of adverse effects. Cognitive Level: Applying; Client
the child does not yet associate medicine with getting better. Need: Health Promotion and Maintenance; Nursing Process:
Threatening patients to get them to take medicine is never appro- Evaluation
priate in any situation. Three-year-olds do not imitate actions 5 Answer: 2 Rationale: Thirty-one percent of older adult
unless they want to, and saying that a roommate took the medi- patients report that they did not take their medication because
cine may not result in the child doing the same. Cognitive Level: they did not have it on hand when it was time to take it. Options
Applying; Client Need: Physiological Integrity; Nursing Process: 1, 3, and 4 are incorrect. These are other reasons cited for nonad-
Implementation herence, but they are not the most frequently cited answer. Cogni-
5 Answer: 3 Rationale: Drugs with extensive protein binding tive Level: Analyzing; Client Need: Health Promotion and
compete for binding sites, resulting in increased absorption and Maintenance; Nursing Process: Evaluation
1430 Appendix A Answers to Chapter Review
6 Answer: 1 Rationale: Older adults may comply with pre- self-report may not be a reliable method, and the patient may not
scribed drug regimens because of confidence in the ability of have taken a particular drug before. Learning more about genetic
their provider. Making the statement “It doesn’t matter if the effects on pharmacotherapy is important, but each patient
medication works as long as the doctor prescribed it” indicates response is unique. Other patients’ responses to a drug will not
that the patient is not aware of how to monitor the drug’s effec- help predict the response in another patient and there are many
tiveness or for its adverse effects, and more teaching is required. genetic variations, even within racial groups. Cognitive Level:
Options 2, 3, and 4 are positive responses by the patient that Applying; Client Need: Physiological Integrity; Nursing Process:
indicate that teaching has been effective toward increasing the Implementation
potential for adherence. Cognitive Level: Analyzing; Client
Need: Health Promotion and Maintenance; Nursing Process: Chapter 13
Evaluation
1 Answer: 1 Rationale: Muscarinic agonists may cause reflex
Chapter 11 tachycardia, which is precipitated by a drop in the patient’s blood
pressure. When this occurs, the baroreceptors recognize the
1 Answer: 2 Rationale: The statement reflects an attempt to decline in pressure and alert the medulla to increase the heart rate
understand the patient holistically. The nurse understands that as a compensatory mechanism. Options 2, 3, and 4 are incorrect.
multiple contributing factors may contribute to illness and involv- Although the heart rate increases, muscarinic agonists do not
ing the patient helps elicit possible factors. Options 1, 3, and 4 are directly affect the sinoatrial node. Hypertension is not a problem
incorrect. Tylenol should not be recommended initially because it with this drug therapy; however, hypotension may occur. Musca-
may not address the possible causative factors related to the head- rinic drugs stimulate bronchial smooth muscles; however, this
aches. Monitoring the patient’s pupil response to light, although does not impact the heart rate. Cognitive Level: Applying; Client
eventually appropriate, should not be performed initially. An Need: Physiological Integrity; Nursing Process: Implementation
ophthalmology referral may be inevitable; however, making such 2 Answer: 3 Rationale: Pyridostigmine is used primarily for
a referral should be done after ruling out other possible sources of myasthenia gravis, a neurologic disorder characterized by muscle
the headaches. Cognitive Level: Applying; Client Need: Health weakness and ptosis. A decrease in these symptoms is an expected
Promotion and Maintenance; Nursing Process: Implementation therapeutic outcome for this drug. Options 1, 2, and 4 are incor-
2 Answer: 3 Rationale: Factors associated with a drug’s rect because the symptoms listed are not usual problems faced by
expense and the patient’s ability to purchase or access needed the patient with MG and would therefore be inappropriate out-
medication are considered psychosocial variables that may influ- come statements. Cognitive Level: Applying; Client Need: Physi-
ence adherence to drug therapy. Options 1, 2, and 4 are incorrect. ological Integrity; Nursing Process: Planning
Unpleasant taste or medications that are difficult to swallow may 3 Answer: 4 Rationale: Bethanechol works on the muscles
hinder patient adherence; however, the problem is physiologic needed for urination by increasing ureteral peristalsis and pro-
rather than psychosocial. Liver damage (hepatotoxicity) is also a moting urinary bladder elimination. Options 1, 2, and 3 are incor-
physiologic factor. Cognitive Level: Analyzing; Client Need: rect. Bethanechol does not cause changes to urinary structures,
Health Promotion and Maintenance; Nursing Process: Evaluation nor does it increase urine production or renal blood flow. Cogni-
3 Answer: 2 Rationale: Cultural beliefs refer to the cumulative tive Level: Applying; Client Need: Physiological Integrity; Nurs-
ideas of knowledge, experiences, values, attitudes, meanings, and ing Process: Implementation
roles acquired by a group of people. A preference for traditional 4 Answer: 1, 2, 3, 5 Rationale: Common adverse effects of
healers, such as a Shaman, reflects these beliefs. Options 1, 3, and bethanechol include abdominal discomfort, sweating, flushed
4 are incorrect. Ethnicity is a population of human beings whose skin, and blurred vision. Option 4 is incorrect because bethanechol
members identify with each other either on the basis of common increases GI peristalsis and promotes bowel evacuation. Cogni-
genealogy or ancestry. Genetic polymorphisms are changes in tive Level: Analyzing; Client Need: Physiological Integrity; Nurs-
enzyme structure and DNA function that occur within a specific ing Process: Evaluation
subset of the population. A health-related bias is a prejudice or a 5 Answer: 3 Rationale: Because of the potential for broncho-
sense of preference for one particular point of view and is not spe- constriction, patients with COPD should be treated cautiously
cifically culturally related. Cognitive Level: Analyzing; Client with cholinergic agonists. Options 1, 2, and 4 are incorrect. Neo-
Need: Health Promotion and Maintenance; Nursing Process: stigmine is used to reduce postoperative abdominal distention.
Evaluation Urinary retention may also be relieved with the administration
4 Answer: 1 Rationale: Patients who are known as slow acety- of neostigmine. Neostigmine may be used to reverse the effects
lators have reduced hepatic metabolism and reduced clearance by of nondepolarizing muscle relaxants. Cognitive Level: Apply-
the kidney. These patients have a greater potential for drug toxic- ing; Client Need: Physiological Integrity; Nursing Process:
ity. Options 2, 3, and 4 are incorrect. Acetylation is a metabolic Evaluation
process that does not influence absorption. The route or form of 6 Answer: 4 Rationale: Symptoms of a cholinergic crisis
administration is not associated with acetylation, and protein include tachycardia, hyperglycemia, and muscle weakness pro-
intake does not affect the rate of acetylation. Cognitive Level: gressing to paralysis, which may require intubation and mechani-
Applying; Client Need: Physiological Integrity; Nursing Process: cal ventilation if profound. Options 1, 2, and 3 are incorrect.
Implementation Nausea, vomiting, miosis, drooling, and involuntary muscle
5 Answer: 1, 2, 3, 4 Rationale: All of these factors—fat-to-mus- twitching are common adverse effects and may be treated with
cle ratio, cerebral blood flow, limited drug research on women, atropine. Atropine is also the antidote for cholinergic crisis. Cog-
and health beliefs—may be considered gender factors that influ- nitive Level: Analyzing; Client Need: Physiological Integrity;
ence pharmacotherapy. Option 5 is incorrect. Dietary consider- Nursing Process: Evaluation
ations are a potential ethnic or cultural consideration. Cognitive
Level: Applying; Client Need: Physiological Integrity; Nursing Chapter 14
Process: Evaluation
6 Answer: 4 Rationale: Drug response is unique to each indi- 1 Answer: 2 Rationale: Anticholinergic drugs such as toltero-
vidual. The nurse should observe the responses and exercise cau- dine can cause constipation by slowing GI motility. Therefore,
tion with all medications. Options 1, 2, and 3 are incorrect. Patient
Appendix A Answers to Chapter Review 1431
increases in dietary fiber and water intake will help avoid consti- rebound congestion as well as necrosis of the nasal mucosa due to
pation. Options 1, 3, and 4 are incorrect. Daily exercise helps in the severe vasoconstriction caused by the drug. Due to the CNS
avoiding muscle atrophy and anticholinergic drugs are not related stimulation, nasal adrenergic drugs are not indicated in children
to muscle atrophy. Consuming foods high in iron to increase red and infants. Options 3 and 5 are incorrect. The drug causes CNS
blood cell production is not related to the effects of anticholinergic stimulation rather than depression. People with diabetes must use
drugs. Anticholinergic drugs cause tachycardia, not bradycardia. caution when using adrenergic drugs and must monitor their
Cognitive Level: Applying; Client Need: Health Promotion and blood glucose levels more frequently for hyperglycemia. They are
Maintenance; Nursing Process: Implementation also at higher risk for adverse cardiac effects. Cognitive Level:
2 Answer: 1, 2, 3, 4 Rationale: These drugs cause mydriasis Applying; Client Need: Health Promotion and Maintenance;
and paralysis of the ciliary muscle, which is useful in ophthalmic Nursing Process: Implementation
examinations. These drugs are therapeutic in correcting cardiac
rhythm abnormalities such as bradycardia. Muscarinic antago- 3 Answer: 4 Rationale: Epinephrine is used during anaphy-
nists, most notably ipratropium and tiotropium, are useful in laxis to prevent hypotension and bronchoconstriction. Options 1,
treating asthma due to their ability to dilate the bronchi. These 2, and 3 are incorrect because the administration of epinephrine
drugs are used to reverse the symptoms of overdose of organo- for anaphylaxis does not prevent the formation of histamine or
phosphate insecticides or ingestion of poison mushrooms. antibodies in response to an invading antigen nor does it affect
Option 5 is incorrect. Urinary retention is an adverse effect of white blood cell function. Cognitive Level: Applying; Client
these drugs. Cognitive Level: Applying; Client Need: Physiologi- Need: Physiological Integrity; Nursing Process: Evaluation
cal Integrity; Nursing Process: Evaluation
3 Answer: 2 Rationale: Atropine causes urinary retention to 4 Answer: 1 taRkaetniotnoaolec:loWsehteonbbedettaim2-aed, trheenepragtiicenatgmonaiystesxpsuecrih-
worsen in patients with BPH. Options 1, 3, and 4 are incorrect as albuterol are
because these are not contraindications for using atropine. Cogni- ence insomnia. Options 2, 3, and 4 are incorrect because all adren-
tive Level: Analyzing; Client Need: Physiological Integrity; Nurs- ergic agonists act as stimulators, and urticaria and tinnitus are not
ing Process: Evaluation adverse effects associated with this drug therapy. Cognitive Level:
4 Answer: 1 Rationale: Muscarinic drugs affect the intraocular Applying; Client Need: Physiological Integrity; Nursing Process:
pressure by causing mydriasis and paralysis of the ciliary muscle. Evaluation
Options 2, 3, and 4 are incorrect because the drug does not pro-
mote infections, cause miosis, or affect the retina. Cognitive Level: 5 Answer: 2 Rationale: At high dosage, dopamine stimulates
Applying; Client Need: Safe and Effective Care Environment; abllpoohda1p-ardesresunreer.gOicprteicoenpst1o,rs3,, causing vasodilation and increased
Nursing Process: Implementation and 4 are incorrect. Dopamine does
5 Answer: 3 Rationale: Cholinergic antagonists typically cause not affect the reflexes responsible for pupillary response or the
dry eyes and the patient should be encouraged to use lubricating patient’s gag reflex, and it does not directly affect the patient’s
eyedrops. Options 1, 2, and 4 are incorrect. These statements sug- level of consciousness. Cognitive Level: Applying; Client Need:
gest that the patient has understood the teaching. Patients receiv- Physiological Integrity; Nursing Process: Evaluation
ing anticholinergic antagonists frequently report extreme dry
mouth discomfort and increased fluid intake may ease this symp- 6 Answer: 1, 4 Rationale: The nurse should consult with the
tom. Many anticholinergic antagonists may cause drowsiness ini- prescriber when adrenergic drugs are prescribed for individuals
tially. Women receiving anticholinergic therapy should be advised with hyperthyroid disease or dysrhythmias. The medication will
to avoid breastfeeding until the medication is discontinued. Cog- further increase the already overactive metabolic system in hyper-
nitive Level: Analyzing; Client Need: Health Promotion and thyroidism and may increase the risk for dysrhythmias due to the
Maintenance; Nursing Process: Evaluation cardiac stimulation caused by these medications. Options 2, 3,
6 Answer: 1 Rationale: The therapeutic effect of succinylcho- and 5 are incorrect. These are therapeutic indications for the
line is to paralyze skeletal muscles. However, this drug does not administration of adrenergic agonists. Cognitive Level: Analyz-
produce anesthesia or a loss of consciousness. Options 2, 3, and 4 ing; Client Need: Physiological Integrity; Nursing Process:
are incorrect. Succinylcholine produces no change in the patient’s Implementation
sensorium (consciousness) and the patient can still experience
pain. The effect of succinylcholine is total muscle paralysis, not Chapter 16
muscle relaxation. Cognitive Level: Applying; Client Need: Physi-
ological Integrity; Nursing Process: Implementation 1 Answer: 1 Rationale: With beta-adrenergic blockers such as
propranolol, the most important action is to monitor the patient
Chapter 15 for adverse effects associated with the cardiovascular system such
as changes in pulse and blood pressure. Options 2, 3, and 4 are
1 Answer: 1 Rationale: Phenylephrine causes vasoconstric- incorrect. Elevation of the head of the bed is not specifically
tion, reducing the swelling in the nasal passages. Options 2, 3, and required for this drug regimen. Inderal can be taken anytime
4 are incorrect. The drug does not destroy organisms or coat nasal regardless of meals, and its therapeutic action is not contingent on
passages. Whereas some drugs may be swallowed via the naso- serum K+ levels. Cognitive Level: Applying; Client Need: Physio-
pharynx, localized action is predominant, and excessive drug use logical Integrity; Nursing Process: Planning
and swallowing may result in adverse effects. Cognitive Level: 2 Answer: 4 Rationale: Beta-adrenergic antagonists may cause
Applying; Client Need: Physiological Integrity; Nursing Process: hypoglycemic episodes in patients with diabetes. The patient
Implementation should be instructed to monitor blood glucose levels frequently ini-
2 Answer: 1, 2, 4 Rationale: Adrenergic agonist nasal sprays tially and to notify the prescriber of a decrease. Options 1, 2, and 3
should not be shared among individuals due to the risk of spread- are incorrect. Insulin dosages are never arbitrarily increased with-
ing infection. Individuals should be taught the dangers of using out checking with a healthcare provider. Patients with diabetes
adrenergic nasal sprays for longer than 3 days. These medications should remain on their normal diabetic diets even though they may
can cause increased blood pressure, increased heart rate, and be taking antihypertensive medications. Elevation of the extremi-
insomnia. Habitual use of nasal adrenergic drugs can also cause ties is not relevant to a patient with diabetes taking beta-adrenergic
blocker drugs. Cognitive Level: Applying; Client Need: Health Pro-
motion and Maintenance; Nursing Process: Implementation
3 Answer: 1 Rationale: Initial doses of drugs that cause a
“first-dose phenomenon” should be very low and administered at
1432 Appendix A Answers to Chapter Review
bedtime. The decline in blood pressure due to prazosin is often to receiving general anesthesia are all appropriate for phenobarbi-
marked when beginning pharmacotherapy and when increasing tal. Cognitive Level: Applying; Client Need: Physiological Integ-
the dose. This “first-dose phenomenon” can lead to syncope due rity; Nursing Process: Implementation
to reduced blood flow to the brain. Options 2, 3, and 4 are incor- 5 Answer: 3 Rationale: Client safety is the major concern with
rect. Doses of antihypertensive medications should never be dou- sedative–hypnotics, so prevention of falls is the highest priority.
bled but should be gradually increased to avoid hypotension, and Options 1, 2, and 4 are incorrect. The client may experience uri-
the best time to give prazosin in the initial phases of therapy is at nary incontinence, activity intolerance, or poor nutritional intake
bedtime. Cognitive Level: Applying; Client Need: Physiological related to drug therapy or other reasons. Safety, however, is the
Integrity; Nursing Process: Implementation priority concern. Cognitive Level: Analyzing; Client Need: Physi-
ological Integrity; Nursing Process: Evaluation
4 Answer: 1 Rationale: The nurse should suspect that the 6 Answer: 1 Rationale: Smoking enhances the metabolism of
patient is describing orthostatic hypotension induced by the med- benzodiazepines, so the medication is broken down and removed
ication. Most patients find it helpful to move slowly from a recum- from the body more quickly if the client is a smoker. Therefore, a
bent position to avoid dizziness and syncope. Options 2, 3, and 4 smoker may require a larger dose of a benzodiazepine to get the
are incorrect. Although drinking a full glass of water with the same effect as that of a nonsmoker. Options 2, 3, and 4 are incor-
medication is a health promotion activity that the nurse might rect. A smaller or half dose, or a single extra dose, may not ade-
suggest, this action does not eliminate orthostatic hypotension. quately help relieve the client’s symptoms. Cognitive Level:
Sleeping positions do not influence the presence of orthostatic Applying; Client Need: Physiological Integrity; Nursing Process:
hypotension. The patient should never abruptly stop taking anti- Implementation
hypertensive medication. Such action could result in hypertensive
crisis, stroke, or heart attack. Cognitive Level: Applying; Client Chapter 19
Need: Physiological Integrity; Nursing Process: Implementation
1 Answer: 1 Rationale: Imipramine should not be used by
5 Answer: 4 tRacahtiyocnaarlde:iOa.nPeaatdievnetrsseeexfpfeecrtioenf aclipnhgat1-aacdhryecnaerrdgiiac patients with seizure disorders because it lowers the seizure
antagonists is threshold. Options 2, 3, and 4 are incorrect. Imipramine is a drug
asshcnrodiub3elddarnfeooirtnrBceoPcrHerievcbete. acAalpluphshaea11-t-ahadedryreenrneeelrarggxiiccmaaunnsttacaglgeoosnniiinssttsst.haeOrepptroiofotsnetnsat1ep,.re2A-, that is effective in treating depression, and is one of only two
pheochromocytoma is a benign tumor of the adrenal medulla that drugs approved for enuresis (bedwetting) in children. Like other
rsaeendctrauegctoeensthiscetastHedcTihmNoilnaasimsshoinctiehaset.evdAalwspoihstahp1a-thsamdesrseenatusesrmogcoicirasta.enAdtalwpghoitanh1i-sRatdasryhennealeuprdgti’ocs TCAs, imipramine has a number of off-label indications. These
disease. Cognitive Level: Applying; Client Need: Physiological include the adjuvant treatment of cancer or neuropathic pain.
Integrity; Nursing Process: Implementation Cognitive Level: Applying; Client Need: Physiological Integrity;
Nursing Process: Implementation
6 Answer: 2, 3, 4 Rationale: Beta-adrenergic blockers can have 2 Answer: 3 Rationale: Full therapeutic effects of fluoxetine
dramatic metabolic effects that produce an increase in serum tri- may take up to 1 month. Options 1, 2, and 4 are incorrect. Normal
glycerides and hypoglycemia. Additionally, these drugs can affect water and sodium intake do not affect fluoxetine. The patient can-
the sexual function of men by decreasing libido. Options 1 and 5 not take an MAOI or other CNS depressant concurrently. The use
are incorrect. Anorexia and thrombocytopenia are not adverse of other drugs or CNS depressants such as alcohol could increase
effects associated with beta-adrenergic antagonists. Cognitive the risk of adverse effects or increased depression. Cognitive
Level: Analyzing; Client Need: Physiological Integrity; Nursing Level: Analyzing; Client Need: Physiological Integrity; Nursing
Process: Evaluation Process: Evaluation
3 Answer: 1, 2 Rationale: Persistent GI upset and confusion
Chapter 18 are signs of elevated lithium levels between 1.5 and 2.0, which
signify early toxicity. Options 3, 4, and 5 are incorrect. Polyuria is
1 Answer: 3 Rationale: Ataxia, weakness, restlessness, dizzi- an adverse effect that may occur in early therapy, but is not associ-
ness, and other motor problems can occur with lorazepam. ated with early toxicity. Convulsions may occur at serum levels
Options 1, 2, and 4 are incorrect. These are not adverse effects above 2.5, but not in early stages of toxicity. Ataxia is also not a
associated with lorazepam. Cognitive Level: Applying; Client sign of early lithium toxicity. Cognitive Level: Analyzing; Client
Need: Physiological Integrity; Nursing Process: Implementation Need: Physiological Integrity; Nursing Process: Evaluation
2 Answer: 4 Rationale: Sleeping for 7 h is the desired effect of 4 Answer: 1 Rationale: The patient taking lithium must be
temazepam. Options 1, 2, and 3 are incorrect. The client should conscious of maintaining normal sodium intake. Because lithium
experience periods of sleep lasting longer than 3 h and should is a salt, if sodium intake is low the body will replace the sodium
obtain a full night’s sleep. The client will be taking temazepam to with lithium, leading to lithium toxicity. Options 2, 3, and 4 are
assist with insomnia, not to treat anxiety related to everyday incorrect. The patient taking lithium must have regular blood
stress or to help control panic attacks. Cognitive Level: Applying; studies and toxicity is a very real concern; hence the necessity for
Client Need: Physiological Integrity; Nursing Process: Evaluation routine blood studies. Women should refrain from breastfeeding
3 Answer: 3 Rationale: This medication must be gradually while taking lithium. Cognitive Level: Analyzing; Client Need:
reduced, not abruptly terminated. Abrupt termination may cause Physiological Integrity; Nursing Process: Evaluation
withdrawal symptoms (nausea, vomiting, abdominal cramps, 5 Answer: 3 Rationale: An atypical antidepressant such as
diaphoresis, confusion, tremors, seizures). Options 1, 2, and 4 are venlafaxine may take up to 3 weeks or longer to reach full thera-
incorrect. These are appropriate statements, and indicate that the peutic effect, so the patient must continue taking the medication
client understands the teaching. Cognitive Level: Analyzing; as ordered so that therapeutic drug levels can be reached and
Client Need: Health Promotion and Maintenance; Nursing maintained. Options 1, 2, and 4 are incorrect. It is not within a
Process: Evaluation nurse’s scope of practice to suggest changes in medication routine
4 Answer: 2 Rationale: Panic disorder is not an appropriate without consulting the prescriber, and these comments are not
use for phenobarbital. Options 1, 3, and 4 are incorrect. Treatment helpful to maintaining a therapeutic nurse–patient relationship.
of status epilepticus, use prior to diagnostic testing, and use prior Cognitive Level: Analyzing; Client Need: Health Promotion and
Maintenance; Nursing Process: Evaluation
Appendix A Answers to Chapter Review 1433
6 Answer: 2, 3 Rationale: Fluoxetine causes weight loss in Hypotension is related to adverse reactions the patient may expe-
some patients while others experience weight gain or fluctuations rience and must be monitored and reported if it occurs. Cognitive
in weight. A healthy diet and adequate exercise will help maintain Level: Analyzing; Client Need: Physiological Integrity; Nursing
normal weight while on this drug. While rare, an increased risk of Process: Evaluation
suicide has been noted in patients up to age 24, and the patient 6 Answer: 1 Rationale: Fever, tachycardia, stupor, and inconti-
should be carefully monitored, especially during the early initia- nence are symptoms of neuroleptic malignant syndrome (NMS), a
tion of therapy. Options 1, 4, and 5 are incorrect. Fluoxetine may potentially fatal adverse effect of antipsychotics that must be
cause insomnia but not sedation. Abrupt withdrawal of fluoxetine diagnosed and treated immediately. Options 2, 3, and 4 are possi-
may lead to withdrawal symptoms. If the drug needs to be dis- ble adverse reactions, but are not life threatening, and therefore
continued, gradually tapering the dose is recommended. Fluox- do not need to be reported with the same urgency as symptoms of
etine is not known to cause excessive thirst. Cognitive Level: NMS. Cognitive Level: Analyzing; Client Need: Physiological
Analyzing; Client Need: Physiological Integrity; Nursing Process: Integrity; Nursing Process: Evaluation
Evaluation
Chapter 21
Chapter 20
1 Answer: 2 Rationale: Benztropine, a cholinergic antagonist,
1 Answer: 4 Rationale: Antipsychotic medications treat the is frequently used as combination therapy with other antipar-
symptoms associated with mental illness but do not cure these kinson drugs to decrease tremors. Options 1, 3, and 4 are incor-
disorders. Without the medication, the symptoms will return. rect. Amantadine acts to increase dopamine’s release, but only as
Options 1, 2, and 3 are incorrect. These are not symptoms associ- long as dopamine is available. Haloperidol is a phenothiazine
ated with abrupt withdrawal of an antipsychotic medication. antipsychotic that may lead to pseudo-Parkinson’s disease in
Cognitive Level: Analyzing; Client Need: Physiological Integrity; many people. Donepezil prolongs the time between diagnosis
Nursing Process: Evaluation and the institutionalization of the patient with Alzheimer’s dis-
2 Answer: 2 Rationale: Grapefruit and grapefruit juice are ease and is not used for Parkinson’s disease. Cognitive Level:
known to interact with drugs and may increase drug levels of Analyzing; Client Need: Physiological Integrity; Nursing
aripiprazole to potentially toxic concentrations. Options 1, 3, and Process: Implementation
4 are incorrect. Social withdrawal is a symptom of the disease, and 2 Answer: 3 Rationale: Being independent with ADLs shows
slowed activity may occur as a result of the medication. Tardive an improvement in physical abilities. Options 1, 2, and 4 are incor-
dyskinesia is not commonly noted with aripiprazole. SSRIs such rect. Drowsiness is a common adverse effect of antiparkinson
as fluoxetine inhibit CYP2D6, which can cause reduced metabo- medications. Anorexia or loss of appetite is a common adverse
lism of aripiprazole, raising serum levels, and potentially causing effect, not an expected therapeutic effect. Itchy skin is not directly
toxicity. Cognitive Level: Analyzing; Client Need: Physiological related to PD symptoms or to the medications used. Cognitive
Integrity; Nursing Process: Implementation Level: Applying; Client Need: Health Promotion and Mainte-
3 Answer: 1 Rationale: Benztropine is classified as an auto- nance; Nursing Process: Evaluation
nomic nervous system drug and an anticholinergic. It suppresses 3 Answer: 3 Rationale: It is important that the caregivers
tremor and rigidity by decreasing the excess cholinergic effect understand that there is no cure for AD, but that the medication
associated with dopamine deficiency. Options 2, 3, and 4 are may delay the worsening of symptoms. Options 1, 2, and 4 are
incorrect. Diazepam and lorazepam are antianxiety medications incorrect. The medication should be given continuously and not
that will not improve the patient’s symptoms. Haloperidol is an only when the symptoms are present. The patient may become
antipsychotic medication that may cause these symptoms. Cogni- constipated but does not require emergency treatment. The drug
tive Level: Analyzing; Client Need: Physiological Integrity; Nurs- may cause bradycardia or atrial fibrillation and the pulse rate
ing Process: Planning should be checked weekly, but it is not necessary to take the
4 Answer: 2, 4 Rationale: EPS occur frequently, especially at patient’s vital signs before each dose of medication. Cognitive
the beginning of therapy with haloperidol. An individual with Level: Applying; Client Need: Health Promotion and Mainte-
Parkinson’s disease, seizure disorders, alcoholism, or severe men- nance; Nursing Process: Evaluation
tal depression should not take haloperidol because they are all 4 Answer: 1, 2, 5 Rationale: Alzheimer’s patients and their
disorders that affect the CNS. Dementia, seizures, depression, and families may struggle with complex medication routines, and it
severe CNS depression are known to occur with the use of halo- is difficult to remember to take a medication multiple times a
peridol in these patients. Options 1, 3, and 5 are incorrect. Halo- day. Donepezil has not been associated with hepatotoxicity. It
peridol and antacids may be given simultaneously; there are no requires once per day dosing, usually at bedtime. While it does
known interactions between these two medications. Haloperidol not cure AD, donepezil may lengthen the time between when
must be taken as ordered, on a regular schedule. Taking the drug the patient is diagnosed and memory care in a skilled facility is
prn will not reduce symptoms of psychosis because it takes sev- needed. Options 3 and 4 are incorrect. There is a risk of GI bleed-
eral weeks of regular administration before therapeutic levels are ing, especially in patients with a history of peptic ulcers or
reached. Sustained release medications should never be crushed. chronic NSAID use. Potentially life-threatening cardiac dys-
If the patient cannot take the medication, another form should be rhythmias, including atrial fibrillation and sinus bradycardia,
used. Cognitive Level: Applying; Client Need: Physiological are possible adverse effects associated with donepezil. Cognitive
Integrity; Nursing Process: Implementation Level: Applying; Client Need: Physiological Integrity; Nursing
5 Answer: 4 Rationale: The patient taking risperidone or any Process: Planning
antipsychotic medication should refrain from consuming alcohol. 5 Answer: 1 Rationale: Rivastigmine has no significant drug
Concurrent use of alcohol with antipsychotic medications will interactions. This is thought to be true because there is no interaction
increase CNS depression. Because there is an increased risk of with enzymes in the liver that metabolize drugs. Options 2, 3, and 4
hyperglycemia or diabetes in patients taking risperidone, alcohol are incorrect because they do not apply to rivastigmine. Cognitive
should also be avoided because it may affect blood sugar levels. Level: Applying; Client Need: Physiological Integrity; Nursing Pro-
Options 1, 2, and 3 are incorrect. Weight gain may occur, and cess: Planning
obtaining a weekly weight will help the patient track any gain. 6 Answer: 1, 2, 4 Rationale: Flulike symptoms with general
Increasing fluids and fiber may help to limit GI adverse effects. malaise, body aches, fever, and headache are common. Insomnia
1434 Appendix A Answers to Chapter Review
and rashes may also occur and may be treated symptomatically ardous activities should be avoided until the effects of the drug
after conferral with the provider. Options 3 and 5 are incorrect. are known. Swelling of the face or tongue may occur and must be
Depression should never be ignored and should be reported reported immediately to the provider. Options 2 and 3 are incor-
immediately. Significant pain with darkening or blackening of the rect. Patients with severe muscle spasms are encouraged to rest
skin at the injection site indicates that tissue necrosis may be affected muscle groups until acute spasms subside. Cyclobenzap-
occurring and requires prompt treatment. Cognitive Level: Ana- rine may cause dry mouth, and alcohol-based mouth rinses may
lyzing; Client Need: Psychosocial Integrity; Nursing Process: exacerbate the condition. Cognitive Level: Applying; Client Need:
Evaluation Physiological Integrity; Nursing Process: Planning
2 Answer: 3 Rationale: Abruptly discontinuing baclofen may
Chapter 22 result in fever, seizures, rebound spasticity, and hallucinations.
