LaCharity Exam 3 452: Neuro, Pharm, Cardiac, Immunity

The patient weighs 80 kg and is about to receive a potassium IV infusion of 10 mEq in 100 mL normal saline. For which finding must the nurse notify the health care provider before completing this prescribed action?

• The patient’s morning serum sodium level was 136 mEq/L.

• The patient’s urine output for the past 24 hours was 550 mL.

• The patient required placement of a new IV access this morning.

• Patient assessment revealed a positive Chvostek sign.

   

Answer explanation

Urine output should exceed 0.5 mL/kg/hr to prevent hyperkalemia. This patient's weight is 80 kg so he should minimally put out 40 mL of urine per hour. His total urine output for the past 24 hours was 550 mL, which equals around 22.9 mL/hr. The health care provider must be notified of this. The patient's sodium level is low normal, placement of a new IV would not interfere with giving the IV potassium, and a positive Chvostek sign is an indicator of hypoparathyroidism.

The nurse is caring for a patient newly diagnosed with hypertension. Blood pressure readings over the past 8 hours have been: 08:00 164/93 mm Hg, 12:00 158/90 mm Hg, and 16:00 166/94 mm Hg. The health care provider prescribes a no added salt diet and plans to start the patient on hydrochlorothiazide 25 mg. Which action is most important for the nurse to take before administering this drug?

• Check the patient’s serum potassium level.

• Review the patient’s urine output for the past 24 hours.

• Instruct the assistive personnel to check the orthostatic blood pressure.

• Check the patient’s cardiac monitor for abnormal heart rhythms.

Answer explanation

Hydrochlorothiazide is a thiazide diuretic often used to treat hypertension. An adverse effect of these diuretics is that when sodium (Na⁺) reabsorption is blocked by thiazide diuretics, this increases Na⁺ delivery to the cortical collecting duct and increases Na⁺ reabsorption in this segment of the nephron. Because Na⁺ reabsorption is coupled to potassium (K⁺) secretion in the cortical collecting duct, these drugs can lead to excessive K⁺ secretion and hypokalemia (where the K⁺ in extracellular fluid is too low). The same is true of loop diuretics (e.g., furosemide). Thiazide and loop diuretics may be combined with potassium-sparing diuretics (e.g., spironolactone) to counteract this possibility. The other actions are also appropriate for this patient but are not as urgent.

A 14-year-old child was recently diagnosed with type 1 diabetes. The patient is prescribed 10 units of regular insulin and 15 units of neutral protamine Hagedorn (NPH) insulin each morning. How should the nurse instruct this patient to give herself the prescribed doses of insulin?

• “First draw up and administer the NPH insulin. Wait at least 15 minutes, then draw up and administer the regular insulin.”

• “First draw up and administer the regular insulin, then draw up and administer the NPH insulin.”

• “First draw up the NPH insulin, then draw up the regular insulin in the same syringe.”

• “First draw up the regular insulin, then draw up the NPH insulin in the same syringe.”

Answer explanation

Remember Clear-Cloudy! Regular is clear, NPH cloudy

A patient is to receive metoprolol tartrate 5 mg IV to control high blood pressure. IV metoprolol tartrate is administered over 2 minutes. Based on the label for the medication, the nurse will administer? _______________ mL/min.

METOPROLOL TARTRATE INJECTION, USP 5 mg/5 mL (1 mg/mL) 5 mL SINGLE DOSE VIAL FOR IV USE Rx Only AMERICAN REGENT, INC. SHIRLEY, NY 11967 NDC 0517-1355-01 Each 5 mL contains: Metoprolol Tartrate 5 mg, Sodium Chloride 45 mg in Water for Injection q.s. PROTECT FROM LIGHT. Store at 20° to 25°C (68° to 77°F) (See USP Controlled Room Temperature). Usual Dosage: See Package Insert. Rev. 10/10

• 5 ml/min

• 2.5 ml/min

• 25 ml/min

• 10 ml/min

Answer explanation

5 mg in 5 mL = 5 mL / 2 min = 2.5 mL/min.

An older patient with chronic obstructive pulmonary disease is to be discharged with prescriptions for albuterol, which is a short-acting beta agonist (SABA), and salmeterol, which is a long-acting beta agonist (LABA) bronchodilator. Which statement by the patient indicates to the nurse that the patient requires additional teaching?

• “I will insert my inhaler into the spacer and shake the whole unit three or four times before taking my dose of the drug.”

•  “I will use my salmeterol whenever I become suddenly short of breath.”

• “I will wait at least 1 minute between the first and second puff of my inhaler.”

•  “I will check my pulse before and after using my bronchodilator inhaler.”

Answer explanation

Salmeterol is a LABA and is used to prevent episodes of shortness of breath. When a patient becomes suddenly short of breath, the drug of choice would be a SABA such as albuterol. Statements 1, 3, and 4 all demonstrate correct understanding of how to use an aerosol inhaler. An older adult may be more sensitive to the cardiac effects of these drugs and should check the heart rate before and after each dose.

