MILESTONE 3.25.23

A client is diagnosed with depression, and is prescribed amitriptyline hydrochloride. During the initial phases of treatment, the client care plan would include which nursing intervention?

• Obtain daily drug blood levels

• Provide the client with a tyramine-free diet

• Assess the client for anticholinergic effects

• Obtain postural blood pressure prior to each medication administration

Answer explanation

Amitriptyline hydrochloride is a tricyclic antidepressant. A common side effect is orthostatic blood pressure changes, which can produce hypotension and tachycardia.

 

The client may experience anticholinergic effects (sedation, dry mouth, constipation, and blurred vision), but they are transient and will diminish over time

A client is prescribed a monoamine oxidase inhibitor. What is the primary reason the nurse needs to assess this client closely?

• Risk of liver damage may be increased

• Bradycardia and hypotension may indicate toxicity

• Headache, hypertension, and nausea & vomiting may indicate toxicity

• Hypotensive crisis may be precipitated by foods rich in tyramine and tryptophan

Answer explanation

Headache, hypertension, tachycardia, nausea, and vomiting are precursors to hypertensive crisis brought about by the ingestion of foods rich in tyramine and tryptophan while the client is taking monoamine oxidase inhibitors (MAOIs)

A client's medication sheet contains a prescription for sertraline. To ensure safe administration of the medication, how would the nurse administer the dose?

• On an empty stomach

• At the same time each evening

• As needed when the client complains of depression.

• Evenly spaced around the clock

Answer explanation

Sertraline is classified as an antidepressant. Sertraline generally is administered once every 24 hours. It may be administered in the morning or evening, but evening administration may be preferable because drowsiness is a side effect.

When would the nurse advise a client being prescribed fluoxetine hydrochloride for depression to take the medication? (a)  

• Just before bedtime
• With the evening meal
• At noon with an antacid
• In the morning on first arising

Answer explanation

Fluoxetine hydrochloride is an antidepressant and is administered in the early morning for depression so that the client will experience an elevated mood during the daytime hours. In addition, fluoxetine can cause insomnia, so taking the medication early in the day will prevent interference with sleep.

The nurse is describing the medication side and adverse effects to a client who is taking amitriptyline. Which information would the nurse incorporate in the discussion?

• Consume a low-fiber diet

• Increase fluids & bulk in the diet

• Rest if the HR begins to beat rapidly

• Walk if you have difficulty urinating because this is a normal side effect

Answer explanation

Amitriptyline causes constipation, and the client is instructed to increase fluid intake and bulk (high fiber) in the diet. If the heart begins to beat fast, the primary health care provider (PHCP) is notified, because this could indicate an adverse effect. Difficulty urinating is an adverse effect and indicates urinary retention; this should also be reported.

The nurse has provided medication instructions to a client with an iron deficiency anemia who will be taking iron supplements. Which statement made by the client indicates an understanding of this medication?

• "I need to increase my fluid intake."

• "I need to eliminate fiber foods from my diet."

• "I need to take the medication with water before a meal."

• "I need to be sure to chew the tablet thoroughly before swallowing it."

Answer explanation

Iron preparations can be very irritating to the stomach and are best taken between meals. Because iron supplements may be associated with constipation, the client would increase fluids and fiber in the diet to counteract this side effect of therapy. Iron preparations need to be taken with a substance that is high in vitamin C to increase its absorption. The tablet is swallowed whole and not chewed.

A client with atrial fibrillation is receiving a continuous heparin infusion at 1000 units/hour. The nurse determines that the client is receiving the therapeutic effect based on which results?

• Prothrombin time of 12.5 seconds

• Activated partial thromboplastin time of 60 seconds

• Activated partial thromboplastin time of 28 seconds

• Activated partial thromboplastin time longer than 120 seconds

Answer explanation

Common laboratory ranges for activated partial thromboplastin time (aPTT) are 30 to 40 seconds. Because the aPTT would be 1.5 to 2.5 times the normal value, the client's aPTT would be considered therapeutic if it was 60 seconds. Prothrombin time assesses response to warfarin therapy.

The home care nurse instructs a client on how to administer enoxaparin subcutaneously. Which statement, if made by the client, indicates an understanding of how to administer this medication?

• "I need to hold my skin flat before I put the needle into my skin."

• "I need to massage the skin with the alcohol wipe after I give the injection."

• "A syringe that has a small 5/8 in (1.5 cm) needle is used to administer the injection."

• "I need to pull back on the syringe and aspirate before pushing the medication into my skin."

Answer explanation

A subcutaneous injection of enoxaparin is performed using the same technique as for a heparin injection. The client would use a 25- to 27-gauge, 5/8 in (1.5 cm) needle to prevent hematoma formation at the injection site. The client needs to be taught to bunch the skin rather than placing it flat. The client would not aspirate before injecting the medication and would not massage the area after injection.

A client in the hospital emergency department who received nitroglycerin for chest pain has obtained relief but now complains of a headache. The nurse would interpret that this client is most likely experiencing which condition?

• An allergic reaction to nitroglycerin

• An expected medication side effect

• An early sign of tolerance to the medication

• A warning that the medication should not be used again

Answer explanation

Headache is a frequent side effect of nitroglycerin, resulting from its vasodilator action. It often subsides as the client becomes accustomed to the medication, and it is effectively treated with acetaminophen. The other options are incorrect interpretations.

Acetylsalicylic acid (ASA), or aspirin, has been prescribed for a client with angina, and the client asks the nurse how the medication will help. The nurse responds that this medication has been prescribed for which purpose?

• To reduce pain

• To reduce inflammation

• To inhibit platelet aggregation

• To maintain a normal body temperature

Answer explanation

ASA is a nonsteroidal agent that is prescribed for its anti-inflammatory, antipyretic, and anticoagulant properties. All of the options identify actions of this medication; however, for the client with angina, this medication is prescribed to inhibit platelet aggregation.