Options 1, 2, and 4 are incorrect. Baclofen may cause weakness,
1 Answer: 3 Rationale: GI effects such as nausea, anorexia, and like other muscle relaxants and antispasmodics, may cause
and abdominal pain are common with ethosuximide. Because the constipation. Being cautious with activities and increasing fluid
patient is still growing, improper nutrition may affect normal and fiber intake will help to limit the adverse effects caused by
growth. Monitoring height and weight weekly will assist in track- baclofen. It may take several months before the full effects of
ing normal growth. Options 1, 2, and 4 are incorrect. Physical baclofen are reached. Cognitive Level: Analyzing; Client Need:
activity will not affect the drug’s metabolism and activity is nor- Physiological Integrity; Nursing Process: Evaluation
mal and needed for healthy growth and development. Ethosuxi- 3 Answer: 2 Rationale: Capsaicin should be applied to the site
mide is not known to cause bone loss or dehydration. Cognitive of pain with a gloved hand to prevent irritation of the skin on the
Level: Applying; Client Need: Health Promotion and Mainte- hands and to avoid introducing the capsaicin to the eyes or other
nance; Nursing Process: Planning parts of the body not under treatment. Options 1, 3, and 4 are
2 Answer: 4 Rationale: Oxcarbazepine is excreted by the kid- incorrect. Capsaicin should only be applied to the site of pain, not
neys, and renal function laboratory studies will be monitored to proximal or distal to the pain. If capsaicin begins to irritate and
detect adverse renal effects. Because hyponatremia may develop cause redness and inflammation, it should be discontinued. Cap-
during treatment, serum sodium levels should also be monitored. saicin should not be applied with a bare hand. Cognitive Level:
Options 1, 2, and 3 are incorrect. Oxcarbazepine does not affect Applying; Client Need: Physiological Integrity; Nursing Process:
CBC, albumin or serum glucose levels, sedimentation rate, or Implementation
platelets. Cognitive Level: Applying; Client Need: Physiological 4 Answer: 2 Rationale: Dysphagia, blurred vision, and ptosis
Integrity; Nursing Process: Planning are all symptoms of possible botulism toxicity and should be
3 Answer: 4 Rationale: Sedation and an increased risk of falls reported immediately. Options 1, 3, and 4 are incorrect. Fever,
are associated with carbamazepine. Options 1, 2, and 3 are incor- aches, and chills are not anticipated adverse effects of this drug,
rect. Carbamazepine is used off-label to treat dementia with and while they should be evaluated, they do not require immedi-
aggressiveness and agitation. The drug is not associated with ate reporting. Moderate levels of muscle weakness may occur
insomnia and has not been demonstrated to increase the risk of after the drug is administered, and strengthening exercises may
stroke. Cognitive Level: Applying; Client Need: Physiological be needed on the affected side. Continuous muscle spasms and
Integrity; Nursing Process: Implementation pain should not occur because the drug blocks muscle contrac-
4 Answer: 2 Rationale: Slurred speech, diplopia, sedation, and tion. Cognitive Level: Analyzing; Client Need: Physiological
dyspnea are symptoms of gabapentin overdose. Options 1, 3, and Integrity; Nursing Process: Evaluation
4 are incorrect. Seizure activity is likely to recur if the drug is 5 Answer: 4 Rationale: Physostigmine may be administered to
stopped abruptly. Neither grapefruit juice nor smoking is known reverse serious anticholinergic adverse effects. Options 1, 2, and 3
to affect drug level. Cognitive Level: Analyzing; Client Need: are incorrect. Naloxone is often used to decrease the effects of opi-
Physiological Integrity; Nursing Process: Evaluation oids on the CNS but is not the preferred drug in the treatment of
5 Answer: 1 Rationale: High doses of phenytoin can cause CNS depression with cyclobenzaprine. Meperidine is a CNS
nystagmus, confusion, ataxia, coma, and seizures and the dos- depressant and should not be administered with cyclobenzaprine.
age should be reduced. Options 2, 3, and 4 are incorrect. Increas- Diazepam is a skeletal muscle relaxant and should not be admin-
ing or maintaining the same dose will continue or exacerbate istered with cyclobenzaprine. Cognitive Level: Applying; Client
the symptoms of toxicity. The drug should not be discontinued Need: Physiological Integrity; Nursing Process: Planning
abruptly because seizure activity may occur. Cognitive Level: 6 Answer: 2, 3, 5 Rationale: Dantrolene may cause hepatotox-
Analyzing; Client Need: Physiological Integrity; Nursing Pro- icity with the greatest risk occurring in women over age 35. Estro-
cess: Planning gen taken concurrently with dantrolene may increase this risk.
6 Answer: 3 Rationale: Carbamazepine is associated with an The drug may cause xerostomia, and sucking on hard candy or ice
increased risk of SJS and toxic epidermal necrosis in genetically chips or sipping water may relieve the dryness. Options 1 and 4
susceptible individuals. Sunburning and a reddish-purple rash, are incorrect. Fluids and fiber may also help diarrhea, but dan-
especially associated with blisters, are possible symptoms of trolene may cause diarrhea, not constipation. Dantrolene may
severe dermatologic reactions and should be evaluated immedi- cause photosensitivity, so patients taking the drug should avoid
ately. Options 1, 2, and 4 are incorrect. Blurred vision, leg cramp- direct exposure to the sun. Cognitive Level: Applying; Client
ing, and lethargy are all possible side effects of carbamazepine but Need: Health Promotion and Maintenance; Nursing Process:
tolerance to these effects usually develops over time. Cognitive Implementation
Level: Applying; Client Need: Physiological Integrity; Nursing
Process: Evaluation Chapter 24
Chapter 23 1 Answer: 4 Rationale: ADHD drugs are Schedule II through
IV drugs that require tight controls. Because they can be abused,
1 Answer: 1, 4, 5 Rationale: Cyclobenzaprine may cause they should be kept under lock and tightly monitored with only
tachycardia, and any palpitations or rapid heart rate should be the minimal number of doses kept at the school as per school pol-
reported. Drowsiness may also occur, and driving or other haz- icy. Options 1, 2, and 3 are incorrect. Keeping the drug in a lunch
bag may lead to the child forgetting to take it or to other children
Appendix A Answers to Chapter Review 1435
taking the drug. Because it is a highly regulated drug, additional function has returned for the patient to start eating, constipation
prescriptions or dosages are not allowed under the schedule is still likely and needs to be prevented by increased dietary fiber
because they could result in the misuse of the drug by people and fluids as well as taking a stool softener. Options 1, 2, and 3 are
other than the student for whom it is prescribed. Cognitive Level: incorrect. Respiratory depression and urinary retention are not
Applying; Client Need: Health Promotion and Maintenance; likely after several days with decreasing opioid use. Addiction is
Nursing Process: Implementation not a concern in the treatment of acute pain in this scenario. Cog-
2 Answer: 2 Rationale: Atomoxetine should decrease hyper- nitive Level: Applying; Client Need: Physiological Integrity;
activity. Options 1, 3, and 4 are incorrect. Atomoxetine should Nursing Process: Planning
increase attention, not decrease it. Mydriasis and elevated liver 3 Answer: 3 Rationale: Chest pain is a serious adverse effect of
enzymes are adverse effects associated with atomoxetine; they sumatriptan and needs to be differentiated from angina, which
are not therapeutic effects. Cognitive Level: Applying; Client can also be caused by the drug. Options 1, 2, and 4 are incorrect.
Need: Health Promotion and Maintenance; Nursing Process: The patient should not use the drug again until being evaluated
Evaluation by the provider and should report the chest pain immediately.
3 Answer: 1 Rationale: Chlorpromazine is the preferred drug Reclining in a quiet room with cold packs is a nondrug treatment
to assist in counteracting amphetamine overdosage. It has strong for migraines, but reporting the chest pain is most important at
alpha-adrenergic blocking actions that treat the effects of amphet- this time. Cognitive Level: Applying; Client Need: Physiological
amine. Options 2, 3, and 4 are incorrect. Phenytoin is an antiepi- Integrity; Nursing Process: Implementation
leptic drug, propofol is a nonbarbiturate sedative–hypnotic, and 4 Answer: 2 Rationale: The patient is describing neuropathic
dexamethasone is a corticosteroid. None of these drugs would pain, which is most likely to respond to the adjuvant analgesic
counteract the effects of an amphetamine overdose. Cognitive gabapentin, an antiseizure drug used for neuropathic pain.
Level: Applying; Client Need: Physiological Integrity; Nursing Options 1, 3, and 4 are incorrect. Nonopioids such as ibuprofen, or
Process: Planning opioids such as methadone, are less effective at relieving pain that
4 Answer: 3 Rationale: Atomoxetine has been linked to sui- is of neurologic origin. Naloxone is an opioid antagonist and will
cidal ideations and an increased risk of suicide. These symptoms not relieve the patient’s pain. Cognitive Level: Applying; Client
should be reported immediately to the family or caregiver for Need: Physiological Integrity; Nursing Process: Planning
assessment and treatment by the healthcare provider. Options 1, 5 Answer: 2 Rationale: Ergot alkaloids such as dihydroergota-
2, and 4 are incorrect. The need for drug withdrawal will be deter- mine (Migranal) are one of the two drug classes for aborting
mined by the provider after assessing the patient. The drug may migraines. Options 1, 3, and 4 are incorrect. Morphine is an opioid
take up to 4 weeks to achieve maximum therapeutic effects, but agonist and is not effective in aborting migraines. Propranolol is a
this patient is experiencing an adverse effect linked to the drug. beta blocker and is used to prevent migraines. Ibuprofen is a non-
Caffeine will not counteract depressive effects and may increase opioid analgesic that is used to treat mild to moderate pain. Cog-
the risk of CNS adverse effects. Cognitive Level: Analyzing; Cli- nitive Level: Applying; Client Need: Physiological Integrity;
ent Need: Psychosocial Integrity; Nursing Process: Evaluation Nursing Process: Planning
5 Answer: 2 Rationale: Palpitations, dysrhythmias, and facial 6 Answer: 4 Rationale: Older adult patients are at highest risk
tingling are all symptoms of a caffeine overdose. Options 1, 3, and for hypotension, respiratory depression, and increased incidence
4 are incorrect. Zolpidem and gabapentin are associated with CNS of adverse CNS effects such as confusion. Options 1, 2, and 3 are
depressant-type effects such as drowsiness, dizziness, and brady- incorrect. Most 23-year-old patients can tolerate opioids without
cardia. Some herbal teas may contain stimulant properties, but adverse effects. Individuals who have experienced a traumatic
many have calming effects and are not as likely as caffeine to injury may receive narcotic analgesia. However, caution should
cause these symptoms. Cognitive Level: Analyzing; Client Need: be taken if the individual has also experienced any type of head
Physiological Integrity; Nursing Process: Evaluation injury. Opioids are often used with individuals who have had an
6 Answer: 3 Rationale: Taking the medication before late MI. No adverse effects such as hypotension or respiratory depres-
afternoon ensures that peak drug activity will occur during wak- sion are usually present if the dose is appropriate for the size of
ing hours. Options 1, 2, and 4 are incorrect. Drinking wine with the patient. Cognitive Level: Analyzing; Client Need: Physiologi-
dinner should not have a noticeable effect on sleep unless taken cal Integrity; Nursing Process: Evaluation
directly before bedtime when the metabolism of the alcohol may
actually diminish sleep as the blood glucose rises and falls. Choc- Chapter 26
olate contains caffeine, and also sugar, which may cause addi-
tional wakefulness. Decaffeinated coffee will limit the intake of 1 Answer: 2 Rationale: In stage 2 the patient becomes excit-
the additional stimulant of caffeine but will not significantly able with hyperactivity and irregular heart and respiratory rates.
improve the patient’s sleep if the methylphenidate is taken later in Options 1, 3, and 4 are incorrect. In stage 1, the patient loses gen-
the afternoon or evening. Cognitive Level: Applying; Client Need: eral sensation but remains awake. In stage 3, the patient’s skeletal
Health Promotion and Maintenance; Nursing Process: muscles become relaxed, and delirium stabilizes. In stage 4, the
Implementation patient has paralysis of the medulla with possible adverse effects
on respiratory and cardiac function. Cognitive Level: Analyzing;
Chapter 25 Client Need: Physiological Integrity; Nursing Process:
Evaluation
1 Answer: 1, 3, 4, 5 Rationale: Common adverse effects of opi- 2 Answer: 1 Rationale: Patients who have an allergy to eggs or
oids include respiratory depression, urinary retention, constipa- soy products may have an allergic reaction to the propofol emul-
tion, and nausea. Option 2 is incorrect. Hypotension, not sion, which contains these products. Options 2, 3, and 4 are incor-
hypertension, is an adverse effect of opioids. Cognitive Level: rect. Patients with allergies to iodine, kidney disease, or Addison’s
Analyzing; Client Need: Physiological Integrity; Nursing Process: disease may be administered propofol cautiously. Cognitive
Evaluation Level: Analyzing; Client Need: Physiological Integrity; Nursing
2 Answer: 4 Rationale: Opioids decrease peristalsis, and Process: Implementation
bowel surgery may produce a temporary cessation of peristalsis 3 Answer: 4 Rationale: Anxiety, excitement, and combative-
(paralytic ileus). Both lead to constipation. Once sufficient bowel ness are signs that the dose of nitrous oxide is high and the patient
1436 Appendix A Answers to Chapter Review
is exhibiting signs of the second stage of anesthesia. Lowering the behavior, depression, hostility, or thoughts of suicide should be
dose may reduce these symptoms. Options 1, 2, and 3 are incor- immediately reported. Options 2 and 3 are incorrect. Varenicline
rect. The dose of nitrous oxide would be lowered, not increased. (Chantix) activates nicotinic acetylcholine receptors in the brain
Propofol would cause additional CNS depression and is not and blocks nicotine from reaching the receptors. It does not pre-
advised. Succinylcholine is a neuromuscular blocking drug that vent nicotine’s harmful effects on body systems from occurring. It
will increase the risk of significant respiratory adverse effects due has several adverse effects, including serious dermatologic and
to its muscle-paralyzing actions. Cognitive Level: Analyzing; Cli- neuropsychiatric effects. Cognitive Level: Applying; Client Need:
ent Need: Physiological Integrity; Nursing Process: Planning Physiological Integrity; Nursing Process: Evaluation
4 Answer: 3 Rationale: Ketamine produces dissociation anes- 4 Answer: 2 Rationale: Sedatives cause a profound suppres-
thesia, which is a feeling of being separated from the environ- sion of the respiratory system through direct action with the CNS.
ment. Options 1, 2, and 4 are incorrect because anxiety and dry Patients who have experienced an overdose of sedatives are at
mouth are not significant adverse effects of ketamine. Ketamine high risk for respiratory arrest. Options 1, 3, and 4 are incorrect.
may cause decreased energy. Cognitive Level: Applying; Client Sedatives do not typically cause any type of stimulation. Long-
Need: Physiological Integrity; Nursing Process: Evaluation term effects of overdose will most likely manifest through liver
5 Answer: 1 Rationale: Epinephrine is administered with lido- and kidney dysfunction, but the immediate need is to determine
caine to increase the duration of the anesthetic action at the site by the current status of the patient. Level of consciousness is one
causing vasoconstriction, keeping the anesthetic localized. of the assessments to be made with a patient receiving sedatives,
Options 2, 3, and 4 are incorrect because epinephrine will cause but the nurse would expect a decrease in consciousness with an
vasoconstriction, not vasodilation at the site; may increase blood overdose of sedatives. Cognitive Level: Applying; Client Need:
pressure if the drug enters the systemic circulation; and neither Physiological Integrity; Nursing Process: Assessment
lidocaine nor epinephrine has any antibacterial properties. Cogni- 5 Answer: 4 Rationale: Typical symptoms of heroin with-
tive Level: Applying; Client Need: Physiological Integrity; Nurs- drawal include chills, dilated pupils, diarrhea, runny nose, mus-
ing Process: Evaluation cle spasms, goose bumps, abdominal pain, sweating, and
6 Answer: 2, 3, 4 Rationale: Alfentanil is a parenteral opioid agitation. Options 1, 2, and 3 are incorrect. Heroin is an opiate that
that promotes general anesthesia. Sufentanil is also a parenteral depresses the CNS, and the patient may exhibit hyperactive
opioid. Remifentanil is an opioid that is used to induce and main- behavior during withdrawal. Dermatologic effects are not com-
tain general anesthesia. Options 1 and 5 are incorrect. Nitrous mon during heroin withdrawal. Paranoia, delusions, or hallucina-
oxide is not an opioid and it is administered by inhalation. Succi- tions are typical effects. Cognitive Level: Applying; Client Need:
nylcholine is a neuromuscular blocking drug. Cognitive Level: Physiological Integrity; Nursing Process: Evaluation
Applying; Client Need: Physiological Integrity; Nursing Process: 6 Answer: 1 Rationale: Disulfiram is a drug used in the reha-
Implementation bilitation of alcoholism. When patients are taking this drug, even
small amounts of alcohol, such as that found in mouthwash and
Chapter 27 many OTC medications, can produce flushing, throbbing in the
head and neck, respiratory difficulty, nausea, vomiting, sweating,
1 Answer: 1 Rationale: Addiction is not a problem for the thirst, chest pain, blurred vision, and confusion. Options 2, 3, and
majority of patients who receive narcotic analgesia in the postop- 4 are incorrect. There is no reason for a patient to avoid dairy
erative period. The nurse should administer the dose to treat the products or foods high in iron. Disulfiram should not directly
pain. Options 2, 3, and 4 are incorrect. Reviewing the patient’s impact the patient’s driving or level of alertness. Cognitive Level:
past medical history is an important assessment that should guide Applying; Client Need: Health Promotion and Maintenance;
nursing practice, but a patient’s past tendencies toward substance Nursing Process: Implementation
abuse are not appropriate criteria to consider in the nurse’s deci-
sion to treat the pain with analgesia. Pain is best treated in the Chapter 29
early stage. If a nurse waits to treat pain until it becomes intolera-
ble, the patient may require a higher dose of the analgesia. There 1 Answer: 1 Rationale: Rhabdomyolysis is a serious adverse
is no evidence that patients request medication when it is not effect of the statins. Early signs include unexplained fatigue or
needed. Cognitive Level: Applying; Client Need: Physiological muscle weakness, pain in joints or muscles, and an increase in CK
Integrity; Nursing Process: Implementation level. Options 2, 3, and 4 are incorrect. The weakness, fatigue, and
2 Answer: 3 Rationale: Patients with a substance use disorder pain that the patient is experiencing are not symptoms of renal
tend to revert back to drug-seeking behavior when they return to failure or hepatic insufficiency. In rheumatoid arthritis, pain is
the company of other substance abusers. Options 1, 2, and 4 are often present but tends to be greatest in the mornings and associ-
incorrect. A good support system can be extremely beneficial ated with red, hot, swollen joints. Cognitive Level: Analyzing; Cli-
when an individual is attempting to withdraw from physiologi- ent Need: Physiological Integrity; Nursing Process: Evaluation
cally and psychologically addictive substances. Patients with sub- 2 Answer: 2 Rationale: One of the most serious adverse effects
stance use disorder may experience the desire to use drugs long of cholestyramine is obstruction of the GI tract. Options 1, 3, and 4
after the drug has physiologically cleared the body. Generally are incorrect. Cholestyramine does not cause orange urine, sore
speaking, individuals who share a common experience will be throat, or fever, nor does it affect capillary refill. Cognitive Level:
perceived as being most helpful to an individual undergoing the Applying; Client Need: Physiological Integrity; Nursing Process:
same or similar experience. Cognitive Level: Analyzing; Client Planning
Need: Health Promotion and Maintenance; Nursing Process: 3 Answer: 1 Rationale: Although there are few contraindica-
Evaluation tions to the use of bile acid sequestrants such as colestipol, they
3 Answer: 1, 4, 5 Rationale: Varenicline (Chantix) doses are should be used cautiously in patients with GI disorders such as
increased over an 8-day period and maintained for 12 to 24 weeks, peptic ulcer disease. Options 2, 3, and 4 are incorrect. MI is not a
reducing withdrawal symptoms and craving for smoking. Serious contraindication for the use of bile acid sequestrants. Bile acid
dermatologic reactions have been noted, and any unusual skin sequestrants do not affect serum sodium levels, and patients aller-
reactions or angioedema should be reported to the provider gic to foods high in tyramine may be prescribed bile acid seques-
immediately and the drug stopped. Varenicline carries a black box trants. Cognitive Level: Applying; Client Need: Physiological
warning for serious neuropsychiatric events, and any changes in Integrity; Nursing Process: Implementation
Appendix A Answers to Chapter Review 1437
4 Answer: 2, 3 Rationale: Intense flushing and hot flashes the effects of the medication are known, the patient should avoid
occur in almost every patient who is taking niacin. Tingling of the driving or other activities requiring mental alertness. One of the
extremities may also occur. Options 1, 4, and 5 are incorrect. Nei- adverse effects associated with diltiazem and CCBs is constipa-
ther fever and chills nor dry mucous membranes are associated tion, which can be reduced by increasing fluid and dietary fiber
adverse effects of niacin therapy. Niacin may cause an increase in intake. Patients should be taught to report a weight gain of 1 kg
fasting blood glucose, especially in people with diabetes. Cogni- (2 lb) per day or 2 kg (5 lb) per week. Diltiazem may cause ortho-
tive Level: Analyzing; Client Need: Physiological Integrity; Nurs- static hypotension. To ensure safety, patients should be instructed
ing Process: Evaluation to rise slowly from sitting or lying positions. Option 5 is incorrect.
5 Answer: 4 Rationale: Grapefruit juice inhibits the metabo- Sudden discontinuation could cause the patient to experience
lism of statins such as lovastatin, allowing them to reach high hypertensive crisis. Cognitive Level: Applying; Client Need:
serum levels. Options 1, 2, and 3 are incorrect. Most patients with Physiological Integrity; Nursing Process: Implementation
lipid disorders are asymptomatic. A patient should be instructed 6 Answer: 3 Rationale: Nifedipine is a negative inotropic drug
that maintenance of optimal body weight will help reduce and symptoms of pulmonary edema call for discontinuation of
unhealthy lipid levels. Because cholesterol biosynthesis in the the drug. The nurse should also monitor more closely for HF and
liver is higher at night, statins are usually best taken in the eve- pulmonary edema if the patient has a medical history of pulmo-
ning. Cognitive Level: Applying; Client Need: Health Promotion nary edema. Options 1, 2, and 4 are incorrect. An appendectomy
and Maintenance; Nursing Process: Evaluation does not warrant monitoring the patient any more than usual.
6 Answer: 1, 4, 5 Rationale: Fibric acid drugs (fibrates) such as Patients receiving renal dialysis should be closely monitored dur-
gemfibrozil may cause or worsen gallbladder disease and may ing therapy with nifedipine due to a reduction in renal function.
enhance the hypoglycemic effects of antidiabetes drugs. Because However, these patients are not as high risk as a patient with pul-
it is excreted through the kidneys, it may be used cautiously in monary edema. Psychotropic drugs are not known to interact
patients with CKD, but the order should be validated with the negatively with this drug. Cognitive Level: Analyzing; Client
provider before giving if the patient has a history of CKD. Need: Physiological Integrity; Nursing Process: Evaluation
Options 2 and 3 are incorrect. Angina and hypertension may indi-
cate the existence of atherosclerosis and arteriosclerosis, both of Chapter 31
which are indications for a lipid-lowering drug. Cognitive Level:
Applying; Client Need: Physiological Integrity; Nursing Process: 1 Answer: 4 Rationale: Lisinopril does not affect serum cal-
Implementation cium levels and, thus, would not cause an elevated blood pres-
sure. Options 1, 2, and 3 are incorrect. Common adverse effects for
Chapter 30 lisinopril are cough, headache, dizziness, orthostatic hypotension,
and rash. These symptoms should be reported to the prescriber.
1 Answer: 1 Rationale: A major complication associated with Salt substitutes usually contain potassium chloride and should be
the administration of CCBs such as nifedipine is HF. Daily weigh- avoided to reduce the risk of hyperkalemia. Patients on this medi-
ing will alert the patient to signs of fluid retention, which may cation should be instructed to stay on regular doses of blood pres-
indicate cardiac dysfunction. A weight gain of 1 kg (2 lb) or more sure medication. If a dose is missed, take it as soon as possible but
in 24 hours indicates possible fluid retention and may signal not too close to the next dose. Never take a double dose. Cognitive
impending HF. Options 2, 3, and 4 are incorrect. Nifedipine does Level: Analyzing; Client Need: Health Promotion and Mainte-
not affect the immune system, and there is no reason to avoid nance; Nursing Process: Evaluation
crowds. The intake of oral or dietary calcium and CCBs has not 2 Answer: 1 Rationale: Lisinopril should be stored in a dry
been shown to be problematic. HTN is asymptomatic, and place at room temperature, because heat and moisture may cause
patients should be instructed to take the medication even when drug breakdown. Options 2, 3, and 4 are incorrect. Heat and mois-
feeling healthy. Cognitive Level: Applying; Client Need: Health ture do not enhance the strength of the drug, crystallize the medi-
Promotion and Maintenance; Nursing Process: Implementation cation, or convert the medication to toxic metabolites. Cognitive
2 Answer: 4 Rationale: Felodipine may cause hypotension Level: Analyzing; Client Need: Health Promotion and Mainte-
with associated reflex tachycardia. Options 1, 2, and 3 are incor- nance; Nursing Process: Evaluation
rect. Rash and chills, increased urine output, and weight loss are 3 Answer: 3 Rationale: ACE inhibitors such as enalapril also
not adverse effects of CCBs. Cognitive Level: Applying; Client prevent the breakdown of bradykinin. Accumulation of bradyki-
Need: Physiological Integrity; Nursing Process: Planning nin in certain tissues such as the lungs can cause adverse effects,
3 Answer: 4 Rationale: An adverse effect of verapamil is HF, as manifested by a nonproductive cough, and may require an
which will be reflected in the patient’s intake and output ratio and antihistamine for treatment. Options 1, 2, and 4 are incorrect. Dry
weight gain of more than 1 kg (2 lb) per 24 hours. Options 1, 2, mucous membranes are not adverse effects related to ACE inhibi-
and 3 are incorrect. Verapamil does not affect coagulation or tors. The expected outcome associated with ACE inhibitors is a
thrombocytes. Verapamil is usually given during hours that the decline in blood pressure, and the nurse should expect both sys-
patient is awake; however, it can be administered at any time. tolic and diastolic pressures to be reduced. Cognitive Level:
Cognitive Level: Applying; Client Need: Physiological Integrity; Applying; Client Need: Physiological Integrity; Nursing Process:
Nursing Process: Implementation Implementation
4 Answer: 2 Rationale: Grapefruit juice will enhance the 4 Answer: 2 Rationale: The most common adverse effects of
absorption of nifedipine. Options 1, 3, and 4 are incorrect. Nife- losartan are headache, dizziness, nasal congestion, fatigue, and
dipine should not be taken with antacids since this will affect the insomnia. Options 1, 3, and 4 are incorrect. Irritability, tremors,
absorption rate of the drug. Patients should never double the dose sleepiness, slurred speech, pruritus, and rash are not common
of nifedipine because life-threatening hypotension could result. adverse effects associated with losartan. Cognitive Level:
Nifedipine does not affect the efficacy of birth control pills. Cogni- Analyzing; Client Need: Physiological Integrity; Nursing Process:
tive Level: Analyzing; Client Need: Health Promotion and Main- Evaluation
tenance; Nursing Process: Evaluation 5 Answer: 1 Rationale: Patients with severe dehydration
5 Answer: 1, 2, 3, 4 Rationale: Diltiazem reduces the patient’s may experience hypovolemia and are at high risk of life-threat-
blood pressure, which may result in syncope or dizziness. Until ening hypotension. Options 2, 3, and 4 are incorrect. Irbesartan
may be prescribed for the prevention of diabetic nephropathy,
1438 Appendix A Answers to Chapter Review
HTN, and as an off-label use for heart failure. Cognitive Level: trolytes, including potassium; and recording I&O and daily
Applying; Client Need: Physiological Integrity; Nursing Process: weight are important nursing interventions but are not the main
Implementation nursing priority in the early administration of mannitol. Cogni-
6 Answer: 3 Rationale: Patients receiving benazepril should tive Level: Applying; Client Need: Physiological Integrity; Nurs-
avoid driving or engaging in other potentially hazardous activi- ing Process: Implementation
ties until the effects of the drug are known. Benazepril may cause 6 Answer: 1 Rationale: Patients receiving acetazolamide are at
adverse effects that impair thinking and reaction time. Options 1, risk for metabolic acidosis due to excess bicarbonate loss.