The RN is supervising a student nurse caring for a patient with hypertension. The health care provider prescribed enalapril 2.5 mg orally twice a day. The student tells the nurse that the patient has swelling around the eyes and lips. What does the nurse tell the student is the first best action?

• Assess the patient's ability to speak and breathe.

• Apply ice to the patient's eyes and lips.

• Check the patient's white blood cell count.

• Check the patient's vital signs.

Answer explanation

Enalapril is an angiotensin-converting enzyme (ACE) inhibitor. Swelling of the eyes, mouth, and tongue may indicate angioedema, which is an adverse effect of ACE inhibitors. This can lead to swelling of the trachea, which interferes with breathing and can be life threatening. After the nurse assesses the patient's breathing, the health care provider should be notified. Ice may help reduce swelling but is not a priority at this time. Checking the white blood cell count, especially neutrophils, is important if neutropenia is suspected. Checking vital signs is a good idea but not the highest priority in this situation.

The nurse is providing patient teaching for an older adult about spironolactone. Which key points would the nurse include? Select all that apply.

• Avoid the use of salt substitutes.

• Do not consume excessive amounts of foods that are high in potassium.

• Be prepared for a decrease in your urine output.

• This drug works by conserving sodium and excreting potassium.

• Older adults may be more sensitive to the action of this drug.

  AND

  As an older adult, you are more likely to experience side effects from this drug.

Answer explanation

Spironolactone is a potassium-sparing diuretic, so patients should avoid excessive intake of foods high in potassium such as bananas, broccoli, and spinach. Salt substitutes should also be avoided because the sodium is replaced with potassium. Urine output should increase, not decrease. The drug works by increasing excretion of water and sodium, but not potassium, in urine. Older adults are more sensitive to the action of this drug and are also more likely to experience side effects.

A patient has been taking prednisone 20 mg orally each day for 10 days for a severe allergic skin reaction. The patient tells the nurse that she no longer needs to take the prednisone because she is feeling better and the reaction has cleared up. What is the nurse's best response?

• "After taking this drug for over 1 week, it must be slowly decreased to allow the adrenal glands to begin making cortisol."

• "When the health care provider (HCP) visits, I will ask if he will write an order prescribing that this drug be discontinued."

• "You may need to continue taking the prednisone for another week or two to be sure that the skin allergic reaction is under control."

• "Because you have taken prednisone for 10 days, it will be necessary for the HCP to order a topical form of the drug for use as needed."

Answer explanation

Prednisone is a corticosteroid drug that is similar to the natural cortisol secreted by the adrenal glands. The amount of cortisol made each day is influenced by the amount circulating in the blood. When a patient takes this drug, the adrenal glands reduce production of cortisol. After taking the drug for more than 1 week, it is necessary to taper the drug before stopping it to give the adrenal glands time to produce more cortisol. The HCP would not suddenly discontinue the drug or continue it at the same level when it is no longer needed. A topical form of the drug would not be needed.

The nurse is providing care for a patient with chronic kidney disease who receives hemodialysis 3 days a week. As the nurse prepares to administer the patient's dose of epoetin alfa subcutaneously, the patient asks why the shot is necessary. What is the nurse's best response?

• It will help stimulate production of white blood cells to protect you from infection."

• "It will help stimulate production of platelets to improve your ability to form clots."

• "It will help stimulate production of phagocytes to engulf and kill bacteria."

• "It will help stimulate production of red blood cells (RBCs) to increase your RBC count."

Answer explanation

Epoetin alfa is a colony-stimulating factor, an erythropoiesis-stimulating agent that helps stimulate production of RBCs, and is often used for patients who have chronic kidney disease, anemia from chemotherapy, or need to increase their RBC count before surgery. Another type of colony-stimulating factor is oprelvekin, a thrombopoiesis-stimulating agent that helps increase platelet counts. Both types of colony-stimulating factors are used to decrease the need for transfusion of blood and blood products.

The RN is preparing to administer drugs to a group of patients with gastrointestinal disorders. Which drug is most important to discuss with the health care provider before administering?

• Omeprazole for the patient with peptic ulcer disease (PUD)

• Famotidine for the patient with gastroesophageal reflux disease (GERD)

• Diphenoxylate with atropine for the patient with constipation

• Ondansetron for the patient with nausea because of chemotherapy

Answer explanation

Diphenoxylate with atropine is an antimotility drug commonly used to treat diarrhea. The actions of this drug would not relieve a patient's constipation but would likely make it much worse. Omeprazole is a proton pump inhibitor often used to treat PUD and GERD, famotidine is a histamine₂ blocker used to treat GERD and PUD, and ondansetron is a 5H3-receptor antagonist used to treat nausea caused by chemotherapy. Appropriate drugs to treat constipation include emollient stool softeners (e.g., docusate), stimulants (e.g., bisacodyl), and osmotic laxatives (e.g., lactulose).