2, and 4 are incorrect. The patient or family should be taught Options 2, 3, and 4 are incorrect. Metabolic alkalosis is character-
methods of home blood pressure measurement and maintenance ized by a deficit of bicarbonate and is not an adverse effect of acet-
of a blood pressure log while taking benazepril. OTC medications azolamide (Diamox). Acetazolamide does not cause respiratory
for colds, sinus, fever, asthma, or appetite control should be acidosis. Respiratory alkalosis is also not an expected adverse
avoided because they may increase blood pressure. The consump- effect of acetazolamide. Cognitive Level: Analyzing; Client Need:
tion of alcohol while taking benazepril can lower blood pressure, Physiological Integrity; Nursing Process: Evaluation
which will lead to dizziness and fainting. Cognitive Level: Ana-
lyzing; Client Need: Health Promotion and Maintenance; Nursing Chapter 33
Process: Evaluation
1 Answer: 1 Rationale: The serum pH is a measure of alka-
Chapter 32 linity or acidity in the blood. The administration of bicarbonate
neutralizes acidic conditions and causes the patient’s serum to
1 Answer: 2 Rationale: As a diuretic, furosemide may dra- become more alkaline. Options 2, 3, and 4 are incorrect.
matically reduce the patient’s circulating blood volume, thus Changes in the pH can affect the ability of RBCs to release oxy-
producing episodes of orthostatic hypotension. Patients may gen, but administration of sodium bicarbonate will not influ-
minimize this effect by rising slowly from sitting or lying posi- ence the number of circulating RBCs. The liver does not
tions. Options 1, 3, and 4 are incorrect. Cabbage, cauliflower, metabolize sodium bicarbonate; it is naturally occurring in the
and kale are high in vitamin K, but furosemide does not require body and does not metabolize. Liver function tests are not indi-
restricted consumption of these foods. Monitoring pulse rate cators of the drug’s effectiveness. Although sodium bicarbon-
during administration of furosemide for reflex tachycardia sec- ate excretion occurs in the kidneys, the blood urea nitrogen
ondary to hypotension is advised, but it is not required that it level will not reflect the effectiveness of this drug. Cognitive
be taken before the dose or for 1 full minute. Due to the poten- Level: Applying; Client Need: Physiological Integrity; Nursing
tial for significant diuresis, fluids should not be restricted Process: Evaluation
unless ordered by the healthcare provider. Cognitive Level:
Applying; Client Need: Physiological Integrity; Nursing Pro- 2 Answer: 2 Rationale: Liquid preparations are very irritating
cess: Implementation to the gastric mucosa and should always be diluted with juice or
2 Answer: 2 Rationale: Loop diuretics such as bumetanide water. Options 1, 3, and 4 are incorrect. Salt substitutes are high in
cause a significant loss of potassium. Hypokalemia is often the potassium and should be avoided by patients on potassium sup-
most predominant electrolyte imbalance. Options 1, 3, and 4 are plementation. Symptoms such as weakness or fatigue may be the
incorrect. Hypernatremia is unlikely with the administration of first indicators of potassium imbalances. The GI secretions are
bumetanide because it promotes sodium loss. Hyperkalemia is rich in potassium. Episodes of persistent vomiting may lead to
inconsistent with the administration of bumetanide due to the hypokalemia and should be reported to the healthcare provider.
increase in potassium excretion. If elevated potassium levels are Cognitive Level: Applying; Client Need: Physiological Integrity;
present in these patients, other etiologies should be investigated. Nursing Process: Evaluation
Bumetanide does not cause hypocalcemia but may cause hyper-
calciuria with an increased risk of calcium-based kidney stones. 3 Answer: 4 Rationale: Dextran 40 interferes with coagulation
Cognitive Level: Analyzing; Client Need: Physiological Integrity; and reduces blood viscosity. Bleeding, potentially severe, is asso-
Nursing Process: Evaluation ciated with these effects. Options 1, 2, and 3 are incorrect. Dextran
3 Answer: 3 Rationale: Muscle cramps and weakness may solutions are used to correct low circulating blood volume states.
indicate hypokalemia and should be reported to the healthcare This solution does not cause dehydration. Dextran increases the
provider. Options 1, 2, and 4 are incorrect. Many patients taking circulating volume and thereby increases urine output, which is a
diuretic therapy are instructed to monitor the intake of both therapeutic effect of the solution. Dextran is used for shock (hypo-
sodium and water to maintain adequate but not excessive volemia); it does not cause shock. Cognitive Level: Analyzing; Cli-
amounts. Patients should ingest foods high in potassium, not vita- ent Need: Physiological Integrity; Nursing Process: Evaluation
min K. Thiazide diuretics and antihypertensive drugs are not
known to cause sleepiness when taken together. Cognitive Level: 4 Answer: 2 Rationale: This solution is often used to dilute
Applying; Client Need: Physiological Integrity; Nursing Process: (reconstitute) powdered forms of drugs that are intended to be
Implementation given parenterally. Options 1, 3, and 4 are incorrect. This solution
4 Answer: 1 Rationale: Spironolactone is a potassium-sparing can cause hyperglycemia in the patient with diabetes due to the
diuretic and may cause hyperkalemia. Options 2, 3, and 4 are dlietexrtroofsethcoisntseonlut.tDio5nWsuispcpolinessidoenrelyd a crystalloid solution. One
incorrect. This drug does not have a direct effect on magnesium 170 calories, which is not
and does not cause hypokalemia. It does not have calcium- enough to supply the metabolic nutritional needs of adult
binding effects. Cognitive Level: Applying; Client Need: Physio- patients. Cognitive Level: Applying; Client Need: Physiological
logical Integrity; Nursing Process: Assessment Integrity; Nursing Process: Implementation
5 Answer: 4 Rationale: In the early stages of the administra-
tion of mannitol, fluid is drawn into extracellular spaces and vas- 5 Answer: 4 Rationale: Magnesium sulfate toxicity may cause
cular compartments. Pulmonary and peripheral edema may significant neuromuscular depression as noted by changes in
occur, and increased intracranial pressure may also occur along level of consciousness and diminished deep tendon reflexes.
with an early change in level of consciousness. Options 1, 2, and 3 Options 1, 2, and 3 are incorrect. Pupillary constriction to bright
are incorrect. Keeping a urinal or bedpan nearby; monitoring elec- light is a normal physiologic response. The nurse should notify
the prescriber when the patient develops chest congestion and
coughing, but they are not directly associated with magnesium
sulfate toxicity. Elevated blood pressure is common in preeclamp-
sia but it is not associated with magnesium toxicity. Cognitive
Appendix A Answers to Chapter Review 1439
Level: Applying; Client Need: Physiological Integrity; Nursing incorrect. Past alcohol use will not determine whether thiocyanate
Process: Implementation poisoning develops or influences its symptoms. While flushing of
6 Answer: 1, 3, 4 Rationale: Normal serum albumin is a the skin may occur with nitroprusside administration, skin color
product derived from blood. Although rare, transfusion reac- and turgor are not reliable indicators of thiocyanate poisoning.
tions can still occur with normal serum albumin. Albumin Cognitive Level: Analyzing; Client Need: Physiological Integrity;
causes intercellular and interstitial fluid to move into the intra- Nursing Process: Evaluation
vascular compartment. This movement of fluid will cause
increases in the patient’s blood pressure and heart rate. The Chapter 35
nurse should monitor the patient for fluid overload with this
solution. As the circulating fluid volume is corrected, the 1 Answer: 3 Rationale: Patients should be taught to remove
patient’s urinary output will increase. Options 2 and 5 are incor- the old ointment before applying the next dose. Options 1, 2,
rect. Patients receiving normal serum albumin typically do not and 4 are incorrect. Nitroglycerin should be kept at room temper-
have any dietary restrictions while receiving this solution. ature, not in the refrigerator. Patients should take the medication
Serum albumin is not administered for potassium imbalances. before chest pain becomes severe. Nitroglycerin can be applied to
Cognitive Level: Applying; Client Need: Physiological Integrity; any skin surface. However, absorption is decreased when applied
Nursing Process: Planning to hairy areas, soles of feet, and palms. Cognitive Level: Applying;
Client Need: Health Promotion and Maintenance; Nursing
Chapter 34 Process: Implementation
1 Answer: 1 Rationale: Hot baths and showers, prolonged 2 Answer: 4 Rationale: A decline in blood pressure is an
standing in one position, and strenuous exercise may enhance expected adverse effect. The nurse should always assess the blood
orthostatic hypotension. Options 2, 3, and 4 are incorrect. Methyl- pressure prior to and 5 minutes after administering nitroglycerin.
dopa does not discolor the urine. Bloating and weight gain are not Options 1, 2, and 3 are incorrect. Photosensitivity, vomiting, and
typical adverse effects of methyldopa, and methyldopa can be diarrhea are not expected adverse effects. Nitroglycerin will cause
taken without food. Cognitive Level: Applying; Client Need: a decline in blood pressure, not an increase. Cognitive Level:
Physiological Integrity; Nursing Process: Implementation Applying; Client Need: Physiological Integrity; Nursing Process:
2 Answer: 4 Rationale: Orthostatic hypotension is a common Planning
adverse effect of vasodilators such as hydralazine. Options 1, 2,
and 3 are incorrect. Hydralazine does not typically cause atelecta- 3 Answer: 4 Rationale: Skin irritation due to the nitroglyc-
sis. Crystalluria is not an adverse effect of hydralazine and it does erin ointment can occur if the same site is used repeatedly.
not cause photosensitivity. Cognitive Level: Applying; Client Options 1, 2, and 3 are incorrect. Patients should be instructed to
Need: Physiological Integrity; Nursing Process: Planning rotate the site of application when using nitroglycerin ointment.
3 Answer: 2, 3, 4, 5 Rationale: Adverse effects of ACE inhibi- Repeated use of the same application site may actually decrease
tors such as enalapril (Vasotec) include persistent cough and absorption. Rebound phenomenon is not an expected occur-
orthostatic hypotension. Hyperkalemia may occur and can be a rence with nitroglycerin. Cognitive Level: Applying; Client
major concern for those patients with CKD and in patients who Need: Health Promotion and Maintenance; Nursing Process:
are taking potassium-sparing diuretics. Though rare, the most Implementation
serious adverse effect of ACE inhibitors is the development of
angioedema. Option 1 is incorrect. Hypotension with reflex tachy- 4 Answer: 3 Rationale: Patients may experience lightheaded-
cardia is a possibility depending on how low or how fast the blood ness or dizziness as a result of the hypotensive effects of isosor-
pressure decreases. Cognitive Level: Analyzing. Nursing Process: bide. Options 1, 2, and 4 are incorrect. Because the oral form of
Evaluation. Client Need: Physiological Integrity isosorbide has a slower onset than sublingual forms, a flushing
4 Answer: 4 Rationale: The nurse will titrate (adjust) the rate sensation and headache are not usually experienced as they are
of infusion based on the patient’s blood pressure. Options 1, 2, with sublingual nitroglycerin. Tremors and anxiety are not associ-
and 3 are incorrect. Listening for bowel sounds in the patient with ated adverse effects with this drug. Isosorbide does not usually
hypertensive crisis is not a nursing priority. Urine specific gravity cause sleepiness or lethargy, and if these occur they should be
and glucose levels may be obtained but are not associated with evaluated. Cognitive Level: Analyzing; Client Need: Physiologi-
hypertensive crisis or the administration of this drug. Observing cal Integrity; Nursing Process: Evaluation
skin pressure points is a nursing intervention that does not
directly relate to hypertensive crisis or nitroprusside therapy. 5 Answer: 1 Rationale: Atenolol increases blood flow to the
Cognitive Level: Applying; Client Need: Physiological Integrity; myocardium, thereby increasing oxygen supply by reducing the
Nursing Process: Implementation heart rate and decreasing the contractility. Options 2, 3, and 4 are
5 Answer: 2, 3, 4 Rationale: New guidelines in the JNC-8 incorrect. Atenolol is a beta-adrenergic blocker, which decreases
report recommend ACEIs or ARBs, CCBs, and thiazide diuretics heart rate. This drug does not affect the sodium channels.
as primary treatment options for most patients. Options 1 and 5 Although this drug reduces blood pressure, the mechanism of
are incorrect. Beta blockers may still be used for some patients but aAcptipolnyiinsgn; oCtlibeyntbNloecekdin: Pghtyhseioallopghicaa2lrIencteepgtroitrys.; Cognitive Level:
are no longer recommended for primary treatment of HTN. Implementation Nursing Process:
Direct-acting vasodilators are used to treat hypertensive crisis and
for patients who have not responded adequately to other antihy- 6 Answer: 1, 3 Rationale: Verapamil decreases blood pressure
pertensive drugs. Cognitive Level: Analyzing; Client Need: Physi- and heart rate. The administration of this drug may cause signifi-
ological Integrity; Nursing Process: Planning cant bradycardia and hypotension in some patients. Options 2, 4,
6 Answer: 1, 2, 4 Rationale: Thiocyanate poisoning may and 5 are incorrect. Verapamil may be used to treat fast heart rates
develop more quickly in patients with CKD. Renal function and and HTN in addition to angina. Tinnitus and hearing loss are not
creatinine levels should be evaluated before starting the drug. adverse effects associated with verapamil. Cognitive Level: Ana-
Signs of thiocyanate poisoning include hypotension, lethargy, lyzing; Client Need: Physiological Integrity; Nursing Process:
unconsciousness, and faint heart sounds. Options 3 and 5 are Evaluation
Chapter 36
1 Answer: 2 Rationale: ACE inhibitors such as enalapril lower
peripheral resistance through the inhibition of angiotensin II
1440 Appendix A Answers to Chapter Review
formation, and reduce blood volume through inhibition of aldo- atrial tachycardia, and atrial fibrillation are indications for the use of
sterone secretion. This reduces arterial blood pressure, decreasing procainamide. Cognitive Level: Applying; Client Need: Physiologi-
afterload and increasing cardiac output. Options 1, 3, and 4 are cal Integrity; Nursing Process: Implementation
incorrect. Enalapril is not a positive inotropic drug and does not 2 Answer: 3 Rationale: Early signs of lidocaine toxicity include
strengthen the force of myocardial contraction. It does not slow CNS effects such as paresthesias, drowsiness, confusion, anxiety,
heart rate (negative chronotropic and dromotropic effects) and it or tremors. Options 1, 2, and 4 are incorrect. Decreased platelet
does not have diuretic effects. Cognitive Level: Analyzing; Client levels are not related to the administration of lidocaine. Unless the
Need: Physiological Integrity; Nursing Process: Evaluation patient experiences hypotension, there is no need to routinely
2 Answer: 2 Rationale: The patient will be taught to take the keep the patient supine. Although coughing and deep breathing
pulse daily and to contact the prescriber if the pulse rate is less are effective nursing strategies to maintain pulmonary function,
than 60 or greater than 100 beats/min. Options 1, 3, and 4 are they are not pertinent for the administration of IV lidocaine. Cog-
incorrect. The medication should be taken at the same time each nitive Level: Applying; Client Need: Physiological Integrity;
day, but preferably after the patient has been active for a period of Nursing Process: Implementation
time (midmorning). Typically, the pulse rate will be lower in the 3 Answer: 3 Rationale: The therapeutic goal of verapamil is to
morning before the patient rises. Digoxin should be withheld if stabilize the dysrhythmia by slowing the conduction. While the
the pulse rate is below 60 beats/min. A high-fiber diet may atrial dysrhythmia may continue, the rate should return to a nor-
decrease the absorption of digoxin, and the drug should not be mal range (e.g., 60–100 beats/min in an adult). Options 1, 2, and 4
taken along with meals high in fiber. Furthermore, foods high in are incorrect. Verapamil may cause hypotension, but as an adverse
calcium may create hypercalcemia, which will potentiate the pos- rather than a therapeutic effect. It should not cause an increase in
sibility of digoxin toxicity. Cognitive Level: Applying; Client potassium levels or a reduction in urine output. Cognitive Level:
Need: Health Promotion and Maintenance; Nursing Process: Analyzing; Client Need: Physiological Integrity; Nursing Process:
Implementation Evaluation
3 Answer: 1 Rationale: Milrinone is a positive inotropic drug 4 Answer: 4 Rationale: Adenosine has an extremely short
and is given to increase the force of the contraction of the heart, half-life and must be administered by rapid IV push, over 1 to
which improves cardiac output. Options 2, 3, and 4 are incorrect. 2 seconds. Options 1, 2, and 3 are incorrect. Adenosine is not
Inotropic effects increase the volume of the cardiac output rather given by IV infusion or slowly. While potassium is an important
than decrease it and do not relax the myocardial muscle. Milri- electrolyte to monitor in patients with dysrhythmias, adenosine
none may cause cardiac dysrhythmias as an adverse effect. Cogni- does not cause hypo- or hyperkalemia. Cognitive Level: Apply-
tive Level: Analyzing; Client Need: Physiological Integrity; ing; Client Need: Physiological Integrity; Nursing Process:
Nursing Process: Evaluation Implementation
4 Answer: 4 Rationale: Hydralazine with isosorbide may 5 Answer: 3 Rationale: Beta blockers such as propranolol are
cause hypotension with reflex tachycardia, resulting in dizziness negative inotropic drugs and reduce myocardial contractility. In
and rapid heart rate. Options 1, 2, and 3 are incorrect. Hydralazine patients with existing HF, this may result in less cardiac output
with isosorbide does not cause confusion, agitation, bleeding, tin- and worsening of symptoms. Options 1, 2, and 4 are incorrect.
gling, or cramping of the extremities. If these occur, other causes Propranolol does not cause sodium retention and its adverse
should be investigated. Cognitive Level: Analyzing; Client Need: effects include hypotension rather than HTN. It may cause bron-
Physiological Integrity; Nursing Process: Evaluation choconstriction because it is a nonselective beta-adrenergic antag-
5 Answer: 1 Rationale: Beta-adrenergic blockers such as onist (blocker), but this effect does not worsen HF. It warrants
carvedilol must be started at 1/10 to 1/20 of a usual dose and caution or is contraindicated in patients with COPD and other
gradually increased to a target dosage. Options 2, 3, and 4 are respiratory conditions. Cognitive Level: Analyzing; Client Need:
incorrect. Because lower dosages are required, a higher loading Physiological Integrity; Nursing Process: Evaluation
dose will not be given, and beta-adrenergic blockers are often 6 Answer: 3 Rationale: An adverse effect associated with ami-
combined with ACE inhibitors, although dosage will not be odarone is photosensitivity. The patient should be instructed to
directly related to the ACE inhibitor. While caution is required if avoid direct sunlight, wear protective clothing, and use adequate
beta-adrenergic blockers are used to treat HF, they are an impor- sunscreen lotions of SPF 15 or higher. Options 1, 2, and 4 are incor-
tant drug group used to treat heart failure. Cognitive Level: rect. Amiodarone is not known to cause immunosuppression or to
Applying; Client Need: Physiological Integrity; Nursing Process: interact with oral contraceptives. Increased bleeding tendencies
Implementation are not an adverse effect of amiodarone. Cognitive Level: Apply-
6 Answer: 1, 2, 4 Rationale: Beta-adrenergic blockers require ing; Client Need: Health Promotion and Maintenance; Nursing
gradual increases in dosage amount approximately every 2 weeks Process: Implementation
to a target dosage. Significant improvement may not be noticed in
early therapy and the patient may feel worse during initiation of Chapter 38
therapy. Overall, however, the therapy has been proven to reduce
the number of HF-related hospitalizations and mortalities. 1 Answer: 1 Rationale: An activated partial thromboplastin
Options 3 and 5 are incorrect. Beta-adrenergic blocker therapy time (aPTT) is the appropriate laboratory value to monitor with
may require alterations in dosage for other cardiac drugs but not heparin infusions. When the patient is receiving this drug, the
all drugs will be affected. Lifestyle changes may be advisable in results should be 1.5 to 2 times that patient’s baseline, or 60 to
HF but are not necessarily directly related to beta-adrenergic 80 seconds. Options 2, 3, and 4 are incorrect. A PT or INR is used
blocker use. Cognitive Level: Applying; Client Need: Health Pro- to monitor the effectiveness of warfarin. Platelets are not affected
motion and Maintenance; Nursing Process: Planning by anticoagulants and are therefore not used in the monitoring of
these drugs. Cognitive Level: Analyzing; Client Need: Physiologi-
Chapter 37 cal Integrity; Nursing Process: Evaluation
2 Answer: 1, 2, 3 Rationale: The patient should be taught
1 Answer: 4 Rationale: Procainamide should be avoided in proper injection technique, including the need to inject the hepa-
patients with severe HF since this drug can worsen the condition. rin into the deep subcutaneous fat layer. A soft toothbrush
Options 1, 2, and 3 are incorrect. Ventricular tachycardia, paroxysmal should be used for oral hygiene. Puncture wounds or cuts will
require longer than normal pressure held at the site to stop
Appendix A Answers to Chapter Review 1441
bleeding—15 minutes or longer. Options 4 and 5 are incorrect. erythropoietin. Hematopoietic growth factors are often prescribed
Dental flossing should be avoided while the patient is receiving for these patients. Chemotherapy also causes anemia and patients
anticoagulants. The flossing can cause gum irritation and exces- may require hematopoietic growth factors if the anemia is severe.
sive bleeding. Aspirin has antiplatelet effects and concurrent use Cognitive Level: Applying; Client Need: Physiological Integrity;
may increase the risk of bleeding or hemorrhage. Cognitive Nursing Process: Implementation
Level: Applying; Client Need: Health Promotion and Mainte-
nance; Nursing Process: Planning 3 Answer: 3 Rationale: Neupogen increases WBC counts. The
3 Answer: 3 Rationale: Many drugs such as aspirin and ibu- nurse would monitor for effectiveness by examining this labora-
profen have strong anticoagulant effects. When the patient on tory value. Options 1, 2, and 4 are incorrect. Epoetin alfa is the
warfarin takes these drugs, the increased risk of bleeding can be drug that increases RBC count. Oprelvekin may be given to
hazardous. Options 1, 2, and 4 are incorrect. Drugs such as aspirin increase platelet levels. Reticulocytes are immature RBCs and
and ibuprofen do not neutralize the effect of an anticoagulant. MCV is a measure of the volume of RBCs. Cognitive Level: Ana-
Anticoagulants do not influence the half-life of any drugs. The lyzing; Client Need: Physiological Integrity; Nursing Process:
pain associated with arthritis is not worsened by the combination Evaluation
of these drugs. Cognitive Level: Applying; Client Need: Physio-
logical Integrity; Nursing Process: Implementation 4 Answer: 4 Rationale: Oprelvekin does not affect iron lev-
4 Answer: 2 Rationale: Because of the risk of hemorrhage, els and there would be no reason to instruct the patient to
dysrhythmias, and hypotension, the patient should remain supine increase dietary intake of it. Options 1, 2, and 3 are incorrect.
during and for up to 8 hours post–drug infusion. Options 1, 3, and Oprelvekin is used to stimulate the production of platelets in
4 are incorrect. The patient will remain in the hospital for a mini- patients who are at risk for severe thrombocytopenia. Oprelve-
mum of 24 hours or longer post-procedure for monitoring per kin may cause severe fluid retention that may lead to pulmo-
agency protocol. The risk of bleeding remains elevated for 2 to nary edema, pericardial effusion, and ascites. Patients should
4 days postinfusion. Oral anticoagulants such as warfarin or anti- monitor weight gain and report significant increases to the
platelet drugs will be ordered after the infusion; increasing vita- healthcare provider. Visual impairment, including blurred
min K in the diet or by supplement may increase the risk of vision, papilledema, and optic neuropathy, may occur with
clotting. Cognitive Level: Applying; Client Need: Physiological oprelvekin, and vision changes should be reported. Cognitive
Integrity; Nursing Process: Implementation Level: Analyzing; Client Need: Physiological Integrity; Nursing
5 Answer: 1 Rationale: Clopidogrel is an antiplatelet drug Process: Evaluation
used to prevent blood clots from forming inside arteries by inhib-
iting platelet aggregation. Options 2, 3, and 4 are incorrect. Hepa- 5 Answer: 1 Rationale: Patients who regularly consume large
rin is an anticoagulant that blocks the formation of blood clots by amounts of alcohol often have a nutritional sdyemfipcittoomf sv.iOtapmtiionnBs122,,
activating antithrombin III. Warfarin is a vitamin K antagonist which can manifest as abnormal neurologic
used to prevent the blood from clotting. The drug alteplase is a 3, and 4 are incorrect. Alcohol interferes with folate metabolism
tissue plasminogen activator that dissolves fibrin clots. Cognitive in the liver, but lack of folate does not cause destruction of vita-
Level: Applying; Client Need: Physiological Integrity; Nursing smamosialunuybbBlsle1te2aa.dnvPcitteeoarnmntehiiceenidoaaeunndsedtmaoniisaeabm,nsnoioaotrtbissntvoceirauteautdmrsoeiipdnnebtBnhy1iae2a.fbrVlooaimdctakymt.hoCifenoiGngBtIn1r2tiirtniaissvciaetc, factor,
Process: Implementation which
6 Answer: 1, 3, 4, 5 Rationale: Ginger, garlic, and green tea water-
may all increase the risk of bleeding. Dabigatran may be used for Level:
DVT and is monitored by aPTT, similar to heparin. The drug is Applying; Client Need: Physiological Integrity; Nursing Process:
contraindicated in patients with gastritis because of the increased Implementation
erinshkanocf ebtlheeedriensgp.onOspetoiofnda2biigsaitnracnor. rCeoctg.nVitiitvaemLinevBel1:2Adpopelsyinnogt;
Client Need: Physiological Integrity; Nursing Process: Planning 6 Answer: 1, 2, 3 Rationale: Ferrous preparations bind to
many substances including food and other drugs. To ensure
Chapter 39 complete absorption of the drug, iron supplements should be
taken 1 hour before or 2 hours after eating. Liquid iron prepara-
1 Answer: 2 Rationale: The patient who receives epoetin alfa tions are often given to children. Such preparations should be
has anemia. This reduction in RBCs produces cellular oxygen given with a straw to prevent contact with the teeth, which can
deficiency, which causes severe fatigue and weakness. Patients produce staining. After swallowing, the patient should be
receiving this drug should be taught to take scheduled rest peri- instructed to brush the teeth or thoroughly rinse the mouth to
ods to avoid overexertion. Options 1, 3, and 4 are incorrect. Avoid- prevent staining. The patient should be informed that iron
ing fresh fruits and vegetables or uncooked meat would be preparations can cause dark tarry-like or green-tinged stools
instructions more appropriate for an individual with neutropenia. and may cause constipation. When patients take iron prepara-
Limiting exposure to direct sunlight and using sunscreen would tions, increased fiber and water intake are measures to take to
be appropriate instructions for a patient who is receiving a drug decrease constipation. Options 4 and 5 are incorrect. Vitamin C
that causes photosensitivity, but epoetin alfa is not associated increases the absorption of iron preparations, not vitamin E.
with this adverse effect. Patients with anemia are not necessarily Caffeinated beverages inhibit the absorption of this drug. Cog-
thrombocytopenic and do not routinely need to avoid activities nitive Level: Applying; Client Need: Physiological Integrity;
that may cause injury. Cognitive Level: Applying; Client Need: Nursing Process: Planning
Health Promotion and Maintenance; Nursing Process: Planning
2 Answer: 2 Rationale: Darbepoetin should not be given to Chapter 41
patients with uncontrolled HTN because hematopoietic growth
factors can increase blood pressure. Options 1, 3, and 4 are incor- 1 Answer: 2 Rationale: Acetaminophen overdose is treated
rect. Patients with HIV may receive hematopoietic growth factors with PO or IV acetylcysteine. For maximum effectiveness, the
such as epoetin alfa to correct anemia caused by their HIV drug antidote should be administered within 8 hours of acetaminophen
therapy. Patients with chronic kidney disease often also have ane- ingestion. Options 1, 3, and 4 are incorrect. The administration of
mia because they are unable to secrete sufficient endogenous 1000 mL/h of normal saline IV would place the patient at risk for
fluid volume overload. The patient will not require cardioversion
to treat acetaminophen poisoning. The patient’s hepatic enzymes
will be assessed; however, these enzymes only provide informa-
tion as to the extent of liver damage. They do not treat acute acet-
aminophen overdose; they merely monitor for the effectiveness of
1442 Appendix A Answers to Chapter Review
the treatment and any effects of the overdose itself. Cognitive WBCs to below 4000/mm3 should be reported to the provider.
Level: Applying; Client Need: Physiological Integrity; Nursing Options 1, 3, and 4 are incorrect. Cyclosporine does not cause an
Process: Planning elevation in RBCs. The provider should be notified if platelet
2 Answer: 3 Rationale: Acetaminophen is the preferred drug counts drop below 75,000/mm3, but a count of 100,000/mm3 is
for reduction of fever in the event the patient has a hypersensitiv- within acceptable limits. A creatinine level of less than 1 mg/100 mL
ity to aspirin. Options 1, 2, and 4 are incorrect. A patient who has is within normal limits. Cognitive Level: Applying; Client Need:
hypersensitivity to aspirin should not be administered ibuprofen Physiological Integrity; Nursing Process: Assessment
or celecoxib due to the risk of hypersensitivity with the NSAIDs. 4 Answer: 3 Rationale: Azathioprine should be used with
Ketorolac is not administered for reduction of fever; it is adminis- extreme caution in patients with a previous history of varicella zos-
tered for pain control. Cognitive Level: Applying; Client Need: ter (chickenpox, shingles) because the immunosuppression may
Physiological Integrity; Nursing Process: Planning cause the virus to reactivate and cause a serious infection. Options
3 Answer: 1 Rationale: Ketorolac is administered parenter- 1, 2, and 4 are incorrect. Benign prostatic hyperplasia and cataracts
ally for pain. Options 2, 3, and 4 are incorrect. Ketoprofen, ibu- are not contraindications for the drug. Azathioprine may be used as
profen, and celecoxib are all administered PO. Cognitive Level: a treatment for severe RA. Cognitive Level: Applying; Client Need:
Applying; Client Need: Physiological Integrity; Nursing Process: Physiological Integrity; Nursing Process: Assessment
Implementation 5 Answer: 4 Rationale: Tacrolimus is a potent immunosup-
4 Answer: 4 Rationale: Ibuprofen should be discontinued 7 to pressant and patients should decrease their risk for infection by
14 days before surgery to reduce the risk of bleeding. Options 1, 2, taking precautions such as avoiding raw fruits and vegetables
and 3 are incorrect. Ibuprofen should not be continued until sur- that may harbor pathogens on the skin or inside, and by eating
gery and the patient should continue her anti-inflammatory med- only fully cooked meats after the heat of cooking has destroyed
ication until 7 to 14 days before surgery to maintain its antiarthritis pathogens. Options 1, 2, and 3 are incorrect. Aspirin may increase
effects. Cognitive Level: Applying; Client Need: Physiological GI irritation, placing the patient at risk for GI infections gaining
Integrity; Nursing Process: Implementation entry through the inflamed mucosa. Physical activity is important
5 Answer: 1 Rationale: Acetaminophen is metabolized in the to overall health, but this drug has no direct connection with
liver. The patient with cirrhosis of the liver has impaired liver weight gain. Tacrolimus is not known to have significant cardiac
function and should not receive acetaminophen for pain or fever effects, although HTN is a possible adverse effect and the blood
reduction. Options 2, 3, and 4 are incorrect. A patient who has pressure should be monitored. Cognitive Level: Applying; Client
COPD, breast cancer, or who is taking warfarin can be adminis- Need: Health Promotion and Maintenance; Nursing Process:
tered acetaminophen for fever and analgesia. Cognitive Level: Planning
Applying; Client Need: Physiological Integrity; Nursing Process: 6 Answer: 3 Rationale: Aldesleukin causes capillary leak syn-
Implementation drome, which causes fluid to exit the capillary beds and vascula-
6 Answer: 1, 2, 3, 4 Rationale: A patient who is experiencing ture, decreasing the circulating blood volume. As many as 70% of
toxic effects from aspirin may experience tinnitus, hyperventila- patients will develop hypotension. With the drop in blood pres-
tion, GI bleeding, or decreased urine output related to renal sure, organs may not perfuse adequately, and urine output will
impairment. Option 5 is incorrect. A patient with salicylate toxic- assess the adequacy of renal blood flow. Options 1, 2, and 4 are
ity does not tend to experience peripheral neuropathy. Cognitive incorrect. Altered skin condition, rashes, increased pancreatic
Level: Analyzing; Client Need: Physiological Integrity; Nursing enzymes such as amylase and lipase, and alterations in vision and
Process: Evaluation hearing are not symptoms of capillary leak syndrome. Cognitive
Level: Analyzing; Client Need: Physiological Integrity; Nursing
Chapter 42 Process: Assessment
1 Answer: 1 Rationale: Interferon alpha-2b causes flulike Chapter 43
symptoms in up to 50% of patients receiving the drug. Options 2,
3, and 4 are incorrect. While depression with suicidal thoughts 1 Answer: 2 Rationale: A parent’s preconceived ideas or reser-
has been reported, it is not a common effect. Edema, hypotension, vations about accepting vaccinations will be most influential on
tachycardia, fluid volume overload, hypertension, and renal whether the infant receives the scheduled injections. This also
insufficiency are not adverse effects commonly associated with presents an excellent teaching opportunity for the nurse to answer
this drug. Cognitive Level: Analyzing; Client Need: Physiological questions, allay any fears the mother may have, and teach post-
Integrity; Nursing Process: Assessment vaccination care. Options 1, 3, and 4 are incorrect. An allergy his-
2 Answer: 2 Rationale: The patient’s high fever (39.4°C tory will be taken, but unless the infant has demonstrated an
[103°F]) and chills are indicative of an infectious process. The use allergy to the components in the vaccine, allergies to other medi-
of two immunosuppressant drugs (i.e., basiliximab and cyclospo- cations will not necessarily increase the risk of reaction, nor will
rine) increases the risk of infection related to the additional immu- the parents’ allergies increase the risk. Nurses working with pedi-
nosuppressant effects. Options 1, 3, and 4 are incorrect. Basiliximab atric patients should be knowledgeable about the recommended
(Simulect) has fewer significant adverse effects than other MABs; schedule and, when in doubt, verify the necessary immunizations
however, GI effects (nausea, vomiting, abdominal pain) are com- needed. Cognitive Level: Analyzing; Client Need: Physiological
mon and anaphylaxis has been reported. Capillary leak syndrome Integrity; Nursing Process: Assessment
is a condition in which fluid and protein leak out of tiny blood 2 Answer: 3 Rationale: The MMR vaccination is an attenuated
vessels and flow into surrounding tissue. This complication is not (live) virus and there is a slight risk that the virus could be trans-
associated with basiliximab administration. Graft-versus-host dis- mitted to the child’s father because he is immunocompromised
ease is a type of transplant rejection, and androgen insensitivity is from the chemotherapy. The nurse would check with the provider
a genetically linked syndrome. Both are unrelated to the drug. about delaying the vaccine until the father is finished with the
Cognitive Level: Analyzing; Client Need: Physiological Integrity; chemotherapy. Options 1, 2, and 4 are incorrect. The nurse would
Nursing Process: Assessment teach the mother the signs of reaction and when to report them,
3 Answer: 2 Rationale: Cyclosporine is toxic to bone marrow and the family can safely go out of town if healthcare is available
although less so than other immunosuppressants. A decrease in at their destination. Although additional teaching may be required
to allay the mother’s fears of reaction, the mother’s reaction to
Appendix A Answers to Chapter Review 1443
MMR will not necessarily result in a reaction in the child. As long mon. Cognitive Level: Applying; Client Need: Physiological
as the brother’s immune system is healthy, he should not have Integrity; Nursing Process: Implementation
any adverse effects from his sister’s MMR vaccination because of 4 Answer: 1, 2 Rationale: Because corticosteroids such as
his cold. Cognitive Level: Applying; Client Need: Physiological beclomethasone decrease the immune response, the risk for infec-
Integrity; Nursing Process: Implementation tions is increased. Corticosteroids also increase blood glucose,
3 Answer: 3, 4 Rationale: This child would need to receive thus increasing the possibility of hyperglycemia. Options 3, 4, and
rabies immunoglobulin to provide passive immunity to the 5 are incorrect. Corticosteroids do not cause urinary retention, do
potential exposure. A series of five rabies vaccines will be started not increase the likelihood of tachycardia, and do not cause pho-
over a 28-day period unless it is confirmed that the dog did not tophobia. Cognitive Level: Applying; Client Need: Physiological
have rabies. If the dog is shown not to have rabies, the series can Integrity; Nursing Process: Assessment
be stopped. Options 1, 2, and 5 are incorrect. Tetanus and DTaP 5 Answer: 1 Rationale: Beta agonists may be given to children
would not be required as long as the child was current on her vac- younger than age 5 to manage asthma. They are available in for-
cination schedule. Rabies is a viral disease and the use of rabies mulations suitable for nebulizer treatments. Options 2, 3, and 4
toxoid would be ineffective. Cognitive Level: Applying; Client are incorrect. Beta antagonists, corticosteroids, and leukotriene
Need: Physiological Integrity; Nursing Process: Planning modifiers will not cause the rapid bronchodilation required in an
4 Answer: 4 Rationale: Acetaminophen (Tylenol) or ibuprofen acute asthma attack. Cognitive Level: Applying; Client Need:
(Advil) is an appropriate analgesic to treat the soreness that occurs Physiological Integrity; Nursing Process: Planning
post–tetanus toxoid vaccination. Options 1, 2, and 3 are incorrect. 6 Answer: 3 Rationale: Some patients have difficulty master-
There is no requirement to keep the arm still; in fact, motion may ing the coordination between inhalation and activation of the
help disperse the medication and help it to absorb. There is no medication. In these instances, a spacer will hold the medication
need to restrict fluids or to avoid crowds with a toxoid vaccina- cloud so that this is not a concern. The spacer has additional
tion. Cognitive Level: Analyzing; Client Need: Health Promotion advantages because it results in more effective delivery of the
and Maintenance; Nursing Process: Evaluation drug to the site of action and less drug deposition in the mouth
5 Answer: 3 Rationale: Known hypersensitivity to yeast is an and oropharynx. Options 1, 2, and 4 are incorrect. Additional
absolute contraindication for hepatitis B vaccine. Options 1, 2, and practice may help in the long term, but it is not the priority for an
4 are incorrect. Smoking and HTN are not contraindications for immediate solution to the problem and may only serve to frus-
the vaccine and present an opportunity for health teaching. Hepa- trate the patient further. The healthcare provider would not need
titis B is available only by injection and the nurse would explore to be contacted because the patient has difficulty learning, pro-
methods to help the patient be less fearful of the injection prior to vided that a solution is readily available. Substitution of an oral
administration. Cognitive Level: Analyzing; Client Need: Physio- form of the drug is not within the nursing scope of practice. Cog-
logical Integrity; Nursing Process: Assessment nitive Level: Analyzing; Client Need: Health Promotion and
6 Answer: 1 Rationale: Hypersensitivity reactions are likely to Maintenance; Nursing Process: Planning
occur within the first 20 minutes of administration. The nurse
should closely monitor the patient’s vital signs during the initial Chapter 45
period. Options 2, 3, and 4 are incorrect. RhoGAM does not cause
thrombocytopenia or anemia or increase liver enzymes. There is 1 Answer: 2, 4 Rationale: Before using intranasal prepara-
no need for a low-saturated-fat, low-cholesterol diet after receiv- tions, the nose should be cleared by blowing to ensure the drug
ing Rho immune globulin, and RhoGAM does not cause a cough. reaches the mucosa. Oxymetazoline should not be used for more
Cognitive Level: Applying; Client Need: Physiological Integrity; than 3 to 5 days to prevent rebound congestion. Options 1, 3, and
Nursing Process: Implementation 5 are incorrect. The medication is inhaled so a full glass of water
after the drug is not needed, although any liquid that drips into
Chapter 44 the oral pharynx should be spit out. As a sympathomimetic,
drowsiness is not an expected side effect of this drug. Inhaled
1 Answer: 1 Rationale: A quick-acting inhaled beta agonist sympathomimetic drugs such as oxymetazoline work quickly, but
such as albuterol is used to abort bronchospasm. Options 2, 3, and inhaled corticosteroids may take up 3 weeks to become fully effec-
4 are incorrect. Beclomethasone, ipratropium, and montelukast tive. Cognitive Level: Applying; Client Need: Physiological Integ-
are drugs used to prevent and control bronchospastic attacks and rity; Nursing Process: Planning
will not cause bronchodilation quickly enough to abort an attack. 2 Answer: 4 Rationale: Pseudoephedrine is a sympathomi-
Cognitive Level: Applying; Client Need: Physiological Integrity; metic and is used only for nasal decongestion. Options 1, 2, and 3
Nursing Process: Implementation are incorrect. Both dextromethorphan and diphenhydramine are
2 Answer: 3 Rationale: Corticosteroids can decrease the bene- effective for some coughs associated with allergic rhinitis and the
ficial oral flora that will allow for an overgrowth of fungal infec- common cold. Mucolytics are found in some OTC cough prepara-
tions such as Candida. Rinsing the mouth removes any tions used in colds but are best used to treat chronic productive
corticosteroid drug deposited there and prevents it from being coughs. Cognitive Level: Applying; Client Need: Health Promo-
swallowed, decreasing the likelihood of systemic absorption. tion and Maintenance; Nursing Process: Implementation
Options 1, 2, and 4 are incorrect. Inhaled corticosteroids such as 3 Answer: Because diphenhydramine may cause dizziness and
beclomethasone do not cause tachycardia, nervousness, or trem- drowsiness, an increased risk of falls is possible, particularly in
ors, and caffeine does not need to be avoided while the drug is the older adult. Cognitive Level: Applying; Client Need: Safe and
being used. Cognitive Level: Applying; Client Need: Health Pro- Effective Care Environment; Nursing Process: Implementation
motion and Maintenance; Nursing Process: Implementation 4 Answer: 4 Rationale: Second-generation (nonsedating) anti-
3 Answer: 1 Rationale: Bronchodilators such as albuterol may histamines such as fexofenadine have been associated with
have an adverse effect on heart rate elevation and palpitations dysrhythmias in the sensitive individual. Options 1, 2, and 3 are
related to dosage. Options 2, 3, and 4 are incorrect. Bronchodila- incorrect. A history of osteoporosis, peptic ulcer disease, or psori-
tors do not decrease the immune response or increase alertness. asis is not a contraindication for the drug. Cognitive Level: Ana-
While some bronchodilators have been known to cause unex- lyzing; Client Need: Physiological Integrity; Nursing Process:
pected problems and paradoxical bronchospasm, this is uncom- Assessment
1444 Appendix A Answers to Chapter Review
5 Answer: 3 Rationale: The phenylephrine should be used however, is associated with antigen and antibody reactions.
first to decrease intranasal swelling. After waiting 5 minutes to Cognitive Level: Analyzing; Client Need: Physiological Integ-
allow the phenylephrine to work, the fluticasone will reach deeper rity; Nursing Process: Assessment
into the nasal passages for better effects. Options 1, 2, and 4 are 6 Answer: 1 Rationale: Ampicillin should be taken on an
incorrect. Fluticasone is used to prevent nasal congestion due to empty stomach to ensure adequate absorption. Options 2, 3, and 4
allergic rhinitis and should be used consistently. Instilling flutica- are incorrect. A black and furry tongue is the symptom of an oral
sone first may not reach deeper nasal passages if congestion is superinfection and should be reported. The patient should be
present. Level: Applying; Client Need: Health Promotion and taught to take the full prescription even if the symptoms subside.
Maintenance; Nursing Process: Implementation Patients should never take two doses because this will place them
6 Answer: 4 Rationale: The syrup base of an antitussive cough at risk for toxicity. Cognitive Level: Analyzing; Client Need:
syrup such as dextromethorphan will help to soothe throat irrita- Health Promotion and Maintenance; Nursing Process: Evaluation
tion, and the patient should avoid drinking fluids immediately
following drug administration. Increasing overall fluid intake Chapter 48
throughout the day will help moisten irritated mucous mem-
branes as well as loosen secretions for better effects from the 1 Answer: 4 Rationale: Tetracycline potentially causes photo-
expectorant, guaifenesin. Options 1, 2, and 3 are incorrect. The sensitivity. Options 1, 2, and 3 are incorrect. Calcium products
patient does not have to remain supine after administration, and should not be taken at the same time as tetracycline but taken
taking the drug with food will not enhance the effects. Avoiding 1 hour before or 2 hours after the dose. Brushing will not remove
fluid intake will not prevent cough and may cause additional teeth staining caused by the drug. The staining of teeth due to
respiratory tract dryness. Cognitive Level: Applying; Client Need: medication can be removed only by a dental specialist. Ototoxic-
Physiological Integrity; Nursing Process: Implementation ity is not associated with tetracycline use, and any tinnitus or diz-
ziness may be related to other causes. Cognitive Level: Applying;
Chapter 47 Client Need: Health Promotion and Maintenance; Nursing Pro-
cess: Implementation
1 Answer: 3 Rationale: Ampicillin may decrease the effective- 2 Answer: 1 Rationale: Longer duration of action is one of the
ness of oral contraceptives, and the patient should be instructed to benefits of azithromycin therapy. Options 2, 3, and 4 are incorrect.
use a barrier method to avoid unwanted pregnancies while on the There is no evidence that azithromycin causes any more nausea
antibiotic and until the next cycle of oral contraceptives is started. than other antibiotics. Azithromycin is not affected by gastric con-
Options 1, 2, and 4 are incorrect. The combination of ampicillin tents and can be taken any time. Azithromycin is not affected by
and oral contraceptives will not increase the risk of adverse effects calcium-based foods. Cognitive Level: Analyzing; Client Need:
related to the antibiotic. Oral contraceptive effectiveness may be Physiological Integrity; Nursing Process: Evaluation
reduced during ampicillin therapy, and ampicillin will not create 3 Answer: 1 Rationale: Weight gain may be an early sign asso-
serious toxicity related to the use of oral contraceptives. Cognitive ciated with renal damage secondary to amikacin toxicity.
Level: Applying; Client Need: Health Promotion and Mainte- Options 2, 3, and 4 are incorrect. Adverse effects of amikacin are
nance; Nursing Process: Implementation not manifested by visual disturbances, mental depression, or uri-
2 Answer: 3 Rationale: Ototoxicity is associated with serum nary frequency. Cognitive Level: Applying; Client Need: Physio-
concentrations of vancomycin above 60 to 80 mcg/mL and mani- logical Integrity; Nursing Process: Planning
fests with tinnitus, dizziness, or balance and coordination effects. 4 Answer: 1 Rationale: Drug-induced nephrotoxicity would
Options 1, 2, and 4 are incorrect. Redness of the ears, itching of the cause an elevated serum creatinine level and should be reported
ears, and ocular pain are not symptoms related to ototoxicity to the healthcare provider. Options 2, 3, and 4 are incorrect. BUN
caused by vancomycin. Cognitive Level: Analyzing; Client Need: level is more commonly associated with hepatic toxicity but
Physiological Integrity; Nursing Process: Evaluation would be elevated and not decreased if nephrotoxicity is present.
3 Answer: 2 Rationale: A vaginal yeast infection with dis- Nephrotoxicity is not typically indicated via the WBC levels or
charge may be a symptom of a superinfection. Superinfection is a changes in serum iron levels. Cognitive Level: Analyzing; Client
possible adverse effect associated with all antibiotics and particu- Need: Physiological Integrity; Nursing Process: Assessment
larly with fungal and viral infections. Options 1, 3, and 4 are 5 Answer: Rationale: Tetracycline antibiotics should not be
incorrect. A hypersensitivity reaction is not usually manifested by taken concurrently with dairy products, iron-containing prepara-
vaginal discharge. The symptoms associated with PMC are sig- tions (e.g., multivitamins), or antacids. If these products are to be
nificant GI effects. Vaginal discharge is not a symptom of antibi- consumed, they should be taken 1 hour before or 2 hours after the
otic toxicity. Cognitive Level: Applying; Client Need: Physiological tetracycline. Cognitive Level: Applying; Client Need: Health Pro-
Integrity; Nursing Process: Evaluation motion and Maintenance; Nursing Process: Implementation
4 Answer: 4 Rationale: Watery diarrhea containing mucus, 6 Answer: 1, 2, 4, 5 Rationale: Aminoglycosides are renal, oto-,
blood, or pus is symptomatic of CDAD and must be monitored and neurotoxic. They may also cause neuromuscular blockade.
closely for progressing to PMC; both are adverse effects related to Increases in serum creatinine may indicate nephrotoxicity. Urine
antibiotic use. Options 1, 2, and 3 are incorrect. These symptoms output should also be monitored. Dizziness, vertigo, or tinnitus
are not related to peptic ulcers, malabsorption, or hypersensitivity may be signs of ototoxicity. Muscle weakness may indicate neuro-
reactions. Cognitive Level: Analyzing; Client Need: Physiological muscular blockade and may last for several days. Option 3 is
Integrity; Nursing Process: Evaluation incorrect. Gentamicin is not metabolized, and changes in liver
5 Answer: 1 Rationale: Shortness of breath, mouth and function tests would not be drug related. Cognitive Level: Ana-
tongue swelling, and generalized itching are signs of hypersen- lyzing; Client Need: Physiological Integrity; Nursing Process:
sitivity reaction. Options 2, 3, and 4 are incorrect. Blood dyscra- Assessment
sias include such problems as thrombocytopenia and
neutropenia, and the drug does not cause these symptoms. Beta Chapter 49
lactamase is a substance secreted by some bacteria that renders
the antibiotic ineffective. Drug toxicity may result from an exces- 1 Answer: 2 Rationale: Because pathogens grow rapidly and
sive level of the medication or adverse effects on body organ are constantly proliferating, all antibiotic therapies should be
systems related to age or other changes. Hypersensitivity,
Appendix A Answers to Chapter Review 1445
taken around the clock. Taking the drug as evenly spaced apart Chapter 50
during the day as possible will help ensure a steady serum drug
level to fight the bacteria. Options 1, 3, and 4 are incorrect. Cipro- 1 Answer: 3 Rationale: Crystalluria is the excretion of crys-
floxacin is not known to cause problems with patients’ sleep pat- tals in the urine. To prevent this adverse effect, patients are
terns. Superinfections occur when an antibiotic eradicates normal instructed to consume approximately 2 to 3 L of fluid per day.
flora and an opportunistic organism invades. This is a problem This action will flush the crystals from the renal system. Options
associated with antibiotic therapy in general and is not caused by 1, 2, and 4 are incorrect. Limiting foods high in calcium will not
not adhering to the prescribed schedule. Allergic reactions are prevent crystalluria. Positional changes are not related to the
very common with antibiotic therapy, but they do not result from adverse effects of crystalluria. Alcohol should be avoided when
failing to adhere to the medication schedule. Cognitive Level: taking most medications. However, the effects attributed to alco-
Applying; Client Need: Physiological Integrity; Nursing Process: hol consumption do not include crystalluria. Cognitive Level:
Implementation Applying; Client Need: Physiological Integrity; Nursing Pro-
2 Answer: 3, 4, 5 Rationale: Itching, even without the presence cess: Implementation
of a rash, may indicate histamine release from a drug allergy. 2 Answer: 1 Rationale: Nitrofurantoin is prescribed most com-
Swelling of the face, lips, or tongue, known as angioedema, is also monly for the prophylaxis of recurrent UTIs. Options 2, 3, and 4
a symptom of allergy. Nervousness or anxiety may indicate an are incorrect. Furadantin has no analgesic effect. The excretion of
adrenergic response secondary to an allergic reaction and, while urine is not affected by this drug, and the drug is not used for
they may have other causes, should be investigated further to rule pyelonephritis. Cognitive Level: Applying; Client Need: Physio-
out a developing allergic reaction. Options 1 and 2 are incorrect. logical Integrity; Nursing Process: Planning
Common adverse effects of ofloxacin are headache, nausea, and 3 Answer: 2, 4, 5 Rationale: Trimethoprim-sulfamethoxazole
vomiting. Cognitive Level: Analyzing; Client Need: Physiological (TMP-SMZ) is a sulfonamide and would be contraindicated in a
Integrity; Nursing Process: Assessment patient with a previous history of allergy. The drug is pregnancy
3 Answer: 1, 2 Rationale: Ciprofloxacin is excreted renally category C (D in the third trimester), and the use of the drug may
and increasing fluid intake will help to prevent drug accumula- result in kernicterus in the newborn. For people with diabetes
tion in the kidneys. Dairy products and antacids taken concur- who are taking oral sulfonylureas, an increased risk of hypoglyce-
rently may inhibit absorption of the ciprofloxacin. Options 3, 4, mia is possible when TMP-SMZ is used; hence, blood sugars must
and 5 are incorrect. Vitamin C does not need to be avoided while be monitored closely. Options 1 and 3 are incorrect. The occur-
on ciprofloxacin; however, products containing iron or zinc rence of migraine headaches is not affected by TMP-SMZ. Urinat-
should be avoided. An antihistamine does not need to be taken ing before or after sexual intercourse will not affect the use of
concurrently and may mask the symptoms of adverse effects TMP-SMZ. Cognitive Level: Applying; Client Need: Physiological
such as allergy. Excessive caffeine intake may increase the chance Integrity; Nursing Process: Assessment
of nervousness or anxiety and should be avoided. Cognitive 4 Answer: 3 Rationale: Nausea and vomiting are the most
Level: Applying; Client Need: Physiological Integrity; Nursing common adverse effects of oral sulfonamide therapy but should
Process: Implementation not occur with topical use. If they occur, the patient should be
4 Answer: 1 Rationale: Fluoroquinolones such as levofloxacin evaluated for possible systemic effects and for the proper self-
have been associated with tendonitis and tendon rupture, espe- administration of the topical drug. This statement indicates that
cially in patients over age 65. Any unusual joint or tendon pain or the patient has understood the teaching and when to report
difficulty moving or walking should be reported to the provider. potential adverse effects. Options 1, 2, and 4 are incorrect. The
Options 2, 3, and 4 are incorrect. Many multivitamins may contain drug should be applied topically only to affected areas. Stinging
iron and zinc, and concurrent administration with levofloxacin and burning are common effects of the topical application of this
will impair the antibiotic’s absorption. Fluoroquinolones do not drug. Excess potassium consumption should be avoided with the
impair vitamin D absorption and may cause dermatologic toxici- oral forms of sulfonamides but is not necessary with the topical
ties such as photosensitivity and photoallergy. Sunscreen and pro- drug. Cognitive Level: Analyzing; Client Need: Physiological
tective clothing should be used if sun exposure is anticipated. Integrity; Nursing Process: Evaluation
Fluoroquinolones may be nephrotoxic and increased fluid intake is 5 Answer: 1 Rationale: Nitrofurantoin is associated with pul-
advised. Cognitive Level: Applying; Client Need: Physiological monary toxicities such as interstitial pneumonitis and pulmonary
Integrity; Nursing Process: Implementation fibrosis. The drug should be used with extreme caution or not at
5 Answer: 4 Rationale: Fluoroquinolones such as ciprofloxa- all in the patient with preexisting pulmonary disease. Options 2,
cin may cause profound muscle weakness in patients with myas- 3, and 4 are incorrect. Diabetes, rheumatoid arthritis, or angina
thenia gravis. Options 1, 2, and 3 are incorrect. Anxiety and and hypertension are not contraindications for the drug. Cogni-
nervousness do not require cautious use and are not contraindi- tive Level: Applying; Client Need: Physiological Integrity; Nurs-
cations to ciprofloxacin. While the incidence of tendonitis and ing Process: Assessment
tendon rupture is higher in the adult over age 65, the drug is not 6 Answer: 3 Rationale: TMP-SMZ causes dermatologic toxici-
contraindicated in this population. However, more frequent ties including SJS. Unusual, blistering-type rashes with purplish-
monitoring may be needed. Cross-allergy to penicillins is not red discoloration should be immediately reported to the provider.
known for the fluoroquinolones and a history of penicillin Options 1, 2, and 4 are incorrect. Fungal superinfections may be
allergy is not a contraindication to ciprofloxacin. Cognitive wet or dry and are reddened, possibly denuded areas. Viral erup-
Level: Analyzing; Client Need: Physiological Integrity; Nursing tions are most often vesicular rashes. Nonadherence with drug
Process: Assessment therapy would not result in a rash. Cognitive Level: Applying;
6 Answer: 1 Rationale: Polymyxin B is a topical antibiotic Client Need: Physiological Integrity; Nursing Process:
used to promote wound healing. Options 2, 3, and 4 are incorrect. Implementation
Skin and mucous membranes cannot be made sterile. Polymyxin B
will cause cell death of the invading pathogenic bacteria but will Chapter 51
not completely sterilize the skin. Polymyxin B does not prevent
allergic reaction, nor does it provide pain relief to wounds. Cogni- 1 Answer: 2 Rationale: For some antituberculosis drugs such
tive Level: Applying; Client Need: Physiological Integrity; Nurs- as isoniazid (INH), peripheral neuropathy is problematic. This is
ing Process: Planning due to a decrease in the activity of pyridoxine on the nervous
1446 Appendix A Answers to Chapter Review
atidssvueer.seSuepffpeclet.mOepnttiaolnvsit1a,m3,inanBd6 is often prescribed to prevent this 3 Answer: 1, 2 Rationale: Unless otherwise directed by the
4 are incorrect. Isoniazid does not provider, small amounts of water after a feeding will rinse the
cause an increase in nerve ending sensitivity, nor does it accelerate mouth of milk proteins and sugars that can provide an ideal
the excretion of neurotransmitters. Isoniazid does not affect ascor- medium for Candida to grow. The suspension should be applied
bic acid levels. Cognitive Level: Analyzing; Client Need: Physio- to all surfaces of the mouth and tongue, by syringe or applicator,
logical Integrity; Nursing Process: Evaluation and the infant should swallow the remainder to treat possible GI
Candida. Options 3, 4, and 5 are incorrect. Nystatin suspension
2 Answer: 2, 3, 4, 5 Rationale: Once the diagnosis of pulmo- does not require chilling before administration. The suspension
nary TB is verified, sputum specimens are routinely collected to should not be added to formula or given before feedings; it
determine the effectiveness of the drug therapy. Ethambutol should be administered after feedings so that it can be retained
(Myambutol) may cause hepatotoxicity and decreases renal excre- in the mouth to treat the area of infection. Cognitive Level:
tion of uric acid. Hepatic function tests and uric acid levels will be Applying; Client Need: Physiological Integrity; Nursing Pro-
monitored before beginning the drug and routinely thereafter. It cess: Implementation
may also cause optic neuritis and vision acuity, and color vision 4 Answer: 4 Rationale: Nails grow very slowly and lengthy
sense will be tested before starting the drug and periodically treatment may be required to adequately treat the infection.
while the drug is used. Option 1 is incorrect. Coagulation studies Options 1, 2, and 3 are incorrect. The infection will be evaluated
are not affected by ethambutol. Cognitive Level: Applying; Client during the treatment period but it will take many months to ade-
Need: Physiological Integrity; Nursing Process: Assessment quately treat the infection. Purchasing more pills at one time does
not necessarily reduce the cost of the prescription. Toxic doses are
3 Answer: To ensure that the patient is not experiencing adverse never administered, even to shorten treatment cycles. Cognitive
effects related to the acetylation process, both hepatic function Level: Applying; Client Need: Health Promotion and Mainte-
and serum drug level will be monitored frequently. Cognitive nance; Nursing Process: Implementation
Level: Applying; Client Need: Physiological Integrity; Nursing 5 Answer: 3 Rationale: Amphotericin B can cause a number of
Process: Planning serious adverse effects including fever, chills, and headache. Pre-
treatment with corticosteroids, antihistamines, and antipyretics
4 Answer: 4 Rationale: Treatment of MAC infections in may reduce the severity of these distressing adverse effects.
patients who are HIV positive is prolonged and relapse rates are Options 1, 2, and 4 are incorrect. Pretreatment does not enhance
as high as 20%. Options 1, 2, and 3 are incorrect. MAC is not con- the effectiveness of this antifungal drug. The by-products of
sidered a contagious infection. Treatment is prolonged and is indi- amphotericin are not affected by the pretreatment of the patient,
cated when CD4 counts drop below 50 cells/mL. Cognitive Level: and pretreatment does not affect the half-life of the drug. Cogni-
Applying; Client Need: Physiological Integrity; Nursing Process: tive Level: Applying; Client Need: Physiological Integrity; Nurs-
Implementation ing Process: Planning
6 Answer: 3 Rationale: Depending on which oral antidiabetes
5 Answer: 1 Rationale: The nurse should observe for any red- medication is used (e.g., glyburide), fluconazole (Diflucan) may
dish-brown discoloration of skin, cornea, conjunctiva, and body decrease blood sugar levels, and an adjustment in antidiabetes
fluids. This adverse effect occurs in 75% to 90% of patients within treatments may be required. Options 1, 2, and 4 are incorrect. Flu-
a few weeks of treatment. Even after discontinuation of therapy, conazole (Diflucan) has an effect when given concurrently with
skin discoloration may take months or years to fade. Options 2, 3, some antidiabetes drugs (e.g., glyburide) and may cause hypogly-
and 4 are incorrect. The drug does not cause constipation, chills, cemia. It does not antagonize the effect of antidiabetes medica-
dehydration, hypoglycemia, impaired memory, impotence, tions and does not cause an increase in blood sugar level.
memory loss, nervousness, or pruritus. Cognitive Level: Analyz- Cognitive Level: Applying; Client Need: Physiological Integrity;
ing; Client Need: Physiological Integrity; Nursing Process: Nursing Process: Implementation
Evaluation
Chapter 53
6 Answer: 3 Rationale: Isoniazid may increase glucose levels
and more frequent monitoring is required. Options 1, 2, and 4 are 1 Answer: 1 Rationale: Atovaquone-proguanil (Malarone)
incorrect. Isoniazid does not cause a decrease or rapid rises and therapy begins 1 or 2 days before entering a malaria-endemic area
falls of glucose levels. Cognitive Level: Applying; Client Need: and continues during the stay and for 7 days after return.
Physiological Integrity; Nursing Process: Evaluation Options 2, 3, and 4 are incorrect. Three days is not a sufficient
amount of time to ensure that the patient has adequate protection
Chapter 52 against malaria infection. If the patient develops symptoms of
malaria, prophylaxis is no longer indicated, but the drug may be
1 Answer: 2, 3, 4 Rationale: When administered too rapidly, continued as part of the treatment regimen. Cognitive Level:
amphotericin B may cause hypotension, hypokalemia, and shock. Applying; Client Need: Health Promotion and Maintenance;
Options 1 and 5 are incorrect. Amphotericin is not known to cause Nursing Process: Evaluation
laryngeal spasms or hypoglycemia. Cognitive Level: Analyzing; 2 Answer: 1, 4 Rationale: Hydroxychloroquine has anti-
Client Need: Physiological Integrity; Nursing Process: Evaluation inflammatory effects and is used in the treatment of systemic
2 Answer: 1 Rationale: Patients who take fluconazole (Diflu- lupus erythematosus, rheumatoid arthritis, and other inflamma-
can) may experience nausea, vomiting, and diarrhea. Nutritional tory diseases. Options 2, 3, and 5 are incorrect. Hydroxychloroquine
intake is especially important to maintain optimal health in a is not used to treat roundworm, leishmaniasis, or urinary tract
patient with AIDS. Keeping a food diary will assist the provider in infections. Cognitive Level: Applying; Client Need: Physiological
determining overall calorie and fluid intake. Antinausea medica- Integrity; Nursing Process: Assessment
tion may be helpful if nausea or vomiting is severe. Options 2, 3, 3 Answer: 3 Rationale: Many patients report experiencing an
and 4 are incorrect. Loss of muscle mass is not related to flucon- unpleasant metallic taste that can be caused by metronidazole.
azole therapy. The decision to wear a high-filtration mask is not Options 1, 2, and 4 are incorrect. Flatus and intestinal bloating are
related to fluconazole, and patients on this drug do not need to not characteristic adverse effects of metronidazole. Metronidazole
avoid fat-based soaps. Allowing adequate air circulation to body does not cause bad breath (halitosis) and if it occurs, other causes
areas will help prevent surface fungal infections but is not
required as part of fluconazole therapy. Cognitive Level: Apply-
ing; Client Need: Physiological Integrity; Nursing Process:
Implementation
Appendix A Answers to Chapter Review 1447
should be considered. Alopecia (hair loss) is not associated with 4 Answer: 4 Rationale: Zanamivir must be started within
metronidazole. Cognitive Level: Applying; Client Need: Health 48 hours after the onset of symptoms to be effective. Options 1, 2,
Promotion and Maintenance; Nursing Process: Implementation and 3 are incorrect. Waiting to take the drug longer than 48 hours
4 Answer: 2 Rationale: The use of pyrimethamine is associ- will not shorten the infection period. It should not be saved
ated with megaloblastic anemia, leukopenia, thrombocytopenia, because any future infection should be evaluated at that time to
and pancytopenia as possible adverse effects. Unusual bleeding ascertain it is the flu and that it will respond to the zanamivir.
or fatigue, sores that do not heal, or low-grade fevers may indicate Cognitive Level: Applying; Client Need: Health Promotion and
that blood cell counts are low and should be assessed by the Maintenance; Nursing Process: Implementation
healthcare provider. Options 1, 3, and 4 are incorrect. Pyrimeth- 5 Answer: 2 Rationale: Tenofovir is known to cause lactic aci-
amine is associated with nausea, vomiting, and abdominal dosis. Symptoms such as anxiety, fatigue, nausea, vomiting, palpi-
cramping as adverse effects, and increasing fiber-rich foods will tations, lethargy, rapid breathing and heart rate, weakness, chest
not affect these. Increasing fluid intake is important with most pain or tightening, hypotension, or shortness of breath should be
anti-infective drugs but 3 L per day is not required for this drug. immediately reported to the provider. Options 1, 3, and 4 are
Adverse eye effects are not associated with pyrimethamine and incorrect. Tenofovir is not associated with systemic yeast infec-
sulfadiazine. Cognitive Level: Applying; Client Need: Physiologi- tions, heart failure, or ventricular dysrhythmias. Cognitive Level:
cal Integrity; Nursing Process: Implementation Applying; Client Need: Physiological Integrity; Nursing Process:
5 Answer: 4 Rationale: To reduce the risk of reinfection, bed Implementation
linens and undergarments should be washed thoroughly after 6 Answer: 4 Rationale: Ribavirin is associated with an
treatment is given. Options 1, 2, and 3 are incorrect. Mebendazole increased risk of hemolytic anemia. Increased fatigue, dizziness,
is usually given as a single dose but may be repeated for up to headache, abdominal pain, pallor, and chest pain are associated
3 days. Family members are also at risk and should be evaluated with this anemia. Options 1, 2, and 3 are incorrect. Neurologic,
or treated empirically. Although consuming citrus products may respiratory, or dermatologic adverse effects may occur but are not
increase the risk of GI adverse effects, citrus and dairy do not as severe as the hemolytic anemia associated with this drug. Cog-
need to be eliminated from the diet. Cognitive Level: Applying; nitive Level: Analyzing; Client Need: Physiological Integrity;
Client Need: Health Promotion and Maintenance; Nursing Pro- Nursing Process: Evaluation
cess: Implementation
6 Answer: 1 Rationale: An acute onset of any CNS abnormal- Chapter 55
ity may indicate metronidazole toxicity. If ataxia and confusion
suddenly develop after the initiation of metronidazole, the nurse 1 Answer: 2 Rationale: This is a false statement. No vaccine
should discontinue the medication and contact the healthcare pro- currently exists to provide immunity to HIV infection, although
vider. Options 2, 3, and 4 are incorrect. Adverse effects to metroni- testing is ongoing. Options 1, 3, and 4 are incorrect. The patient
dazole are rare; however, nausea and diarrhea can occur. Anorexia should be informed that therapy for HIV will require lifelong
and dryness of the mouth are common adverse effects. However, treatment because there is no cure. Since treatment is often com-
these adverse effects will usually disappear as the therapy contin- plex and lifelong, the patient should be taught how to adjust the
ues. Weight gain and irritability are not typical adverse effects daily schedule so as to not interfere with ADLs. With recent
associated with metronidazole. Cognitive Level: Analyzing; Cli- advances in pharmacotherapy for HIV, many individuals are able
ent Need: Physiological Integrity; Nursing Process: Evaluation to live symptom-free lives. Cognitive Level: Applying; Client
Need: Health Promotion and Maintenance; Nursing Process:
Chapter 54 Evaluation
2 Answer: 2, 3, 5 Rationale: Hyperglycemia, pancreatitis, and
1 Answer: 1 Rationale: Acyclovir is associated with nephro- hepatic failure are adverse effects associated with lopinavir with
toxicity, especially when given IV. The drug should be adminis- ritonavir. Options 1 and 4 are incorrect. CKD and bone marrow
tered IV slowly, over a minimum of 1 hour, and increased fluid suppression are not adverse effects associated with lopinavir with
intake encouraged throughout the day to prevent adverse renal ritonavir. Cognitive Level: Analyzing; Client Need: Physiological
effects. Options 2, 3, and 4 are incorrect. Acyclovir is not associ- Integrity; Nursing Process: Evaluation
ated with an increased risk of fungal infections or eye discomfort. 3 Answer: 4 Rationale: Lactic acidosis is known to occur with
Itching and skin irritation may occur with topical use but if it all NRTIs, although the risk with emtricitabine is less than that of
occurs with IV drug administration, drug allergy should be ques- some drugs. It is one of the preferred drugs for initial HIV ther-
tioned and the administration stopped until evaluated. Cognitive apy. Options 1, 2, and 3 are incorrect. Ventricular cardiac dys-
Level: Applying; Client Need: Physiological Integrity; Nursing rhythmias, pulmonary fibrosis, and necrotic bowel syndrome are
Process: Implementation not associated with emtricitabine. Cognitive Level: Applying; Cli-
2 Answer: 3 Rationale: Zepatier may be used in combination ent Need: Physiological Integrity; Nursing Process: Evaluation
with ribavirin. Options 1, 2, and 4 are incorrect. Zepatier is a fixed- 4 Answer: 3 Rationale: Nausea, vomiting, diarrhea, abdomi-
dose PO combination of elbasvir and is not a topical or IV drug. nal pain, and headache are common with protease inhibitor regi-
Zepatier is used for a 12- to 16-week course of therapy, not 12 to mens. Options 1, 2, and 4 are incorrect. Fatigue, generalized
16 months. The drug is well tolerated with the most common weakness, and myalgia are common adverse effects for NRTIs
adverse effects being fatigue, headache, and nausea. Cognitive and NtRTIs; headache, diarrhea, nausea, fatigue, and insomnia
Level: Applying; Client Need: Health Promotion and Mainte- are common with integrase inhibitors; and respiratory tract
nance; Nursing Process: Implementation infections, cough, pyrexia, rash, and dizziness are common with
3 Answer: 2, 3, 5 Rationale: Amantadine is associated with miscellaneous antiretrovirals. Cognitive Level: Applying; Client
nephrotoxicity; possible severe CNS effects including seizures, Need: Health Promotion and Maintenance; Nursing Process:
psychosis, and suicidal ideation; and peripheral edema and heart Planning
failure. Options 1 and 4 are incorrect. Amantadine is not known to 5 Answer: 1, 2, 3 Rationale: Patients receiving antiretroviral
interfere or affect the white blood cell or platelet count. Potassium therapy are immunocompromised and should avoid sources of
and sodium levels are not affected by amantadine. Cognitive infection such as crowds and individuals who have infections.
Level: Applying; Client Need: Physiological Integrity; Nursing The patient should be instructed to notify the healthcare provider
Process: Assessment
1448 Appendix A Answers to Chapter Review
at the first sign of a rash. Several antiretroviral medications may tract, an adverse effect of chemotherapy and radiation treatment
cause SJS, a dermatologic adverse effect that can be fatal. Current for cancer. Patients experiencing this adverse effect should be
research has shown that ART, especially when started early in instructed to eat a bland diet with low roughage and to use a soft
HIV infection, significantly reduces viral load, reducing the toothbrush or plain water rinses for oral care if the mucositis is
chance of transmission. Transmission, however, is still possible severe. Options 1, 2, and 4 are incorrect. Most OTC mouthwashes
and infection control measures should still be practiced. Options 4 contain a significant amount of alcohol, which will further inflame
and 5 are incorrect. Total discontinuation of medication is not rec- the oral tissue and should be avoided. Citrus foods and beverages
ommended because viral load increases when drug therapy is dis- should be avoided because their acidic nature would cause pain.
continued. Some herbal supplements, such as St. John’s wort, Mucositis can last for the duration of the chemotherapy treatment
interfere with antiretroviral therapy. Cognitive Level: Applying; and should be treated rather than ignored. This condition will
Client Need: Health Promotion and Maintenance; Nursing Pro- prevent intake of adequate nutrition to build new cells. Cognitive
cess: Planning Level: Applying; Client Need: Physiological Integrity; Nursing
6 Answer: 2, 3 Rationale: Drug therapy for women with HIV Process: Implementation
infection is begun as soon as possible once pregnancy is con- 5 Answer: 1 Rationale: Myelosuppression is the most com-
firmed to decrease viral load and the potential to transmit the mon dose-limiting adverse effect of chemotherapy and the one
infection to the infant. Drug therapy is also started as soon as pos- that most often causes discontinuation or delays of chemotherapy.
sible in infants born to mothers with HIV infection. Options 1, 4, Options 2, 3, and 4 are incorrect. Although alopecia may be dis-
and 5 are incorrect. Waiting to confirm the viral load in an infant tressing for the patient, its presence does not determine when the
born to a mother with HIV infection delays necessary treatment next round of chemotherapy can be administered. Mucositis is not
and may allow the viral load to increase. Treatment of the infant a reason that subsequent rounds of chemotherapy should be
whose mother was not taking antiretroviral drugs during preg- delayed. Cachexia is the physical wasting with loss of weight and
nancy should be given over 6 weeks. Currently, the CDC does not muscle mass caused by disease. Although it is undesirable, it is
recommend breastfeeding because the virus is present in breast not the most common reason for delaying chemotherapy. Cogni-
milk and many antiretroviral drugs also are found in breast milk. tive Level: Applying; Client Need: Physiological Integrity; Nurs-
Cognitive Level: Applying; Client Need: Health Promotion and ing Process: Planning
Maintenance; Nursing Process: Planning 6 Answer: 4 Rationale: Many antineoplastics are classified as
vesicant drugs that can cause serious tissue injury if they leak
Chapter 56 into the surrounding tissue from an artery or vein during an infu-
sion or injection. The nurse should closely monitor the infusion
1 Answer: 3 Rationale: Stage I suggests that the tumor is rela- site for swelling and pain. Options 1, 2, and 3 are incorrect. Vesi-
tively small in size, has not invaded the surrounding tissue, and cants do not always cause nausea. It would be inappropriate for
has not been detected in surrounding lymph nodes; thus it has the nurse to monitor the patient’s intake of calcium-rich foods
been detected at an early stage. Options 1, 2, and 4 are incorrect. because this is not related to receiving a chemotherapy drug clas-
Stage I is the earliest staging and has the best prognosis. Cell dif- sified as a vesicant. Respiratory status is not related to the admin-
ferentiation refers to grading of cancer cells, not staging of cancer istration of a vesicant-type chemotherapy drug. Cognitive Level:
cells. Stage I suggests that the tumor is small and has not begun to Applying; Client Need: Physiological Integrity; Nursing Process:
invade surrounding tissue. Cognitive Level: Analyzing; Client Implementation
Need: Physiological Integrity; Nursing Process: Evaluation
2 Answer: 4, 5 Rationale: Patients and family members should Chapter 57
avoid receiving live virus vaccination or exposure to chickenpox.
Varicella (chickenpox) vaccination is usually given to children 1 Answer: 2 Rationale: The nadir indicates that myelosup-
between the ages of 12 and 18 months and the patient should not pression has occurred and is indicated by decreased blood cell
care for her granddaughter if immunization with live virus vac- counts. WBC and ANC are sensitive indicators of the nadir.
cines is planned. The patient should also avoid crowds, especially Options 1, 3, and 4 are incorrect. BUN, creatinine, ionized calcium,
in enclosed areas, to minimize the risk of infection. Options 1, 2, and serum albumin are not indicators of the nadir and myelosup-
and 3 are incorrect. Attending a support group, maintaining nor- pression. Cognitive Level: Analyzing; Client Need: Physiological
mal activities when possible, and eating small, frequent meals Integrity; Nursing Process: Evaluation
with sufficient protein are routine care measures during chemo- 2 Answer: 1, 3, 4 Rationale: The main dose-limiting toxicity to
therapy. Cognitive Level: Analyzing; Client Need: Physiological occur with vincristine is neurotoxicity. Numbness of the hands
Integrity; Nursing Process: Evaluation and feet, constipation related to decreased peristalsis, and dimin-
3 Answer: 1 Rationale: The use of multiple drugs affects dif- ished reflexes are all signs of neurotoxicity. Options 2 and 5 are
ferent stages of the cancer cell’s lifecycle and attacks the various incorrect. Cardiac and pulmonary toxicities are not associated
clones within the tumor via several mechanisms of action, thus with vincristine. Cognitive Level: Analyzing; Client Need: Physi-
increasing the percentage of cell kill. Combination chemotherapy ological Integrity; Nursing Process: Evaluation
also allows lower dosages of each individual drug, thus reducing 3 Answer: 4 Rationale: Tamoxifen is associated with an
toxicity and slowing the development of resistance. Options 2, 3, increased risk of endometrial cancer and monitoring will be nec-
and 4 are incorrect. Staging describes the process of determining essary to detect early changes that may indicate that this adverse
the extent of cancer in the body and where the cancer is located. effect has occurred. Options 1, 2, and 3 are incorrect. Paralytic
Antineoplastic drugs may kill only a small portion of the tumor, ileus and pulmonary fibrosis are not associated with tamoxifen.
leaving some clones unaffected and able to repopulate the tumor Alopecia is a common adverse effect of many chemotherapy
with resistant cells. Combination chemotherapy also allows drugs but will not require long-term monitoring. Cognitive Level:
lower dosages of each individual drug, thus reducing toxicity Applying; Client Need: Physiological Integrity; Nursing Process:
and slowing the development of resistance. Cognitive Level: Implementation
Applying; Client Need: Physiological Integrity; Nursing Process: 4 Answer: 3 Rationale: As with many chemotherapy drugs,
Evaluation doxorubicin is associated with mucositis. Daily mouth rinses will
4 Answer: 3 Rationale: Mucositis is the painful inflammation be prescribed to decrease the risk of opportunistic infections from
and ulceration of the mucous membranes lining the digestive yeast and mouth bacteria. Options 1, 2, and 4 are incorrect.
Appendix A Answers to Chapter Review 1449
Performing active or assisted ROM is an important intervention 6 Answer: 3 Rationale: Antibiotics have no role in the treat-
associated with drugs that cause neurotoxicities. Controlling pain ment of GERD although certain antibiotics are used in treating
is associated with chemotherapy that may cause pain as an PUD to eradicate the H. pylori organism. Options 1, 2, and 4 are
adverse effect. Maintaining bed rest is not related to the use of rineclioervreecsty. mHp2-troemcesptoofr antagonists and PPIs are used routinely to
chemotherapy but may be required for other reasons. Cognitive GERD. OTC antacids provide intermittent
Level: Applying; Client Need: Physiological Integrity; Nursing relief for mild cases. Cognitive Level: Applying; Client Need:
Process: Implementation Physiological Integrity; Nursing Process: Implementation
5 Answer: 1 Rationale: NSAIDs may cause severe and fatal
myelosuppression when taken concurrently with methotrexate. Chapter 60
Options 2, 3, and 4 are incorrect. Antihistamines, laxatives, and
cough suppressants may be used with methotrexate. However, 1 Answer: 3 Rationale: Diphenoxylate with atropine is given
the provider should be consulted if they are needed because for diarrhea. The patient should report a decrease in the number
symptoms associated with these drugs may indicate a more seri- of loose, watery stools after administration. Options 1, 2, and 4 are
ous condition that requires additional treatment. Cognitive Level: incorrect. Although diphenoxylate with atropine may decrease
Applying; Client Need: Physiological Integrity; Nursing Process: abdominal cramping and gas as a result of slowed peristalsis, it is
Implementation not the main therapeutic effect desired from this drug. Slowing
6 Answer: 3 Rationale: Filgrastim increases neutrophil pro- peristalsis may cause a decrease in bowel sounds rather than an
duction and decreases the duration of neutropenia with associ- increase. Cognitive Level: Analyzing; Client Need: Physiological
ated infection risk. Options 1, 2, and 4 are incorrect. Filgrastim Integrity; Nursing Process: Evaluation
does not boost the action of carboplatin, prevent the formation of 2 Answer: 2 Rationale: One adverse effect of sulfasalazine is
additional cancers, or prevent bone loss. Cognitive Level: Apply- blood dyscrasias, which may include anemia, leukopenia, and
ing; Client Need: Physiological Integrity; Nursing Process: thrombocytopenia. Fever, an increase in bruising, and sore throat
Implementation are all possible symptoms of these decreased cell counts. Options
1, 3, and 4 are incorrect. Stevens–Johnson syndrome results in
Chapter 59 inflammation of the skin and mucous membranes and includes a
sunburn-like appearance, blisters, and possible exfoliation of the
1 Answer: 2 Rationale: Magnesium compounds, especially in dermis. Idiosyncratic reactions are aberrant reactions that cannot
higher doses, often cause diarrhea. Options 1, 3, and 4 are incor- be explained by the known pharmacologic action of the drug and
rect. Aluminum compounds and calcium compounds may cause occur only in a small percentage of the population. This patient’s
constipation. Sodium compounds may cause flatulence. Cogni- symptoms are well documented as adverse effects. Hypersensi-
tive Level: Applying; Client Need: Physiological Integrity; Nurs- tivity responses are due to stimulation of the immune system and
ing Process: Evaluation are invoked by an antigen or antibody response. The symptoms
2 Answer: 1, 2, 4, 5 Rationale: Symptoms of GERD include presented do not reflect hypersensitivity to the drug. Cognitive
dysphagia, dyspepsia, nausea, belching, heartburn, and chest Level: Analyzing; Client Need: Physiological Integrity; Nursing
pain. Option 3 is incorrect. The nurse would not expect a decrease Process: Evaluation
in the patient’s appetite due to this medication. Cognitive Level: 3 Answer: 4 Rationale: Ondansetron is known to prolong the
Applying; Client Need: Physiological Integrity; Nursing Process: QT interval and may cause cardiac dysrhythmias. Options 1, 2,
Evaluation and 3 are incorrect. An allergy to soy or soy products, chronic con-
3 Answer: 3 Rationale: The proton pump is activated by food stipation, or glaucoma does not present contraindications to the
intake. Thus, administering it about 20 to 30 minutes before the drugs. Cognitive Level: Analyzing; Client Need: Physiological
first major meal of the day allows peak serum levels to coincide Integrity; Nursing Process: Evaluation
with when the maximum levels of pumps are activated, allowing 4 Answer: 1 Rationale: The enzymes in pancrelipase come
maximum efficiency of the PPI. Options 1, 2, and 4 are incorrect. from pork. If the patient is allergic to or has religious restrictions
The proton pumps are less active at night, in the fasting state, or on pork, the drug is contraindicated. Options 2, 3, and 4 are incor-
between meals. Cognitive Level: Applying; Client Need: Physio- rect. Pancrelipase is not contraindicated for individuals with HTN
logical Integrity; Nursing Process: Planning or coronary artery disease. Pancrelipase is not an iodine-based
4 Answer: 2 Rationale: Blood dyscrasias have been reported, drug. There is no expected cross sensitivity. Cognitive Level:
especially neutropenia and thrombocytopenia, with long-term Applying; Client Need: Physiological Integrity; Nursing Process:
use. Periodic blood counts should be performed. Options 1, 3, and Implementation
4 are incorrect. Ranitidine does not cause photophobia and skin 5 Answer: 4 Rationale: Because magnesium hydroxide will
irritations. Dyspnea and productive cough are not expected stimulate peristalsis, it is important for the nurse to assess for
adverse effects for this medication. Ranitidine is not known to bowel sounds before giving the drug. If blockage or an ileus is
cause these symptoms. Cognitive Level: Applying; Client Need: suspected, the drug should be held and the provider notified.
Physiological Integrity; Nursing Process: Planning Options 1, 2, and 3 are incorrect. Blood pressure is an important
5 Answer: 1, 2, 4 Rationale: First-line therapy for H. pylori vital sign to monitor postoperatively, but the magnesium
includes a combination of a PPI such as omeprazole; antibiotics hydroxide should not have direct effects. The dosage of the opioid
such as metronidazole, clarithromycin, or amoxicillin; and bis- drug and the patient’s ability to ambulate to the bathroom will not
muth subsalicylate. Options 3 and 5 are incorrect. Sucralfate impact the drug’s use or action. Cognitive Level: Applying; Client
stimulates mucus, bicarbonate, and prostaglandin secretion, and Need: Physiological Integrity; Nursing Process: Assessment
acts locally to produce a thick protective barrier that coats and 6 Answer: 1, 3 Rationale: The nurse should explore possible
binds to the ulcer, protecting it against further erosion from acid causes for the diarrhea with the mother before making a recom-
and pepsin to promote healing. It is not used as a first-line drug mendation because if diarrhea is caused by infections, slowing
in H. pylori infections. Fluconazole is an antifungal drug and is motility may allow the infection to increase. Salicylates, including
not used to treat a bacterial infection such as H. pylori. Cognitive bismuth subsalicylate, are contraindicated in children under the
Level: Applying; Client Need: Physiological Integrity; Nursing age of 19 because of an increased risk for Reye’s syndrome.
Process: Planning Options 2, 4, and 5 are incorrect. Activity level and weight are
important growth and development parameters to assess but are
1450 Appendix A Answers to Chapter Review
unrelated to the drug’s use. The school schedule would not have a solution. Regular insulin may be added to the bag, but not NPH
direct impact on which drug is recommended. Cognitive Level: insulin. Cognitive Level: Applying; Client Need: Physiological
Applying; Client Need: Physiological Integrity; Nursing Process: Integrity; Nursing Process: Assessment
Implementation 3 Answer: 4 Rationale: 10% dextrose in water contains the
highest concentration of glucose and should be hung until the
Chapter 61 new TPN bag is available. The solution selected should minimize
the risk of hypoglycemia. Options 1, 2, and 3 are incorrect. They
1 Answer: 2 Rationale: Oral contraceptives may increase the will not be effective in preventing hypoglycemia. Cognitive Level:
levels of vitamin A. Options 1, 3, and 4 are incorrect. Vitamins D Applying; Client Need: Physiological Integrity; Nursing Process:
and E are also fat-soluble vitamins and may be taken along with Implementation
vitamin A. Mineral oil may decrease the fat-soluble vitamins, 4 Answer: 2 Rationale: The patient’s temperature should be
including vitamin A. Antibiotics are not known to have an effect monitored for signs of infection and subsequent sepsis, which are
on the levels of vitamin A. Cognitive Level: Applying; Client complications of TPN therapy. The weight is monitored to assess
Need: Physiological Integrity; Nursing Process: Assessment the nutritional effectiveness of the TPN and to detect signs of fluid
overload. Options 1, 3, and 4 are incorrect. Blood pressure and
2 Answer: Vitamin C may cause a false-negative result in occult pulse are important assessments but do not relate specifically to
blood if taken within 48 to 72 hours of testing. Cognitive Level: the effects of TPN. Cognitive Level: Applying; Client Need: Physi-
Remembering; Client Need: Physiological Integrity; Nursing Pro- ological Integrity; Nursing Process: Assessment
cess: Implementation 5 Answer: 4 Rationale: The nurse should not hang the lipids if
separation of the emulsion or fat globules is visible in the solution.
3 Answer: 4 eRfafeticotns aolfe:aPnytripidaorkxiinneso(vniitsammidnruBg6)sm. Oayptrieovnesrs1e, or The solution should be returned to the pharmacy. Options 1, 2,
antagonize the 2, and 3 are incorrect. Rolling or shaking the container or running
and 3 are incorrect. INH, oral contraceptives, and hydralazine the container under warm water will not correct the separation
(Apresoline) may increase the need for pyridoxine. Cognitive and may increase the risk of harm if the solution is used after sep-
Level: Applying; Client Need: Physiological Integrity; Nursing aration has occurred. Cognitive Level: Applying; Client Need:
Process: Assessment Physiological Integrity; Nursing Process: Implementation
6 Answer: 1, 2 Rationale: Refrigerating unused enteral feed-
4 Answer: 1 Rationale: Zinc is found in protein foods such as ing solutions and limiting the length of time the solution is not
beans, lentils, nuts, meats, and dairy. Options 2, 3, and 4 are incor- refrigerated will prevent the growth of pathogens. Options 3, 4,
rect. Vegetables such as leafy greens, carrots, and squash; crucifer- and 5 are incorrect. Feeding bags and tubes are used for a limited
ous vegetables such as broccoli, cauliflower, and Brussels sprouts; length of time, typically 24 to 72 hours depending on the setting
and citrus fruits are not high in zinc. Cognitive Level: Applying; and patient condition. Washing out the bag and tubing will not
Client Need: Health Promotion and Maintenance; Nursing Pro- prevent or reduce the growth of harmful pathogens, and using
cess: Implementation plain water to irrigate the feeding tube is an accepted technique
but will not help prevent infection. Sterile technique is not needed
5 Answer: 1, 3 Rationale: Vitamin K is routinely given to new- when working with enteral feedings because the solution enters
born infants to prevent bleeding postdelivery. Vitamin K decreases the GI tract. Clean technique is adequate except in severely immu-
the anticoagulant effects of the drug warfarin. Options 2, 4, and 5 nocompromised patients. Cognitive Level: Applying; Client
are incorrect. Vitamin K is not indicated for visual disturbances or Need: Physiological Integrity; Nursing Process: Implementation
in the treatment of hypothyroidism or chronic acne. Cognitive
Level: Applying; Client Need: Physiological Integrity; Nursing Chapter 63
Process: Planning
1 Answer: 1 Rationale: It is recommended that if a 5% weight
6 Answer: 3 Rationale: Muscle cramping and spasms may be loss is not achieved after 12 weeks of therapy with lorcaserin, the
early signs of hypocalcemia. Options 1, 2, and 4 are incorrect. drug be discontinued and other options considered. Options 2, 3,
Night blindness is a sign of possible vitamin A deficiency. Anemia and 4 are incorrect. It is not known whether long-term adverse
may indicate an iron deficiency. Bleeding abnormalities may sig- effects arise after the time lorcaserin is taken or whether the risk
nal a deficiency in vitamin K. Cognitive Level: Analyzing; Client continues after the drug is discontinued. Monthly visits to a cardi-
Need: Physiological Integrity; Nursing Process: Evaluation ologist may be cost prohibitive and will not necessarily determine
conclusively that a cardiovascular risk from the drug is present.
Chapter 62 Because healthcare is an individual’s choice based on personal
preference, insurance coverage, and other factors, the drug com-
1 Answer: 3 Rationale: A patient receiving enteral feedings can pany would not be the best source for a follow-up program. Cog-
be at risk for dehydration caused by an inadequate intake of free nitive Level: Applying; Client Need: Health Promotion and
water (water without solutes). It is important to irrigate the tube Maintenance; Nursing Process: Implementation
with water as ordered, or per protocol (before and after an inter- 2 Answer: 4 Rationale: Phentermine is a pregnancy category X
mittent feeding or medication, or every 4 to 6 hours for continuous drug and should not be used if the patient is pregnant or there is a
feedings), and to include additional free water throughout the day possibility of pregnancy. Options 1, 2, and 3 are incorrect. Phenter-
unless contraindicated. Options 1, 2, and 4 are incorrect. Daily mine is used for short-term treatment of obesity and the presence
weights are important to track fluid balance, but they do not main- of extreme obesity may be an indication for the drug. The drug is
tain fluid balance. The NG tube should be irrigated more than just used cautiously in patients with diabetes and HTN, but neither is
once a day. While assessment of the skin around a PEG tube site is an absolute contraindication for the drug. Careful monitoring will
important, it will not indicate the patient’s fluid balance. This be required if either of these conditions exist. Cognitive Level:
patient is receiving the feeding via an NG tube, which is passed Applying; Client Need: Physiological Integrity; Nursing Process:
through the nose. Cognitive Level: Applying; Client Need: Physi- Assessment
ological Integrity; Nursing Process: Assessment 3 Answer: 4 Rationale: Typically, orlistat is taken just prior to
2 Answer: 1, 3, 5 Rationale: In addition to the base solution, meals containing fats so that the drug can inhibit lipase and thus
TPN contains electrolytes (sodium, potassium, chloride), trace
minerals, and multivitamins. Options 2 and 4 are incorrect. If
diuretics are needed because of an underlying medical condition,
they should be administered separately and not added to the TPN
Appendix A Answers to Chapter Review 1451
the absorption of lipids in the meal. Options 1, 2, and 3 are incor- 4 Answer: 1 Rationale: Octreotide prolongs intestinal transit
rect. Orlistat is taken throughout the day with each meal. It does time and stimulates reabsorption of fluids and electrolytes from
not decrease appetite; it interferes with the absorption of fat in the the GI tract. These effects would have the therapeutic action of
diet. Although exercise is a part of the treatment plan for obesity, decreasing diarrhea related to the cancer or treatment. Options 2,
orlistat does not have to be administered before exercise. Cogni- 3, and 4 are incorrect. Octreotide will not slow cancer growth or
tive Level: Applying; Client Need: Health Promotion and Mainte- metastasis or improve lean body mass or fat deposits. Hypo- and
nance; Nursing Process: Implementation hyperglycemia are possible adverse effects of octreotide, not ther-
4 Answer: 4 Rationale: Intake of the proper amount and type apeutic effects. Cognitive Level: Analyzing; Client Need: Physio-
of vitamins and nutrients is important in a healthy weight loss logical Integrity; Nursing Process: Evaluation
program. Because orlistat interferes with lipid absorption, the 5 Answer: 4 Rationale: Concurrent administration of octreo-
patient should be taught to supplement the diet with a product tide with PO antidiabetic drugs or insulin can produce hypogly-
that contains all the essential fat-soluble vitamins. The supple- cemia. Glucose levels would have to be monitored closely and
ment should be taken at least 2 hours before or after the orlistat. insulin dose adjustments made. Options 1, 2, and 3 are incorrect.
Options 1, 2, and 3 are incorrect. While increasing fluid intake Glaucoma, COPD, or alcoholism would not be contraindications
may assist in a weight loss program, diet soda may contain for this drug. Cognitive Level: Applying; Client Need: Physiologi-
sodium, citric acid, or other ingredients not necessary to a bal- cal Integrity; Nursing Process: Assessment
anced diet. Orlistat does not cause photosensitivity, and addi- 6 Answer: 1 Rationale: A patient with diabetes insipidus (DI)
tional sunscreen is not needed. Orlistat does not cause orthostatic who is responding to therapy with desmopressin would have
hypotension, and no dizziness should be noted when rising from decreasing signs of dehydration. Options 2, 3, and 4 are incorrect.
a lying or sitting position. Cognitive Level: Applying; Client DI is characterized by large volumes of urine output with a very
Need: Health Promotion and Maintenance; Nursing Process: low urine specific gravity accompanied by signs of dehydration,
Implementation including reports of thirst and an increased pulse rate. The
5 Answer: 1 Rationale: Flatus and oily stools are adverse patient responding to desmopressin therapy would see a low-
effects that are often troubling to the patient. The nurse should ered pulse rate related to an increase in circulating volume sec-
inform the patient that these often occur when taking orlistat. ondary to the decrease in urine output. Desmopressin therapy
Options 2, 3, and 4 are incorrect. Heartburn and dyspepsia (indi- would also cause the urine specific gravity to increase, not
gestion), constipation, and nausea and vomiting are not common decrease. Blood glucose levels are not affected by desmopressin.
adverse effects associated with orlistat. Cognitive Level: Apply- Cognitive Level: Analyzing; Client Need: Physiological Integrity;
ing; Client Need: Physiological Integrity; Nursing Process: Nursing Process: Evaluation
Implementation
6 Answer: 1, 2, 3 Rationale: Body weight, body mass index Chapter 66
(BMI), and waist circumference are all indicators used to assess
levels of obesity. Options 4 and 5 are incorrect. A treadmill test 1 Answer: 2 Rationale: Insulin peaks are the times of maxi-
assesses physical fitness, not necessarily obesity. Buoyancy analy- mum insulin utilization with the greatest risk of hypoglycemia.
sis is not a test used to determine the degree of obesity. Cognitive Options 1, 3, and 4 are incorrect. Insulin schedules for the
Level: Applying; Client Need: Physiological Integrity; Nursing patient are developed by the provider and the patient should
Process: Assessment not self-select a schedule for insulin use. Because the risk for
hypoglycemia is highest at peak serum insulin levels, exercise
Chapter 65 or additional insulin may increase the risk further. Cognitive
Level: Applying; Client Need: Physiological Integrity; Nursing
1 Answer: 2 Rationale: GH cannot be given PO; it can be Process: Implementation
administered only subcutaneously by injections. Options 1, 3, and 2 Answer: 2, 3, 5 Rationale: The blood glucose level should be
4 are incorrect. A lack of GH is not associated with mental retarda- checked prior to administering any type of insulin. Because lispro
tion. Children whose epiphyseal plates have closed are not candi- is a rapid-acting insulin, the nurse should ensure that a meal is
dates for GH therapy; therefore, most adolescents would see available and that the patient will be able to eat shortly after
minimal gain in height. Periodic testing for blood hormone levels receiving a dose. If signs of hypoglycemia are present, the insulin
is required during therapy. Cognitive Level: Applying; Client dose should be held and the patient treated for hypoglycemia.
Need: Physiological Integrity; Nursing Process: Planning The provider should be notified. Options 1 and 4 are incorrect.
2 Answer: 1, 2, 3 Rationale: GH increases the length and width Urine testing for glucose and ketones does not give exact informa-
of long bones; promotes organ, muscle, and connective tissue tion, and patients vary on the degree to which glucose and ketones
growth; and increases the synthesis of proteins. Options 4 and 5 will “spill” into the urine. While a check of the pulse or blood
are incorrect. GH may cause an increase in serum glucose levels, pressure may be included in routine vital signs or to further assess
not a decrease. It may improve and decrease fat deposits around symptoms of hypoglycemia, they do not provide information
the abdomen and improve lipid levels. Cognitive Level: Apply- directly pertinent to the administration of insulin. Cognitive
ing; Client Need: Physiological Integrity; Nursing Process: Level: Applying; Client Need: Physiological Integrity; Nursing
Evaluation Process: Implementation
3 Answer: 3 Rationale: Patients on desmopressin need to 3 Answer: 3 Rationale: A serious adverse effect of metformin
obtain a daily weight and should monitor for the presence of any is the risk of developing lactic acidosis. CKD, excess alcohol use,
peripheral edema. Options 1, 2, and 4 are incorrect. Desmopressin and IV contrast agents increase the risk for lactic acidosis and are
must be given in regular doses for continued therapeutic effects. contraindications to the use of metformin. Options 1, 2, and 4 are
Increasing the dosage may cause an increased risk of vasocon- incorrect. Hypoglycemia, GI distress, and weight loss are com-
striction and other adverse effects. Leg cramping when walking mon adverse effects of most oral antidiabetic drugs and are not
may indicate adverse peripheral vascular effects and should be specific to metformin. Cognitive Level: Analyzing; Client Need:
assessed by the provider. Taking NSAIDs concurrently may Physiological Integrity; Nursing Process: Evaluation
increase the antidiuretic effect, leading to adverse effects. Cogni- 4 Answer: 2 Rationale: It can take several weeks for rosigli-
tive Level: Applying; Client Need: Health Promotion and Mainte- tazone to provide full therapeutic effects, so the appropriate
nance; Nursing Process: Planning response would be to give it more time to reach effectiveness.
1452 Appendix A Answers to Chapter Review
Options 1, 3, and 4 are incorrect. It is not within a nurse’s scope of only used short term before more definitive treatment can be
practice to prescribe additional drugs or change the dosage. The accomplished. Options 1, 3, and 4 are incorrect. Iodine deficiency
healthcare provider should be consulted about any change to the is rare and does not cause symptoms of hyperthyroidism, the
patient’s drug regimen. Cognitive Level: Applying; Client Need: indication for the patient’s potassium iodide solution. High-dose
Health Promotion and Maintenance; Nursing Process: iodine is not always used prior to thyroid surgery and the thy-
Implementation roidectomy is not related to a loss of iodine. High doses of iodine
5 Answer: 4 Rationale: Glucagon injections can be repeated if will not prevent diabetes. Cognitive Level: Applying; Client Need:
one dose is not effective. Hypoglycemia is a medical emergency, Physiological Integrity; Nursing Process: Implementation
and because this woman has not fully recovered, medical atten- 6 Answer: 3 Rationale: To closely approximate the body’s own
tion is needed. Options 1, 2, and 3 are incorrect. The patient is still hormone levels, levothyroxine should be taken in the morning,
experiencing symptoms of hypoglycemia, and continued treat- ideally at the same time each day. Options 1, 2, and 4 are incorrect.
ment is indicated. Because she is still groggy and disoriented, it Taking levothyroxine along with food or meals containing high
would not be safe to give this patient anything by mouth. Cogni- fiber may affect the absorption of the drug. Foods such as straw-
tive Level: Applying; Client Need: Physiological Integrity; Nurs- berries, spinach, and kale may inhibit thyroid secretion, reducing
ing Process: Implementation the effectiveness of the levothyroxine. If diarrhea occurs, the pro-
6 Answer: 4 Rationale: Insulin glargine has no definite peak, vider should be notified to determine the need to alter the dose.
so the risk of a hypoglycemic reaction is minimal. Options 1, 2, Cognitive Level: Applying; Client Need: Health Promotion and
and 3 are incorrect. Insulin glargine must be given by subcutane- Maintenance; Nursing Process: Implementation
ous injection, it cannot be given by IM injection, and blood glu-
cose monitoring is required for all patients taking any insulin. Chapter 68
Cognitive Level: Applying; Client Need: Physiological Integrity;
Nursing Process: Implementation 1 Answer: 1, 3, 5 Rationale: Edema, eye pain or vision changes,
and abdominal pain are symptoms of possible adverse effects
Chapter 67 from the methylprednisolone. Options 2 and 4 are incorrect. Tin-
nitus is not an adverse effect commonly associated with methyl-
1 Answer: 4 Rationale: The administration of too much levo- prednisolone and if it occurs, other causes should be investigated.
thyroxine may cause hyperthyroidism, characterized by nervous- Dizziness upon standing indicates possible hypotension.
ness, palpitations, weight loss, diarrhea, and muscle tremors. Hypertension is a possible adverse effect from methylpredniso-
Before altering the dosage, thyroid function studies will be per- lone. Cognitive Level: Analyzing; Client Need: Physiological
formed to verify this condition. Options 1, 2, and 3 are incorrect. Integrity; Nursing Process: Implementation
Nervousness, palpitations, and tremors are not symptoms of 2 Answer: 1 Rationale: An irregular heart rate and rhythm is a
hypothyroidism or normal thyroid states. While these symptoms symptom of hypokalemia. Hydrocortisone given concurrently
may occur with diabetes and hyperglycemia, other symptoms with diuretics such as thiazides, which cause loss of potassium,
would dominate and would be noted before these symptoms increases the risk of hypokalemia. Options 2, 3, and 4 are incor-
occurred. Cognitive Level: Analyzing; Client Need: Physiological rect. While these are common adverse effects of hydrocortisone,
Integrity; Nursing Process: Evaluation they do not require immediate attention. Cognitive Level: Analyz-
2 Answer: 3, 4, 5 Rationale: A euthyroid (normal) state is indi- ing; Client Need: Physiological Integrity; Nursing Process:
cated by a return to normal performance of ADLs without fatigue, Evaluation
normalizing cholesterol levels, and vital signs within normal lim- 3 Answer: 1, 2 Rationale: Weight-bearing exercise 3 to 4 times
its with a pulse rate between 60 and 100 beats/min. Options 1 and weekly and increased dietary intake of calcium and vitamin D
2 are incorrect. Constipation and weight gain are symptoms of may help to prevent bone loss and osteoporosis. Options 3, 4, and
hypothyroidism. Decreased blinking and exophthalmos are 5 are incorrect. Remaining sedentary is not advisable and may
symptoms of hyperthyroidism. Cognitive Level: Applying; Client increase the risk of osteoporosis and other adverse effects such as
Need: Physiological Integrity; Nursing Process: Evaluation thrombophlebitis. Increased fluid intake and avoidance of alcohol
3 Answer: 1 Rationale: Sore throat, low-grade fever, and chills are advised, but carbonated sodas should also be avoided because
are symptoms of a possible infection. Because propylthiouracil they have been linked to an increased risk of osteoporosis. While
may cause agranulocytosis, these symptoms should be reported a bisphosphonate may be needed if bone density studies indicate
to the provider. Options 2, 3, and 4 are incorrect. Increased appe- the development of osteoporosis, it is not necessarily required at
tite and caloric intake signal a return to a more euthyroid state. this time. Cognitive Level: Applying; Client Need: Health Promo-
Tinnitus, altered taste, thickened saliva, insomnia, nightmares, tion and Maintenance; Nursing Process: Implementation
and night sweats are not effects usually associated with propyl- 4 Answer: 4 Rationale: The patient should obtain a daily
thiouracil and if they occur, other causes should be investigated. weight, ideally at the same time each day, to assess for excessive
Cognitive Level: Analyzing; Client Need: Physiological Integrity; fluid retention. Fludrocortisone is a mineralocorticoid and may
Nursing Process: Implementation cause fluid retention, edema, and HTN. Options 1, 2, and 3 are
4 Answer: 3 Rationale: A heart rate of 110 beats/min would incorrect. Abdominal pain and changes to the stool color may
cause the nurse to hold the scheduled dose of levothyroxine, indicate GI bleeding, which is an adverse effect associated with
because it could indicate too high a level of thyroid hormone. glucocorticoids. Increased lipid levels and mood changes are
Options 1, 2, and 4 are incorrect. A low level of thyroid hormone also associated with glucocorticoids. Cognitive Level: Apply-
could cause weight gain or decreased blood pressure. These are ing; Client Need: Physiological Integrity; Nursing Process:
symptoms of hypothyroidism and would not cause the nurse to Implementation
hold the medication. An elevated temperature without other signs 5 Answer: 3 Rationale: The patient is experiencing symptoms
of hyperthyroidism would not warrant withholding the medica- of acute adrenal insufficiency related to the inability to take the
tion. Cognitive Level: Analyzing; Client Need: Physiological prescribed drug for several days and will require immediate IV
Integrity; Nursing Process: Implementation administration of hydrocortisone. Options 1, 2, and 4 are incor-
5 Answer: 2 Rationale: The high levels of iodine found in rect. Fludrocortisone is a mineralocorticoid and is not indicated in
potassium iodide solution will inhibit the synthesis and release of this emergency situation. Ketoconazole and mitotane have anti-
thyroid hormone. The effectiveness decreases over time so it is adrenal effects and would worsen the situation. Cognitive Level:
Appendix A Answers to Chapter Review 1453
Analyzing; Client Need: Physiological Integrity; Nursing Process: periods of varying length, starting the drug on the “last day”
Planning would vary, and the drug might be started sooner or later than
6 Answer: 4 Rationale: Patients receiving replacement therapy the recommended fifth day of the menstrual cycle. Many women
for chronic adrenal insufficiency should carry PO and parenteral do not know when ovulation occurs to be able to take it based on
forms of the drugs they are prescribed in case of emergencies an ovulatory cycle and there is likelihood that this patient is not
where the drugs may not be readily available. Options 1, 2, and 3 experiencing ovulation. Cognitive Level: Applying; Client Need:
are incorrect. Checking BP, avoiding crowds and infections, and Health Promotion and Maintenance; Nursing Process:
monitoring for visual changes are appropriate interventions when Implementation
hyperphysiologic doses are given to treat disease and other condi- 6 Answer: 4 Rationale: Sedation, intense thirst, flushing of the
tions. Patients on replacement therapy for adrenal insufficiency skin, confusion, and muscle weakness are early symptoms of
receive physiologic doses to maintain normal levels of the hor- magnesium toxicity and should be immediately reported to the
mones in their body and should not experience adverse effects provider. Options 1, 2, and 3 are incorrect. The drug decreases
unless the dosage is inappropriate. Cognitive Level: Applying; deep tendon reflexes and CNS stimulation, and hyperactivity or
Client Need: Health Promotion and Maintenance; Nursing Pro- seizure activity would not be expected. Chest congestion and
cess: Implementation cough are not associated with the drug and other causes should
be explored. Cognitive Level: Analyzing; Client Need: Physiologi-
Chapter 69 cal Integrity; Nursing Process: Evaluation
1 Answer: 2, 3, 4 Rationale: A history of thromboembolic con- Chapter 70
ditions, breast cancer, or hyperlipidemia may be contraindications
for the use of HRT for this patient and will require further assess- 1 Answer: 3, 4 Rationale: Smokers have a significantly
ment by the healthcare provider before prescribing conjugated increased risk of serious thromboembolic events when taking
estrogen. Options 1 and 5 are incorrect. Because conjugated estro- OCs. Mood disorders, including depression, may worsen in
gen is metabolized through the CYP450 pathways and the drug patients taking OCs, and additional monitoring may be advised.
may have hepatic effects, women with diabetes may need to more Options 1, 2, and 5 are incorrect. Obesity is a risk factor for both
closely monitor their blood glucose to ensure that their diabetes treatment failure and thromboembolic events; however, this
medications are effective, but this is not considered a contraindi- patient is considered overweight and is not in the high-risk cate-
cation to the drug. A past history of cesarean birth is also not a gory. Patients with asthma are not high risk, and a healthy
contraindication. Cognitive Level: Analyzing; Client Need: Physi- 42-year-old woman with no significant health history is not con-
ological Integrity; Nursing Process: Assessment sidered high risk. Cognitive Level: Analyzing; Client Need: Physi-
2 Answer: 3 Rationale: Regular contractions increasing in ological Integrity; Nursing Process: Assessment
occurrence indicate that the oxytocin is exerting a therapeutic 2 Answer: 1 Rationale: If two consecutive days are missed,
effect. Options 1, 2, and 4 are incorrect. Control of postpartum the patient should take two pills on the day it is discovered, two
hemorrhage is a therapeutic effect of oxytocin but would not be pills the following day, then resume the normal one pill per day
considered a therapeutic effect during labor. Sustained contrac- routine. A second method of contraception should be used for 7
tions are an adverse effect of oxytocin and immediate intervention days after resuming the pills. Options 2, 3, and 4 are incorrect.
is needed to prevent serious injury to the mother or baby should Taking only one pill, skipping additional doses, or stopping the
they occur. Oxytocin stimulates the milk letdown reflex in nurs- drug will not allow continued contraception. If the patient is con-
ing, but this would not be considered a therapeutic effect during cerned about pregnancy due to the missed pills, a pregnancy test
labor. Cognitive Level: Analyzing; Client Need: Physiological may be conducted. Cognitive Level: Applying; Client Need:
Integrity; Nursing Process: Evaluation Health Promotion and Maintenance; Nursing Process:
3 Answer: 4 Rationale: Clomiphene is given over six Implementation
ovulatory-menstrual cycles in increasing doses with HCG added 3 Answer: 4 Rationale: Levonorgestrel–estradiol is taken for
as needed. If no pregnancy has occurred after six cycles, other 84 days followed by a lower dose of estrogen included in the pill
treatment options will be considered. Options 1, 2, and 3 are incor- package for 7 days. Options 1, 2, and 3 are incorrect. Taking levo-
rect. The drug will not be continued for 1 year if pregnancy has norgestrel–estradiol for 3 weeks, year-round, or for 2 months
not occurred, and the dosage may be increased after each cycle. would be incorrect administration cycles. Cognitive Level: Apply-
Clomiphene is a category X drug and should be stopped if preg- ing; Client Need: Health Promotion and Maintenance; Nursing
nancy occurs. Cognitive Level: Applying; Client Need: Health Process: Implementation
Promotion and Maintenance; Nursing Process: Implementation 4 Answer: 3 Rationale: The patient takes misoprostol 24 to
4 Answer: 3 Rationale: Medroxyprogesterone is known to 48 hours after taking the mifepristone. Options 1, 2, and 4 are
decrease bone density over time. The patient should be taught to incorrect. Only one dose of mifepristone is taken. The misoprostol
report any bone, joint, or musculoskeletal pain and to report any is taken within 24 to 48 hours after the mifepristone dose. Bleed-
difficulty or pain with movement or ambulation. Options 1, 2, ing is a common effect of both drugs and is not an indication of
and 4 are incorrect. Insomnia or sleep difficulty and mouth, eye, when or whether to take the misoprostol. Cognitive Level: Apply-
or vaginal dryness are not related adverse effects. The drug may ing; Client Need: Health Promotion and Maintenance; Nursing
cause breakthrough spotting between menstrual cycles, but this Process: Implementation
is a common effect and does not require evaluation unless the 5 Answer: 2 Rationale: Patients should be informed that sper-
bleeding is heavy or continuous. Cognitive Level: Analyzing; Cli- micidal agents have relatively low levels of efficacy when used
ent Need: Physiological Integrity; Nursing Process: alone and should therefore be used only in conjunction with bar-
Implementation rier methods such as condoms and diaphragms. Options 1, 3, and
5 Answer: 2 Rationale: The standard treatment with clomi- 4 are incorrect. Spermicides such as nonoxynol-9 are not extremely
phene is to begin with a low dose for 5 days beginning on the effective in preventing pregnancy, do not cause or protect against
fifth day of the menstrual cycle. Options 1, 3, and 4 are incorrect. HIV or PID, and do not prevent ectopic pregnancies. Cognitive
Starting therapy on the first day of the menstrual cycle would not Level: Applying; Client Need: Health Promotion and Mainte-
be as effective in stimulating ovulation because this usually nance; Nursing Process: Implementation
occurs closer to midcycle. Because women experience menstrual
1454 Appendix A Answers to Chapter Review
6 Answer: 5, 1, 4, 3, 2 The correct ranking from most effective to dysuria have suddenly increased, the patient should be assessed
least effective with typical use of the method is for possible prostate cancer. Options 1, 2, and 3 are incorrect. Con-
tinuing to take the drug after full therapeutic results should have
1. Depo-Provera: 94% effective been realized is not appropriate, given the sudden increase in
2. Oral contraceptives: 91% effective symptoms. Decreasing fluid irritants such as caffeine and alcohol
3. Transdermal (Ortho-Evra): 91% effective may help overall but will not cause the sudden symptoms. A low-
4. Calendar rhythm: 76% effective dose diuretic may not be appropriate in this situation and may
5. Spermicides: 72% effective worsen the dysuria. Cognitive Level: Analyzing; Client Need:
Physiological Integrity; Nursing Process: Evaluation
Cognitive Level: Applying; Client Need: Health Promotion and
Maintenance; Nursing Process: Assessment
Chapter 71 Chapter 72
1 Answer: 2 Rationale: Primary hypogonadism results in 1 Answer: 3 Rationale: Alendronate may cause severe GI
patients with normal pituitary function and testes that are either adverse effects. To decrease this risk, particularly for esophageal
diseased or unresponsive to FSH and LH. A primary goal of ther- irritation, and to promote the absorption of the medication, alen-
apy would be an increased sperm count with an increase in male dronate should be taken with a full glass of water after rising in
masculinization. Options 1, 3, and 4 are incorrect. Testosterone the morning. The patient should not eat or drink anything or lie
should not affect RBC count. Administering testosterone to the down for 30 minutes after administration. Options 1, 2, and 4 are
patient will not increase FSH or LH levels. Cognitive Level: incorrect. The medication should be taken before breakfast, not
Applying; Client Need: Physiological Integrity; Nursing Process: before lunch or at bedtime. The patient should not lie down after
Evaluation taking alendronate for at least 30 minutes, preferably longer. Cog-
2 Answer: 1 Rationale: The use of nitrates is contraindicated nitive Level: Applying; Client Need: Health Promotion and Main-
with sildenafil because dangerous hypotension may result. tenance; Nursing Process: Evaluation
Options 2, 3, and 4 are incorrect. A history of diabetes would not 2 Answer: 1 Rationale: Headache, dizziness, and blurred
be of concern and may be an indication for treatment if ED occurs. vision are all early symptoms of toxicity to methotrexate.
An allergy to penicillin products is not a contraindication for use Options 2, 3, and 4 are incorrect. Hematuria, hiccoughs, jaun-
of sildenafil. There are no expected adverse reactions with silde- dice, ascites, and edema formation are not associated with the
nafil and the use of antiulcer medication. Cognitive Level: Apply- use of methotrexate. While stomatitis may occur, constipation
ing; Client Need: Physiological Integrity; Nursing Process: would be unrelated to methotrexate. Cognitive Level: Analyz-
Assessment ing; Client Need: Physiological Integrity; Nursing Process:
3 Answer: 2, 3, 5 Rationale: Women and children should avoid Evaluation
skin contact with areas where testosterone gels or creams have 3 Answer: 2 Rationale: Colchicine prevents the migration of
been applied to avoid drug absorption. Testosterones may trigger neutrophils (WBCs) into the area of inflammation caused by uric
sodium and water retention and a weight gain of 2 kg (5 lb) or acid crystals, reducing further inflammation and relieving the
more per week should be reported to the provider. They may also symptoms of gout and gouty arthritis. Options 1, 3, and 4 are
increase blood lipid levels. Therefore, the patient should follow a incorrect. Colchicine does not increase uric acid deposits in the
low-fat diet and have periodic blood lipid level assessments. synovial spaces of the joints, prevent accumulation of uric acid
Options 1 and 4 are incorrect. Testosterone gel should be applied crystals in the joints, or increase renal excretion of uric acid crys-
to the upper arms, shoulders, or abdomen and never to the scro- tals. Cognitive Level: Applying; Client Need: Physiological Integ-
tum, perineal area, or on broken or irritated skin. Showering or rity; Nursing Process: Implementation
swimming should be avoided for several hours after application 4 Answer: 1 Rationale: The patient with osteomalacia has low
to allow drug absorption, but a wait of 12 to 14 hours is excessive. serum calcium and low phosphate levels. An indicator that
Cognitive Level: Applying; Client Need: Physiological Integrity; replacement therapy is achieving therapeutic benefits would be
Nursing Process: Implementation increasing serum calcium and phosphate levels. Options 2, 3, and
4 Answer: 2 Rationale: For sildenafil to be effective, the ED 4 are incorrect. Increasing or decreasing actions of the serum cal-
must be physiologic in nature. It is not effective if the dysfunction cium and phosphate levels are incorrectly stated. Cognitive Level:
has solely psychologic origins and therefore does not always Analyzing; Client Need: Physiological Integrity; Nursing Process:
cause an erection. Options 1, 3, and 4 are incorrect. Sildenafil sim- Evaluation
ply enhances, rather than causes, an erection. Prolonged use does 5 Answer: 1 Rationale: Vitamin D toxicity may occur in the
not result in less intense feelings over time. Use of sildenafil by patient receiving calcitriol. Symptoms to assess include muscle
men will not have effects on female sexual function. Cognitive weakness, fatigue, nausea, vomiting, and changes in the color or
Level: Applying; Client Need: Health Promotion and Mainte- amount of urine. Options 2, 3, and 4 are incorrect. Diarrhea,
nance; Nursing Process: Implementation abdominal pain, stomatitis, joint stiffness, photosensitivity, and
5 Answer: 1, 2, 4 Rationale: Finasteride promotes shrinkage tinnitus are not symptoms that would be associated with the
of enlarged prostates and subsequently helps restore urinary effects of vitamin D therapy. Bone pain and fever are symptoms of
function. Women should avoid handling crushed medication vitamin D deficiency. Cognitive Level: Analyzing; Client Need:
because it may be absorbed through the skin and have terato- Physiological Integrity; Nursing Process: Evaluation
genic effects. Maximum benefit may take 6 to 12 months to be 6 Answer: 1, 3, 4 Rationale: DMARDs modify immune and
achieved. Options 3 and 5 are incorrect. Finasteride does not inflammatory responses but may increase the risk of infections
affect vision. Dizziness is a possible adverse effect but significant and malignancies, and reactivate latent TB. Injection-site reac-
dizziness or orthostatic hypotension should not occur and should tions such as pain, swelling, and bruising are common adverse
be reported to the healthcare provider. Cognitive Level: Apply- effects. Options 2 and 5 are incorrect. Adalimumab has not been
ing; Client Need: Physiological Integrity; Nursing Process: associated with an increased risk of osteoporosis and is given
Implementation subcutaneously, every other week. Cognitive Level: Applying;
6 Answer: 4 Rationale: Full effects of finasteride are realized Client Need: Physiological Integrity; Nursing Process:
within 6 to 12 months of therapy. Because the symptoms of Evaluation
Appendix A Answers to Chapter Review 1455
Chapter 73 may cause darkening of the iris, especially noticeable in patients
with light eye colors. Options 3 and 5 are incorrect. Latanoprost
1 Answer: 4 Rationale: Lice and nits can live in areas of the will not cause lightening of the iris or darkening of the sclera or a
body other than the hair on the patient’s head. Options 1, 2, and 3 permanent bluish tint to the conjunctiva. Cognitive Level: Apply-
are incorrect. Permethrin should not be applied after body lotions ing; Client Need: Physiological Integrity; Nursing Process:
and should not be used on eyelashes or eyebrows. Lice can sur- Implementation
vive for up to 24 to 48 hours on inanimate objects. Cognitive 3 Answer: Pilocarpine causes miosis, which stretches the tra-
Level: Applying; Client Need: Health Promotion and Mainte- becular meshwork, allowing greater outflow of aqueous humor
nance; Nursing Process: Implementation and decreasing the IOP. Cognitive Level: Applying; Client Need:
2 Answer: 1 Rationale: Patients taking topical corticosteroids Physiological Integrity; Nursing Process: Implementation
for the treatment of atopic dermatitis may experience burning and 4 Answer: 2, 3, 1, 4 Rationale: The ear should be pulled gently
stinging of the skin in the affected area. Options 2, 3, and 4 are upward and back and the drop instilled, allowing it to flow down
incorrect. Localized pruritus and hives, a loss of hair in the appli- the side of the canal. Dropping the solution directly on the tym-
cation area, or a worsening of acne vulgaris are not symptoms panic membrane may cause dizziness or nausea. The area in front
that would be related specifically to the effects of therapy. Cogni- of the ear (the tragus) should be gently massaged. The patient
tive Level: Applying; Client Need: Physiological Integrity; Nurs- should remain in a side-lying position or with the treated ear
ing Process: Assessment uppermost for 5 minutes to allow complete absorption of the
3 Answer: 1, 2, 3 Rationale: Benzoyl peroxide suppresses solution. If needed, a dry cotton ball may be placed in the outer
sebum production and has antimicrobial action against the bacte- ear area to prevent leakage of solution. Cognitive Level: Apply-
ria that cause acne. It also has a keratolytic effect, drying and ing; Client Need: Health Promotion and Maintenance; Nursing
encouraging more rapid cell turnover in the outer layer of the epi- Process: Implementation
dermis. Options 4 and 5 are incorrect. Microdermal abrasion is not 5 Answer: 4 Rationale: Increasing pain, particularly around
a primary mechanism of action of the drug and benzoyl peroxide the ear area, may indicate worsening infection or mastoiditis and
does not have sunscreen activity. Cognitive Level: Applying; Cli- should be immediately reported. Options 1, 2, and 3 are incorrect.
ent Need: Physiological Integrity; Nursing Process: Evaluation Mild itching and irritation may occur, but severe itching or swell-
4 Answer: 3 Rationale: Tretinoin may cause dryness, irrita- ing should be reported. Gradually decreasing pain is a therapeu-
tion, and erythema. Mild soaps, gentle cleansing, warm but not tic effect as the infection clears. Dizziness may occur if the eardrop
hot water, and gentle drying should be used during tretinoin ther- is instilled directly onto the tympanic membrane. Cognitive Level:
apy. Options 1, 2, and 4 are incorrect. Antiacne soaps often contain Applying; Client Need: Physiological Integrity; Nursing Process:
compounds that dry and desquamate the skin and may cause fur- Planning
ther irritation. Sunscreens with an SPF of 15 and coverings should 6 Answer: Phenylephrine causes mydriasis, allowing better
be used while on tretinoin to avoid sunburn. Alternating tretinoin visualization of the area of the lens during cataract surgery. Cog-
with benzoyl peroxide may cause excessive dryness and irritation nitive Level: Applying; Client Need: Physiological Integrity;
and increase the risk of adverse effects. Cognitive Level: Apply- Nursing Process: Implementation
ing; Client Need: Health Promotion and Maintenance; Nursing
Process: Implementation Chapter 75
5 Answer: 3 Rationale: A small test area should be used if ben-
zocaine has not been used before to assess for allergy. If no symp- 1 Answer: 1 Rationale: No antidote or specific treatment exists
toms are noted within 30 to 60 minutes, it may be used on a wider for radiation poisoning. Supportive therapy for the associated
area. Options 1, 2, and 4 are incorrect. Benzocaine should not be symptoms is the only treatment available. Options 2, 3, and 4 are
used on partial-thickness burns because of the risk of open blistered incorrect. Ultraviolet light does not affect individuals who experi-
areas. The solution should not be warmed to avoid further heat and ence radiation poisoning. An individual with radiation toxicity is
damage to the area of the burn. The burn should not be covered incapable of contaminating other individuals. No antiradiation
with plastic wrap to avoid heat trapping, potentially increasing the medications exist. Cognitive Level: Applying; Client Need: Physi-
damage. Cognitive Level: Applying; Client Need: Health Promo- ological Integrity; Nursing Process: Implementation
tion and Maintenance; Nursing Process: Implementation 2 Answer: 1 Rationale: The preferred drug for Y. pestis expo-
6 Answer: A patient who has been prescribed isotretinoin must sure is doxycycline. Options 2, 3, and 4 are incorrect. Trivalent
comply with the iPledge Program because of the risk of terato- botulinum antitoxin is one of the two available treatments for
genic effects. Cognitive Level: Applying; Client Need: Physiologi- botulism. The other antitoxin for botulism is heptavalent botuli-
cal Integrity; Nursing Process: Assessment num antitoxin. Ribavirin is an antiviral drug that may be used to
treat serious virus infections. Atropine sulfate is a cholinergic
Chapter 74 antagonist used for organophosphate poisoning and other health
problems. Cognitive Level: Applying; Client Need: Physiological
1 Answer: 4 Rationale: Timolol is a beta-adrenergic blocker. To Integrity; Nursing Process: Implementation
prevent swallowing and systemic absorption, pressure is to be 3 Answer: 3 Rationale: Time is a critical factor in acute poison-
applied to the inner canthus of the eye for 1 minute after instilling ings. The emergency should be called into 911 and the rescue
the drop. Options 1, 2, and 3 are incorrect. No other eyedrops or squad should transport the child to the nearest healthcare facility
ointments should be used when taking timolol or other drops for immediately. Options 1, 2, and 4 are incorrect. Instructions for poi-
glaucoma without the approval of the provider. Eye solutions for soning may have changed since the packaging was printed. Based
allergies may contain adrenergic drugs that may worsen glau- on the information provided in the question, the nurse does not
coma. Timolol is not contraindicated during seasonal allergies. It know what chemicals the child has ingested. Forced vomiting is
is not known to worsen seasonal allergies although it may cause contraindicated for most poisonings. Waiting for the child to
bronchoconstriction in the sensitive individual or if swallowed develop seizures or shortness of breath is too late since the devel-
and systemic effects occur. Cognitive Level: Applying; Client opment of these symptoms most likely represents a toxic level of
Need: Physiological Integrity; Nursing Process: Planning the poison. Cognitive Level: Applying; Client Need: Physiological
2 Answer: 1, 2, 4 Rationale: Latanoprost (Xalatan) may cause Integrity; Nursing Process: Implementation
thickening and darkening of the eyelashes and upper eyelid and
1456 Appendix A Answers to Chapter Review
4 Answer: 3 Rationale: Patients with decreased sensorium are and 4 are incorrect. A chelator binds heavy metals but does not
at high risk for pulmonary aspiration. Activated charcoal should deactivate any chemical reactions. Chelation therapy is not
be given to these patients only if the airway is maintained with an involved in metabolism. Glomerular filtration is not affected by
endotracheal tube. Options 1, 2, and 4 are incorrect. Activated chelation therapy. Cognitive Level: Applying; Client Need: Physi-
charcoal is not absorbed in the GI tract and therefore would not be ological Integrity; Nursing Process: Assessment
contraindicated in patients with liver pathology. Activated char- 6 Answer: 2 Rationale: Edetate calcium disodium may pro-
coal is eliminated in the feces and therefore would not be contra- duce renal damage that may be reduced by ensuring adequate
indicated in patients with CKD. Anxiety and nervousness are not diuresis before therapy begins. Options 1, 3, and 4 are incorrect.
reasons to withhold the administration of activated charcoal. Cog- Bowel function is not a critical parameter to consider prior to giv-
nitive Level: Applying; Client Need: Physiological Integrity; ing this drug. Edetate calcium disodium administration is not
Nursing Process: Assessment based on visual acuity. Skin integrity is not a critical parameter to
5 Answer: 1 Rationale: Chelating drugs capture the toxic consider prior to giving edetate calcium disodium. Cognitive
metal through a bonding process. The kidneys remove both the Level: Applying; Client Need: Physiological Integrity; Nursing
chelator and the metal bound to it from the body. Options 2, 3, Process: Assessment
Appendix B
ISMP List of High-Alert
Medications in Acute Care Settings
High-alert medications are drugs that bear a heightened preparation, and administration of these products; improv-
risk of causing significant patient harm when they are used ing access to information about these drugs; limiting access
in error. Although mistakes may or may not be more com- to high-alert medications; using auxiliary labels and auto-
mon with these drugs, the consequences of an error are mated alerts; and employing redundancies such as auto-
clearly more devastating to patients. We hope you will use mated or independent double-checks when necessary.
this list to determine which medications require special (Note: Manual independent double-checks are not always
safeguards to reduce the risk of errors. This may include the optimal error-reduction strategy and may not be prac-
strategies such as standardizing the ordering, storage, tical for all of the medications on the list.)
Classes/Categories of Medications Specific Medications
EPINEPHrine, subcutaneous
adrenergic agonists, IV (e.g., EPINEPHrine, phenylephrine, norepinephrine) epoprostenol (Flolan), IV
insulin U-500 (special emphasis)*
adrenergic antagonists, IV (e.g., propranolol, metoprolol, labetalol) magnesium sulfate injection
methotrexate, oral, non-oncologic use
anesthetic agents, general, inhaled and IV (e.g., propofol, ketamine) opium tincture
oxytocin, IV
antiarrhythmics, IV (e.g., lidocaine, amiodarone) nitroprusside sodium for injection
potassium chloride for injection concentrate
antithrombotic agents, including: potassium phosphates injection
• anticoagulants (e.g., warfarin, low molecular weight heparin, promethazine, IV
vasopressin, IV or intraosseous
IV unfractionated heparin)
• Factor Xa inhibitors (e.g., fondaparinux, apixaban, rivaroxaban) *All forms of insulin, subcutaneous and IV, are considered a class of
• direct thrombin inhibitors (e.g., argatroban, bivalirudin, dabigatran high-alert medications. Insulin U-500 has been singled out for special
emphasis to bring attention to the need for distinct strategies to prevent
etexilate) the types of errors that occur with this concentrated form of insulin.
• thrombolytics (e.g., alteplase, reteplase, tenecteplase)
• glycoprotein IIb/IIIa inhibitors (e.g., eptifibatide) Background
cardioplegic solutions Based on error reports submitted to the ISMP National Medication
Errors Reporting Program, reports of harmful errors in the litera-
chemotherapeutic agents, parenteral and oral ture, studies that identify the drugs most often involved in harmful
errors, and input from practitioners and safety experts, ISMP cre-
dextrose, hypertonic, 20% or greater ated and periodically updates a list of potential high-alert medica-
tions. During May and June 2014, practitioners responded to an
dialysis solutions, peritoneal and hemodialysis ISMP survey designed to identify which medications were most
frequently considered high-alert drugs by individuals and organiza-
epidural or intrathecal medications tions. Further, to assure relevance and completeness, the clinical
staff at ISMP, members of the ISMP advisory board, and safety
hypoglycemics, oral experts throughout the US were asked to review the potential list.
This list of drugs and drug categories reflects the collective think-
inotropic medications, IV (e.g., digoxin, milrinone) ing of all who provided input.
insulin, subcutaneous and IV © ISMP 2014. Used with permission from the Institute for Safe Medication
Practices. Visit www.ismp.org for more medication safety information, or
liposomal forms of drugs (e.g., liposomal amphotericin B) and conven- to report medication errors or near misses to the ISMP Medication Errors
tional counterparts (e.g., amphotericin B desoxycholate) Reporting Program (MERP).
moderate sedation agents, IV (e.g., dexmedetomidine, midazolam) 1457
moderate sedation agents, oral, for children (e.g., chloral hydrate)
narcotics/opioids
• IV
• transdermal
• oral (including liquid concentrates, immediate and sustained-release
formulations)
neuromuscular blocking agents (e.g., succinylcholine, rocuronium,
vecuronium)
parenteral nutrition preparations
radiocontrast agents, IV
sterile water for injection, inhalation, and irrigation (excluding pour
bottles) in containers of 100 mL or more
sodium chloride for injection, hypertonic, greater than 0.9% concentration
Glossary
A Addiction the continued use of a substance despite serious
health and social consequences
Abortifacients drugs used to induce abortion Addison’s disease hyposecretion of glucocorticoids and
Absence seizures seizures with a loss or reduction of normal mineralocorticoids by the adrenal cortex
activity, including staring and transient loss of responsiveness Additive effect type of drug interaction in which two drugs
Absorption the process by which drug molecules move from combine to produce a summation response
their site of administration to the blood; movement of Adherence taking medications in the manner prescribed by
nutrients and other substances from the alimentary canal to the healthcare provider, or in the case of OTC drugs,
the circulation following the instructions on the label or as provided by the
Accessory organs of digestion include the salivary glands, prescriber
liver, gallbladder, and pancreas Adhesins chemicals produced by H. pylori that allow the
Acetylation a general biochemical process that adds a two- organism to penetrate the GI mucosa and cause inflammation
carbon chain to a drug molecule, which usually renders the Adipocytes fat cells
drug less effective Adjuvant analgesics drugs that have indications other than
Acetylcholine (ACh) primary neurotransmitter of the pain but are used to enhance analgesia
autonomic nervous system Adjuvant chemotherapy administration of antineoplastic
Acetylcholinesterase (AChE) enzyme that resides in the drugs after surgery or radiation therapy
synaptic cleft and catalyzes the destruction of ACh Adrenal atrophy condition in which the adrenal cortex
Acetylcholinesterase (AChE) inhibitors indirect-acting shrinks and stops secreting endogenous corticosteroids due
cholinergic agonists that are nonselective and affect all ACh to lack of stimulation by adrenocorticotropic hormone
synapses (ACTH)
Acidosis condition of having too much acid in the blood; Adrenal crisis condition that occurs when corticosteroid
plasma pH below 7.35 medication is abruptly withdrawn
Acne vulgaris disorder of the hair follicles and sebaceous Adrenergic receptors at the ends of postganglionic
glands characterized by small inflamed bumps that appear sympathetic neurons
on the surface of the skin Adrenergic agonists drugs that activate adrenergic receptors
Acquired immunodeficiency syndrome (AIDS) infection in the sympathetic nervous system; also known as
caused by the human immunodeficiency virus (HIV) sympathomimetics
Acquired resistance ability of an organism to become Adrenergic antagonists drugs that block norepinephrine
unresponsive over time to the effects of an anti-infective from reaching its receptors
Acromegaly excessive growth hormone disorder in which Adrenocortical insufficiency lack of adequate corticosteroid
bones become deformed secretion by the adrenal cortex
Activated partial thromboplastin time (aPTT) laboratory test Adrenocorticotropic hormone (ACTH) hormone secreted by
used to measure blood coagulation the anterior pituitary that stimulates the release of
Active immunity resistance resulting from a previous glucocorticoids by the adrenal cortex
exposure to an antigen Adverse drug effect an undesirable and potentially harmful
Acute dystonia occurs during early pharmacotherapy with action caused by the administration of medication
antipsychotics and involves severe muscle spasms, Aerobic pertaining to an oxygen environment
particularly of the back, neck, tongue, and face Aerosol suspension of minute liquid droplets or fine solid
Acute gouty arthritis condition in which uric acid crystals particles in a gas
accumulate in the joints of the big toes, ankles, wrists, fingers, Affinity the ability of some tissues to attract, accumulate, and
knees, or elbows, resulting in extremely painful and red, store drugs in high concentrations relative to other tissues
inflamed tissue Afterload pressure in the aorta that must be overcome for
Acute retroviral syndrome symptoms during the initial blood to be ejected from the left ventricle
phase of HIV infection Agonist drug that activates a receptor and produces the same
Adaptive defenses defenses that are specific to certain type of response as the endogenous substance
threats; the immune response
1458
Glossary 1459
Agoraphobia an extreme avoidance of closed places where a Antagonist drug that blocks the response of another drug
panic attack might occur such as airplanes, public meetings, Antagonistic effect type of drug interaction in which adding
or elevators a second drug results in a diminished pharmacologic
Akathisia inability to rest or relax; constantly moving response
Alimentary canal a long, continuous, hollow tube that Anterior pituitary gland (adenohypophysis) consists of
extends from the mouth to the anus; the GI tract glandular tissue that manufactures and secretes hormones
Alkalosis plasma pH above 7.45 that control major body functions and systems
Alkylating agents agents that kill cancer cells by altering the Anterograde amnesia type of short-term memory loss where
shape of the DNA double helix and preventing the DNA from the user cannot remember events that occurred while under
duplicating during cell division the influence of a drug
Allergic rhinitis inflammation of the nasal mucosa due to Anthrax an acute infectious disease that results from
exposure to allergens exposure to the spore-forming bacterium Bacillus anthracis
Alopecia hair loss Antibiotic natural substance produced by a microorganism
Alpha-adrenergic antagonists drugs that block alpha- that can kill other microorganisms
adrenergic receptors in the sympathetic nervous system Antibodies proteins produced by the body in response to an
Alzheimer’s disease (AD) neurodegenerative disease that antigen; used interchangeably with the term immunoglobulin
involves a chronic progressive loss of cognitive function Anticholinergic syndrome symptoms such as dry mouth,
Amide local anesthetic that has the same mechanism of blurred vision, photophobia, visual changes, difficulty
action as esters but has less effect on myocardial contraction swallowing, agitation, and hallucinations, caused by an
and lower allergic reaction overdose of anticholinergic substances
Amygdala located in the temporal lobe, it is essential for the Anticoagulants natural substances that inhibit the formation
ability to feel certain emotions and to perceive them in other of blood clots
people Antidepressants drugs used to enhance, elevate, or stabilize
Anabolic effects testosterone hormone’s ability to accelerate mood
the growth of red blood cells, muscle, bone, and neural Antidiuretic hormone (ADH) hormone released by the
tissues posterior pituitary gland when blood pressure falls or when
Anabolic steroids testosterone-like substances with the osmotic pressure of the blood increases; most important
hormonal activity that are commonly abused by athletes means by which the body maintains fluid homeostasis
Anaerobic pertaining to an environment without oxygen Antigens microbes and foreign substances that elicit an
Analgesics drugs used to relieve pain immune response
Anaphylaxis life-threatening allergic response that may cause Anti-infective general term for any medication that is
cardiovascular shock and death effective against pathogens
Androgens steroid sex hormones that promote the Antipyretics medications used to reduce body temperature
appearance of masculine characteristics Antiretroviral therapy (ART) therapy designed to reduce the
Anemia decreased oxygen-carrying capacity of the blood replication of HIV as much as possible, as measured by a
Angina pectoris acute chest pain caused by myocardial reduction in plasma HIV RNA to its lowest possible (or
ischemia undetectable) level; formerly called highly active
Angioedema rapid swelling of the throat, face, larynx, and antiretroviral therapy (HAART)
tongue that can lead to airway obstruction and death Antiretrovirals drugs that are effective against retroviruses
Angiogenesis the formation of new blood vessels Antithrombin III (AT-III) protein that prevents abnormal
Angiotensin I a precursor to the formation of angiotensin II clotting by inhibiting thrombin and other clotting factors
that is produced when angiotensinogen is split by the Antitussives medications that control cough
enzyme renin Anxiety state of apprehension, tension, or uneasiness that
Angiotensin II vasopressor substance released in response to stems from the anticipation of danger, the source of which is
falling blood pressure that causes vasoconstriction and largely unknown or unrecognized
release of aldosterone Anxiolytic drugs that relieve anxiety
Angiotensin-converting enzyme (ACE) inhibitor enzyme Apoprotein protein component of a lipoprotein
that blocks the formation of angiotensin II, decreasing blood Appetite a psychologic response that drives food intake
pressure based on associations and memory
Angiotensinogen protein synthesized by the liver that is Aqueous humor fluid that fills the anterior and posterior
continuously circulating in the bloodstream chambers of the eye
Anorexiants drugs used to suppress appetite Asthma chronic inflammatory disease of the lungs
Anovulatory cycles menstrual cycles without ovulation characterized by airway obstruction
Antacids inorganic compounds containing aluminum, Atherosclerosis condition characterized by the presence of
magnesium, sodium, or calcium that neutralize gastric acid plaque within the walls of arteries
and inactivate pepsin Atonic seizures very short-lasting seizures during which the
patient may stumble and fall for no apparent reason
1460 Glossary
Atrial natriuretic peptide (ANP) hormone secreted by Benign prostatic hyperplasia (BPH) nonmalignant abnormal
specialized cells in the right atrium when large increases in enlargement of the prostate gland
blood volume produce excessive stretch on the atrial wall
Atrial reflex causes the heart rate and CO to increase until Best Pharmaceuticals for Children Act authorizes the FDA to
the backlog of venous blood (or IV fluid) is distributed contract for the testing of already approved pediatric drugs,
throughout the body or when the pharmaceutical company declines the option of
Attention-deficit/hyperactivity disorder (ADHD) disorder exclusivity
typically diagnosed in childhood characterized by hyperactivity
as well as attention, organization, and behavior control issues Beta-adrenergic antagonists drugs that block beta-adrenergic
Attenuated organisms that have been rendered less able to receptors; may be nonselective or selective; also called beta
cause disease through the application of heat or chemicals blockers
from which effective vaccines can be developed
Atypical antidepressants diverse class of drugs that act by Beta-lactam ring portion of the chemical structure of
mechanisms other than those of the selective serotonin penicillin and some other antibiotics that is responsible for
reuptake inhibitors, tricyclic antidepressants, and monoamine their antibacterial activity
oxidase inhibitors
Atypical mycobacterial infections (AMIs) nontuberculosis Beta-lactamase any of several enzymes produced by bacteria
opportunistic diseases caused by mycobacteria that are able to render certain antibiotics ineffective
Auras sensory warnings such as flashing lights, visual blind
spots, and arm or leg tingling that precede a migraine Bioavailability the rate and extent to which the active
Automaticity ability of certain myocardial cells to ingredient is absorbed from a drug product and becomes
spontaneously generate an action potential without an available at the site of drug action to produce its effect
outside signal from the nervous system
Automatisms repetitive arm movements, leg movements, Biologic response modifiers natural cytokines that boost
head rolling, chewing, lip smacking, or swallowing that occur specific functions of the immune system
in complex partial seizures
Autonomic nervous system (ANS) portion of the peripheral Biosimilar drug drug that has comparable effectiveness and
nervous system that provides for the involuntary control of safety to an FDA-approved biologic product
vital functions of the cardiovascular, digestive, respiratory,
and genitourinary systems Bioterrorism intentional release of an infectious agent for the
Autonomic tone the background level of autonomic activity purpose of causing harm to a large number of people
that occurs even in the absence of stimuli
Azole term for the major class of drugs used to treat mycoses Bipolar disorder syndrome characterized by extreme and
Azoospermia complete absence of sperm in an ejaculate opposite moods, such as euphoria and depression
B Bisphosphonates class of drugs for treating osteoporosis that
inhibit bone resorption by suppressing osteoclast activity
b-glucan an essential component that shapes and strengthens
the cell walls of fungi Black box warning in some drug inserts, a requirement by
B cell lymphocyte responsible for humoral immunity the FDA that warns prescribers that the drug carries a risk for
Bactericidal drug that kills bacteria serious or fatal adverse effects
Bacteriostatic drug that inhibits the growth of bacteria
Bacteriuria uropathogens Blood–brain barrier network of capillaries in the CNS that
Balanced anesthesia use of multiple medications to produce inhibits many chemicals and drugs from gaining access to the
general anesthesia, provide sedation, rapid induction of brain
unconsciousness, muscle relaxation, and analgesia
Baroreceptors receptors in the aorta and carotid artery that Body mass index (BMI) measurement of obesity determined
sense changes in blood pressure by dividing body weight (in kilograms) by the square of
Barrett’s esophagus precancerous condition of the esophagus height (in meters)
Basal nuclei area of the brain responsible for starting and
stopping synchronized motor activity such as leg and arm Body surface area (BSA) method method of calculating
motions during walking; also called basal ganglia pediatric dosages using an estimate of the child’s BSA
Beers criteria list of drugs compiled by the American
Geriatrics Society that have produced a high incidence of Body weight method method of calculating pediatric dosages
adverse effects in older adults that requires a calculation of the number of milligrams of
Belladonna natural source of alkaloids with anticholinergic drug, based on the child’s weight in kilograms (mg/kg)
activity acquired from the deadly nightshade plant, Atropa
belladonna, which grows throughout the world Bone deposition opposite of bone resorption; bone building
Bone resorption process of bone demineralization or the
breaking down of bone into mineral components
Boosters follow-up doses of vaccines that are required to
provide prolonged protection
Botanical plant extract used to treat or prevent illness
Botulism condition caused by Clostridium botulinum, an
organism that secretes a potent toxin that paralyzes the
muscles after an individual is poisoned
Bradydysrhythmias disorders characterized by a heart rate
less than 60 beats/min
Bradykinesia difficulty initiating movement and controlling
fine muscle movements
Bradykinin chemical released by cells during inflammation
that produces pain and side effects similar to those of
histamine
Broad-spectrum antibiotic an anti-infective that is effective Glossary 1461
against a wide variety of different microbial species
Bronchospasm sudden contraction of the smooth muscle of Chelation therapy use of drugs to detoxify poisonous metals
the airways that causes acute dyspnea such as mercury, arsenic, and lead by converting them to a
Buffers chemicals that help maintain normal body pH by chemically inert form that can be easily excreted
neutralizing strong acids or bases Chemical names standard nomenclature for drugs assigned
by the International Union of Pure and Applied Chemistry
C (IUPAC)
Chemoreceptor trigger zone (CTZ) location in the cerebral
Cachexia general wasting of muscle and other tissue cortex that sends sensory signals to the vomiting center
Calcineurin intracellular messenger enzyme that is activated Chemoreceptors sensory receptors in the aorta and carotid
when a T cell encounters an antigen artery that recognize levels of oxygen, pH, or carbon dioxide in
Calcitonin hormone secreted by the thyroid gland that the blood
decreases plasma levels of calcium by inhibiting resorption Chemotherapy pharmacotherapy of cancer
of calcium from bone and increasing excretion of calcium by Chief cells cells located in the mucosa of the stomach that
the kidneys secrete pepsinogen, an inactive form of the enzyme pepsin
Calcitriol the active form of vitamin D that chemically breaks down proteins
Calcium channel type of voltage-gated channel in cardiac Chloasma darkened pigmentation found on the forehead,
muscle and smooth muscles temples, cheeks, and upper lips
Cancer malignant disease characterized by abnormal, Cholecalciferol inactive form of vitamin D
uncontrolled cell division Cholestatic hepatitis type of liver inflammation caused by
Capillary leak syndrome a serious condition in which obstruction of the bile ducts
plasma proteins and other substances leave the blood and Cholinergic relating to neurons that release acetylcholine (ACh)
enter the interstitial spaces because of porous capillaries Cholinergic agonists drugs and chemicals that increase the
Capsid protein coat that surrounds a virus action of acetylcholine (ACh) at a cholinergic receptor; also
Carbonic anhydrase enzyme that forms carbonic acid by called parasympathomimetics
combining carbon dioxide and water Cholinergic crisis caused by an overdosage with
Carcinogens agents that cause cancer acetylcholinesterase (AChE) inhibitors or poisoning with
Cardiac output (CO) amount of blood pumped by a ventricle organophosphate insecticides or toxic nerve gases;
per minute characterized by intense signs of parasympathetic
Cardiac remodeling change in the size, shape, and structure stimulation such as miosis, nausea, vomiting, urinary
of the myocardial cells (myocytes) that occurs over time in incontinence, increased exocrine secretions, abdominal
heart failure cramping, and diarrhea
Cardiotonic drugs drugs that increase the force of cardiac Cholinesterase inhibitors the most widely prescribed drug
contraction; also called inotropic drugs class for treating Alzheimer’s disease
Cardioversion electrical shock of the heart that under ideal Chronic bronchitis recurrent disease of the lungs
conditions will allow the return to a normal heart rhythm; characterized by excess mucus production, inflammation,
also called defibrillation and coughing
Cataplexy sudden loss of muscle strength manifested as Chronic kidney disease condition characterized by a gradual
slurred speech, sagging of the jaw, head nodding, or even loss of kidney function, usually over a period of months or
complete collapse of the body years; also called renal failure
Catecholamines class of endogenous hormones involved in Chronic obstructive pulmonary disease (COPD) progressive
neurotransmission that include epinephrine (adrenalin), pulmonary disorder characterized by chronic obstructive
norepinephrine, and dopamine airflow
Catechol-O-methyltransferase (COMT) enzyme that Chyme partly digested food that is passed from the stomach
destroys catecholamines such as norepinephrine in kidney to the small intestine
and liver cells Cinchonism syndrome with symptoms such as tinnitus,
Cathartic substance that causes accelerated, stronger, and headache, diarrhea, blurred vision, hearing loss, and
more complete bowel emptying dysrhythmias, caused by high doses of quinidine
CD4 receptor protein that accepts HIV and allows entry of Circadian rhythm cyclic basis by which body temperature,
the virus into the T4 lymphocyte blood pressure, hormone levels, and respiration all fluctuate
Cell-kill hypothesis theoretical model that predicts the throughout the 24-hour day
ability of antineoplastic drugs to eliminate cancer cells Climacteric the period of endocrine, somatic, and
Central nervous system (CNS) stimulants drugs that raise psychologic changes occurring in the transition to menopause
the general alertness level of the brain Clinical phase trials the second stage of drug testing in a
Cerumenolytics agents used to loosen and remove impacted clinical investigation; involves the testing of a new drug in
cerumen from the ear canal selected patients
Closed-angle glaucoma acute glaucoma that is caused by
obstruction of drainage of aqueous humor through the canal
of Schlemm
1462 Glossary
Club drug a diverse group of abused substances taken by Crystalluria crystals that form in the urine and potentially
people at dance clubs, all-night parties, and raves obstruct the kidneys or ureters
Culture set of beliefs, values, religious rituals, language,
Coagulation formation of an insoluble clot customs, and behavioral expectations that provide meaning
for an individual or group
Colloids proteins, starches, or other large molecules that Culture and sensitivity (C&S) testing a laboratory test used
remain in the blood for a long time because they are too large to identify bacteria and the most effective antibiotic
to easily cross the capillary membranes Curare the first neuromuscular blocker, which was initially
extracted from several different plant species native to the
Colony-stimulating factors (CSFs) hormones that activate rain forests of South America
existing white blood cells to fight an infection and stimulate the Cushing’s syndrome condition of high levels of
growth and differentiation of one or more types of leukocytes corticosteroids in the body over a prolonged period of time
Cyclooxygenase (COX) key enzyme in the synthesis of
Combination drugs drug products with more than one active prostaglandin that is blocked by aspirin and other NSAIDs
generic ingredient Cycloplegics drugs that relax or temporarily paralyze ciliary
muscles and cause blurred vision
Comedolytics drugs that prevent and break up the formation Cystitis bladder infection
of clogged pores Cysts protective capsules formed by some protozoa that
allow the organisms to survive in harsh environments in a
Comedones types of acne lesions that develop just beneath dormant state for prolonged time periods
the surface of the skin (whitehead) or as a result of a plugged Cytokine release syndrome an acute inflammatory
oil gland (blackhead) response that occurs 30 to 60 minutes following the initial IV
administration of muromonab due to massive cytokine release
Complement system a cluster of 20 plasma proteins that Cytokines proteins produced by T cells, such as interleukins,
combine in a specific sequence and order when an infection leukotrienes, interferon, and tumor necrosis factor, that guide
occurs the immune response
Complementary and alternative medicine (CAM) diverse D
set of therapies and healing systems that are considered to be
outside of mainstream healthcare Deep vein thrombosis (DVT) thrombosis that occurs
in the legs
Complex partial seizures seizures that originate from a Defecation elimination of indigestible substances from
single focus, usually in the temporal lobe of the brain, and the body
involve sensory, motor, or autonomic symptoms with some Defibrillation electrical shock of the heart that under ideal
degree of altered or impaired consciousness conditions will allow the return to a normal heart rhythm;
also called cardioversion
COMT inhibitors drugs that prevent the destruction of Delirium tremens a syndrome of intense agitation,
catechol-O-methyltransferase (COMT) in peripheral tissues, confusion, terrifying hallucinations, uncontrollable tremors,
thus increasing the amount of levodopa available to enter panic attacks, and paranoia caused by alcohol withdrawal
the brain Delusions false ideas and beliefs not founded in reality
Dementia degenerative disorder characterized by
Conjugation the direct transfer of small pieces of DNA from progressive memory loss, confusion, and the inability to
one bacterium to another think or communicate effectively
Dependence a powerful physiologic or psychologic need for
Constipation infrequent passage of abnormally hard and dry a substance
stools Depolarization loss of membrane potential in a cell
Depression characterized by a sad or despondent mood that
Contraception the use of devices, drugs, or surgery to becomes out of proportion to actual life events
prevent pregnancy Dermatitis superficial inflammatory disorders of the skin
characterized by redness, pain, and pruritus
Contractility the strength with which the myocardial fibers Dermatomycosis fungal infections of the skin and hair
contract Diabetes insipidus (DI) disorder marked by production of
large volumes of urine, usually accompanied by increased thirst
Controlled substances in the United States, drugs whose use Diabetes mellitus metabolic disorder characterized by an
is restricted by the Comprehensive Drug Abuse Prevention imbalance between insulin availability and insulin need
and Control Act Diabetic ketoacidosis (DKA) acute condition that occurs
primarily in patients with type 1 diabetes characterized by
Convulsions involuntary violent spasms of the face, neck, hyperglycemia, metabolic acidosis, and osmotic diuresis
arms, and legs
Coronary artery disease (CAD) a narrowing or occlusion of
one or more coronary arteries
Corpora cavernosa tissue in the penis that fills with blood
during an erection
Corpus luteum endocrine tissue formed from a ruptured
follicle that remains in the ovary after ovulation and secretes
progesterone
Cretinism condition marked by profound mental retardation
and impaired growth that results from untreated congenital
hypothyroidism
Cross-tolerance situation in which tolerance to one drug
makes the patient tolerant to another drug
Crystalloids IV solutions that contain electrolytes and other
agents in concentrations that mimic the body’s extracellular
fluid
Glossary 1463
Diarrhea increase in the frequency and fluidity of bowel Down-regulation the process by which cells make fewer
movements receptors on their surface
Drug any substance that is taken to prevent, cure, or reduce
Dietary Supplement and Nonprescription Drug Consumer symptoms of a medical condition
Protection Act law that requires companies that market Drug allergies a hyperresponse of body defenses to a
herbal and dietary supplements to include their address and particular drug that may result in a diverse range of patient
phone number on the product labels so consumers can report symptoms
adverse events Drug interaction occurs when a medication interacts with
another substance such as another drug, a dietary
Dietary Supplement Health and Education Act of 1994 supplement, an herbal product, or food that is taken
(DSHEA) primary law in the United States regulating herbal concurrently with the medication, and the drug’s actions
and dietary supplements are affected
Drug misuse improper use of drugs, including overuse,
Dietary supplements products available over the counter that underuse, or, in some cases, erratic use
are intended to add to or supplement the nutritional value of Drug–protein complex formed when a drug that binds
the diet reversibly to a plasma protein, particularly albumin, makes
the drug unavailable for distribution to its site of action
Diffusion the movement of a chemical from an area of higher Dry powder inhaler (DPI) device used to convert a solid
concentration to an area of lower concentration drug to a fine powder for the purpose of inhalation
Dwarfism a growth hormone deficiency disorder in children
Digestion the mechanical and chemical breakdown of food associated with normal birth length followed by a slowing of
into a form that may be absorbed into the systemic circulation the growth rate
Dysfunctional uterine bleeding hemorrhage that occurs on a
Digestive system body system consisting of the alimentary noncyclic basis or in abnormal amounts
canal and the accessory organs Dyslipidemia a general term that refers to abnormal amounts
of lipids in the body
Digitalization procedure in which the dose of digoxin is Dysrhythmias disorders of cardiac rhythm characterized by
gradually increased until tissues become saturated with the an abnormal heart rate or irregular contractions
drug, and the symptoms of heart failure diminish Dystonia chronic neurologic disorder that is characterized by
involuntary muscle contraction that forces body parts into
Dihydropyridines the largest class of calcium channel abnormal painful movements or postures
blockers that bind reversibly to closed-type (inactivated)
calcium channels to make them unresponsive to E
depolarization
Eclampsia pregnancy-induced hypertensive disorder
Directly observed therapy (DOT) requires that a healthcare Ectopic foci regions of the heart outside the normal cardiac
provider directly observe the patient swallowing the pills, conduction pathway that may send impulses across the
whether it is in the hospital, office, or home care setting myocardium
Ectopic pregnancy the development of the fetus elsewhere
Disease-modifying antirheumatic drugs (DMARDs) drugs rather than in the uterus
that slow or modify the progression of rheumatoid arthritis Eczema chronic, inflammatory skin disorder
Efficacy the maximal response that can be produced from a
Dissociative anesthesia a trance-like feeling of being particular drug
separated from the environment produced by an anesthetic Electrocardiogram (ECG) graphic recording of the wave of
agent electrical conduction across the myocardium
Electroconvulsive therapy (ECT) treatment used for serious
Distribution the transport of drugs throughout the body and life-threatening mood disorders in patients who are
after they are absorbed unresponsive to pharmacotherapy and psychotherapy
Electrolyte charged substance in the blood such as sodium,
Diuretic substance that increases the rate of urine flow potassium, calcium, chloride, and phosphate
Elemental (monomeric) formulas enteral products that are
Diuretic resistance phenomenon in some patients who become usually lactose free and contain only a small percentage of
less responsive as therapy continues with loop diuretics calories from fat
Emergency contraception (EC) the prevention of implantation
DNA gyrase (topoisomerase II) in bacterial DNA replication, following unprotected intercourse or contraceptive failure
the enzyme that relaxes the supercoil Emergency preparedness the ability to respond quickly and
effectively to an unexpected event that may impact human
DNA helicase in bacterial DNA replication, the enzyme that health
unwinds the two DNA strands after the supercoil is relaxed
DNA polymerase in bacterial DNA replication, the enzyme
that adds the precursor bases to replicate the original DNA
and form new DNA strands
Dopamine chemical precursor in the synthesis of
norepinephrine; classified as a catecholamine
Dopamine system stabilizers (DSSs) partial agonists that
reduce the hyperactivity of dopamine in certain regions of the
brain (to produce therapeutic effects), while at the same time
restoring normal dopamine activity in other regions (to lower
the incidence of adverse effects)
Dopamine type 2 (D2) receptors receptors for dopamine in
the basal nuclei of the brain that are associated with
schizophrenia and antipsychotic drugs
Dose–response relationship the way a patient responds to
varying doses of a drug
1464 Glossary
Emetogenic potential usually applied to antineoplastic drugs; Excretion the process of removing substances from the body
degree to which an agent is likely to trigger the vomiting Exophthalmos an outward bulging of the eyes
center in the medulla, resulting in nausea and vomiting Exotoxins proteins released by bacteria into surrounding
tissues that have the ability to inactivate or kill host cells
Emphysema lung disease characterized by loss of bronchiolar Expectorants drugs used to increase bronchial secretions
elasticity and destruction of alveolar walls Extended release tablets or capsules designed to dissolve
very slowly, resulting in a longer duration of action for the
Endocrine system body system that consists of various medication; also called long-acting or sustained release
glands that secrete hormones Extracellular fluid (ECF) compartment of body fluid lying
outside cells, which includes plasma and interstitial fluid
Endometriosis presence of endometrial tissue in nonuterine Extrapyramidal symptoms (EPS) symptoms of acute
locations such as the pelvis and ovaries; a common cause of dystonia, akathisia, parkinsonism, and tardive dyskinesia
infertility often caused by antipsychotic drugs
Extrapyramidal system part of the CNS that controls
Endorphins a group of neurotransmitters that function as locomotion, complex muscular movements, and posture
endogenous opioids or natural pain modifiers in the CNS Extrinsic pathway activated in response to injury when blood
leaks out of a vessel and enters tissue spaces; the pathway
Endotoxins harmful nonproteins that are part of the normal takes several seconds to complete
cell wall of gram-negative bacteria
F
Enteral nutrition (EN) nutritional support used for patients
with functioning GI tracts but who are unable to orally ingest Fasting plasma glucose (FPG) test a primary blood test for
adequate amounts of nutrients to meet their metabolic needs diagnosing diabetes
Fat-soluble vitamins group of vitamins stored in the liver
Enteral route administration of drugs orally or through and fatty tissue that includes A, D, E, and K
nasogastric or gastrostomy tubes FDA Adverse Event Reporting System (FAERS) a voluntary
program that encourages healthcare providers and
Enteric-coated tablets that have a hard, waxy coating consumers to report suspected adverse effects directly to the
designed to dissolve in the alkaline environment of the small FDA or the product manufacturer
intestine Febrile seizures tonic–clonic motor activity lasting 1 to 2
minutes with rapid return of consciousness that occurs in
Enteric nervous system (ENS) network of neurons in the conjunction with fever
submucosa of the alimentary canal that has sensory and Ferritin one of two protein complexes that maintain iron
motor functions that regulate the GI tract stores inside cells (hemosiderin is the other)
Fetal–placental barrier special anatomic barrier that inhibits
Enteroendocrine cells cells that secrete hormones that many chemicals and drugs from entering the fetus
modify the digestive processes Fibrin an insoluble protein formed from fibrinogen by the
action of thrombin in the blood clotting process
Enterohepatic recirculation recycling of drugs and other Fibrinogen blood protein that is converted to fibrin by the
substances by the circulation of bile through the intestine and action of thrombin in the blood coagulation process
liver Fibrinolysis physiologic process that limits clot formation
and removes existing clots
Enzyme induction process by which a drug increases the Fight-or-flight response characteristic set of actions
activity of the hepatic microsomal enzymes produced when the sympathetic nervous system is activated
that prepares the body for heightened activity and for an
Epilepsy disruption of the activity of clusters of neurons in immediate response to a threat
the brain that is characterized by two or more seizures Filtrate fluid in the nephron that is filtered into the Bowman’s
capsule
Erectile dysfunction (ED) consistent inability to either attain First-dose phenomenon serious orthostatic hypotension that
an erection or to sustain an erection long enough to achieve occurs with the initial doses of alpha1-adrenergic blockers
satisfactory sexual intercourse First-pass effect mechanism whereby drugs are absorbed,
enter into the hepatic portal circulation, and are inactivated
Ergosterol lipid substance in fungal cell membranes by the liver before they reach the general circulation
Folate see Folic acid
Erythema redness associated with skin irritation Folic acid B vitamin that is essential for normal DNA and
RNA synthesis; also called folate
Erythrocytic stage phase in malaria during which infected Food and Drug Administration (FDA) Modernization Act
red blood cells rupture, releasing more merozoites and act that gave financial incentives to pharmaceutical companies
causing acute symptoms
Erythropoietin hormone secreted by the kidney that stimulates
the body’s production of erythrocytes (red blood cells)
Esters local anesthetics that act by decreasing the amount of
sodium that enters the neuron
Estrogen general term that refers to three different steroid
hormones: estradiol, estrone, and estriol
Ethnicity groups of people with biologic and genetic
similarities
Euphoria an intense sense of happiness and well-being
Exclusivity after approval of a drug application by the U.S.
Food and Drug Administration, a period of time when
competing companies are not allowed to market generic
versions of a drug
Excoriation scratches that break the skin surface and fill with
blood or serous fluid to form crusty scales
Glossary 1465
to conduct pediatric research in pharmacology; in exchange Gout form of acute arthritis caused by an accumulation of
for providing pediatric labeling, the legislation gives drug uric acid (urate) crystals in the joints and other body tissues
companies the ability to exclusively market the drug for an Grading process that examines potential cancer cells under a
additional 6 months with no competition microscope and compares their appearance to normal parent
Formulary list of drug and drug recipes commonly used by cells
pharmacists Gram-negative bacteria that do not retain a violet stain
Frequency distribution curve a graphic representation of the because they have thin cell walls
actual number of patients responding to a particular drug Gram-positive bacteria that contain a thick cell wall composed
action at different doses of peptidoglycan and retain the violet color after staining
Fungi kingdom of organisms that includes mushrooms, Graves’ disease syndrome caused by hypersecretion of
yeasts, and molds thyroid hormone
Gray baby syndrome serious condition seen most often in
G premature or newborn infants that occurs when the baby’s
liver is unable to metabolize or excrete chloramphenicol
Gamma aminobutyric acid (GABA) neurotransmitter Growth fraction the ratio of the number of replicating cells to
in the CNS resting cells in a tissue or tumor
Ganglia collection of neuron cell bodies located outside Growth hormone (GH) hormone that is produced and
the CNS secreted by the anterior pituitary gland; also called
Ganglionic blockers drugs that inhibit transmission at the somatotropin or somatropin
ganglia in the sympathetic and parasympathetic nervous
systems H
Gastroesophageal reflux disease (GERD) regurgitation of
acidic stomach contents into the esophagus H+, K+-ATPase enzyme secreting hydrochloride acid in the
Gate control theory proposes a gating mechanism for the stomach
transmission of pain in the spinal cord H1 receptors histamine receptors that, when activated,
General anesthesia medical procedure that produces produce allergy symptoms
unconsciousness and loss of sensation throughout the entire H2-receptor antagonists drugs that suppress gastric acid by
body blocking histamine receptors in the stomach
Generalized anxiety disorder (GAD) difficult-to-control, Hallucinations seeing, hearing, or feeling things that are
excessive anxiety that lasts for 6 months or longer not there
Generalized seizures seizures that travel throughout the Hallucinogens chemicals that have the ability to produce an
entire brain altered, dreamlike state of consciousness
Generic name name assigned to a drug by the U.S. Adopted Hashimoto’s thyroiditis an autoimmune disorder that is the
Name Council most common cause of hypothyroidism
Genetic polymorphism changes in enzyme structure and Healthcare-associated infections (HAIs) infections acquired
function due to mutation of the encoding gene in a healthcare setting that are often resistant to common
Gestational diabetes condition resulting from glucose antibiotics
intolerance with an onset, or first recognition, during pregnancy Healthcare failure mode and effect analysis (HFMEA) a tool
Gigantism unusual tallness that helps healthcare agencies identify processes where
Glaucoma condition that is characterized by optic medication errors may occur related to prescription,
neuropathy with gradual loss of peripheral vision and dispensing, and administration
usually accompanied by increased intraocular pressure Heart failure (HF) inability of the heart to pump enough
Glomerular filtration rate (GFR) the volume of water filtered blood to meet the body’s metabolic needs
through the Bowman’s capsules per minute Helminths various species of multicell parasitic worms
Glomerulus a specialized capillary in the Bowman’s capsule Hemagglutinin an enzyme that facilitates the attachment of
of the kidney that filters the blood during urine formation the virus to host cells
Glucocorticoids class of hormones secreted by the adrenal Hematopoiesis production and maturation of blood cells that
cortex that prepare the body for long-term stress; also called occurs in red bone marrow; also called hemopoiesis
corticosteroids Hematopoietic growth factors drugs that promote the
Gluconeogenesis the production of new glucose from formation of specific blood cells and enhance the ability of the
noncarbohydrate molecules immune system to reduce some of the myelosuppression
Glutamate amino acid that is the most common caused by antineoplastic medications
neurotransmitter in the CNS Hemoglobin A1C test (A1C) a laboratory test used in
Glycogenolysis the process of glycogen breaking down diabetic management; also called glycosylated hemoglobin
Glycoprotein IIb/IIIa receptor found on the surface of platelets Hemophilia series of coagulation disorders caused by genetic
Goiter refers to an increase in the size of the thyroid gland insufficiencies
Gonadocorticoids sex hormones secreted by the adrenal cortex Hemopoiesis production and maturation of blood cells that
occurs in red bone marrow; also called hematopoiesis
1466 Glossary
Hemosiderin one of two protein complexes that maintain Hypnagogic hallucinations vivid, fearful illusions that may
iron stores inside cells (ferritin is the other) be experienced at the onset of sleep or on awakening
Hemostasis the slowing or stopping of blood flow Hypoaldosteronism lack of adequate aldosterone secretion
Hepatic microsomal enzyme system as it relates to Hypogonadism lack of sufficient testosterone by the testes
pharmacotherapy, liver enzymes that metabolize drugs as Hypokalemia serum potassium level below 3.5 mEq/L
well as nutrients and other endogenous substances; Hypomania characterized by the same symptoms as bipolar
sometimes called the CYP450 system disorder, but they are less severe and do not cause impaired
Hepatic portal system a network of venous vessels that functioning
collects blood draining from the stomach, small intestine, and Hyponatremia low sodium level in the blood
most of the large intestine
Hepatitis inflammation of the liver I
Herb plant with a soft stem that is used for healing or as a
seasoning Idiosyncratic response unpredictable and unexplained drug
High-alert medications drugs that have a high risk of reaction
causing significant harm to the patient when used in error Immunity ability to resist injury and infections
High-density lipoprotein (HDL) lipid-carrying particle in Immunization process of disease prevention in which the
the blood that transports excess cholesterol away from body body produces its own antibodies in response to initial
tissues or back to the liver for metabolism exposure to antigens
Histamine chemical released by mast cells in response to Immunomodulator general term referring to any drug or
foreign agents or injury that initiates the inflammatory therapy that affects body defenses
response within seconds Immunostimulants drugs that increase the ability of the
HMG-CoA reductase primary regulatory enzyme for the immune system to fight infection and disease
biosynthesis of cholesterol Immunosuppressants drugs that diminish the ability of the
Hormone replacement therapy (HRT) supplies physiologic immune system to fight infection and disease
doses of estrogen, sometimes combined with progestin, to Impotence inability to obtain or sustain an erection; also
treat unpleasant symptoms of menopause and to prevent called erectile dysfunction
long-term consequences of estrogen loss Incretins hormones released by the mucosa of the small
Hormones chemicals secreted by endocrine glands that act as intestine in response to meals
chemical messengers to maintain homeostasis Incubation period following the first exposure to an antigen,
Host flora microorganisms that normally inhabit the human the time needed for the body to process the antigen and
body mount an effective response
Human immunodeficiency virus (HIV) the causative agent Indications the medical conditions for which a drug is approved
for AIDS Infantile spasm usually occurs in the first year of life and is
Hyperaldosteronism excessive secretion of aldosterone characterized by a sudden bending forward, body stiffening,
Hypercholesterolemia high levels of cholesterol in the blood or arching of the torso; also called West syndrome
Hyperemesis gravidarum condition of continual vomiting Infertility inability to become pregnant after at least 1 year of
during pregnancy frequent, unprotected intercourse
Hyperkalemia serum potassium level above 5 mEq/L Inflammation nonspecific body defense that occurs in
Hyperlipidemia elevated levels of lipids in the blood response to an injury or antigen
Hypernatremia high sodium level in the blood Inflammatory bowel disease (IBD) disease characterized by
Hyperosmolar hyperglycemic state (HHS) acute complication the presence of ulcers in the distal portion of the small
seen in individuals with type 2 diabetes that is characterized intestine (Crohn’s disease) or mucosal erosions in the large
by extreme hyperglycemia, hyperosmolarity with dehydration, intestine (ulcerative colitis)
the absence of ketoacidosis, and CNS dysfunction Influenza a viral infection characterized by acute symptoms
Hypertension (HTN) consistent elevation of systemic arterial that include sore throat, sneezing, coughing, fever, and chills;
blood pressure also called flu
Hypertensive emergency (HTN-E) a diastolic pressure of Ingestion the process of taking food into the body by mouth
greater than 120 mmHg, with evidence of target-organ Innate body defenses those that are present even before an
system damage; also called hypertensive crisis infection occurs and which provide the first line of protection
Hypertensive urgency severe hypertension, but with no from pathogens
evidence of target-organ damage Inoculation the placement of a foreign substance on or in an
Hypertrichosis the elongation, thickening, and increased individual for the purpose of disease prevention using “live”
pigmentation of body hair virus particles obtained from an infected patient
Hypertriglyceridemia refers to an increase in triglyceride levels Inotropic drugs drugs that increase the force of contraction of
Hyperuricemia serum uric acid level 7 mg/dL or higher the heart; also called cardiotonic drugs
Hypervitaminosis intake of toxic levels of vitamins Insomnia inability to fall asleep or stay asleep
Insulin pancreatic hormone that acts to decrease blood glucose
levels
Glossary 1467
Insulin resistance occurs in type 2 diabetes mellitus; cells Leprosy a chronic infection caused by Mycobacterium leprae
become unresponsive to insulin due to a defect in insulin Leptin hormone that regulates hunger and weight
receptor function balance
Insulin-like growth factor (IGF) a family of peptides that Leucovorin rescue therapy drug therapy administered
promote cartilage and bone growth following chemotherapy with toxic folic acid analogs such as
Integrase an enzyme unique to HIV that incorporates the methotrexate to rescue normal cells
viral DNA into the host’s chromosomes Leukotrienes chemical mediators of inflammation stored and
Interferons (IFNs) type of cytokine secreted by T cells in released by mast cells
response to antigens to protect uninfected cells Leydig cells the primary cells in the testes that are
Interleukins (ILs) class of cytokines synthesized by responsible for androgen secretion
lymphocytes, monocytes, macrophages, and certain other Libido interest in sexual activity
cells in response to antigen exposure Limbic system area in the brain responsible for emotional
Intermittent claudication (IC) pain or cramping in the lower expression, learning, and memory
legs that worsens with walking or exercise Lipodystrophy a disorder in which fat is redistributed in
Intracellular fluid (ICF) compartment contains water that is specific areas in the body
inside cells Lipoproteins substances that carry lipids in the
Intracellular parasites infectious microbes that live inside bloodstream that are composed of fat bound to carrier
host cells proteins
Intrinsic activity the ability of a drug to bind to a receptor Loading dose relatively large dose of a drug given at the
and produce a strong action beginning of treatment to rapidly obtain a therapeutic
Intrinsic factor chemical substance secreted by stomach cells response
that is essential for the absorption of vitamin B12 Local anesthesia loss of sensation to a limited part of the
Intrinsic pathway coagulation pathway activated in response body without loss of consciousness
to injury; it takes several minutes to complete Locus coeruleus located within the brainstem, monitors
Intrinsic sympathomimetic activity (ISA) low level of beta- internal and external signals and is the principal site for
agonist activity possessed by certain beta-adrenergic blockers norepinephrine synthesis in the brain
Invasiveness the ability of a pathogen to grow extremely Long-acting reversible contraceptives (LARCs) provide
rapidly and cause direct damage to surrounding tissues by contraception for periods lasting from weeks to years
virtue of sheer numbers Low-density lipoprotein (LDL) lipoprotein that carries the
Investigational New Drug (IND) application to the FDA that highest amount of cholesterol
contains all the animal and cell testing data Lymph nodes the principal lymphoid organs in the body
Iodism toxicity to Lugol’s iodine solution therapy Lymphatic system consists of a network of cells, vessels, and
Ion trapping phenomenon in which alkalinizing drugs are tissues that provide immune surveillance
used to aid in the renal excretion of toxic substances
Irritable bowel syndrome (IBS) disease of the lower GI tract, M
characterized by abdominal pain, bloating, gas, cramping,
and alternating diarrhea and constipation Macrominerals inorganic compound needed by the body in
Irritative voiding symptoms cluster of complaints that amounts of 100 mg or more daily
accompanies cystitis Macula densa specialized cells in the distal convoluted
Isozymes multiple, similar forms of an enzyme that perform tubule of the nephron that sense the flow rate and osmolality
slightly different metabolic functions in the filtrate and send a message to the juxtaglomerular cells
to release more renin
J Maintenance dose amount of drug that keeps the plasma
drug concentration in the therapeutic range
Juxtaglomerular (JG) cells specialized smooth muscle cells Major depressive disorder a depressed mood lasting for a
found in the afferent arteriole that sense blood pressure and minimum of 2 weeks that is present for most of the day, every
release renin day, or almost every day
Malaria disease characterized by severe fever and chills
K caused by the protozoan Plasmodium
Malignant hyperthermia rare but potentially fatal condition
Kappa receptors one of two major receptors in the CNS that is an adverse effect of some general anesthetics;
where opioids act characterized by a rapid onset of extremely high fever with
Keratolytic action that promotes shedding of the outer layer muscle rigidity
of the epidermis Mania condition characterized by an inflated self-esteem,
decreased need for sleep or food, distractibility, increased
L activity, excessive pursuit of pleasurable activities, increased
talkativeness, delusions, paranoia, hallucinations, and bizarre
Laxatives drugs that promote defecation behavior
Lennox-Gastaut syndrome mixed seizure that has character-
istics of tonic–clonic, atonic, and atypical absence seizures
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