Pharmacology

PHARMACOLOGY Pharmacology - most simply defined as study of drug. Fundamentals of Pharmacology 1. Pharmacokinetics - study of drug’s changes as it enters and passes through the body. a. absorption b. distribution c. biotransformation d. excretion 2. Pharmacodynamics - mechanism by which drugs produce changes in body tissue. a. desired effect - intended action of drugs b. adverse effect - harmful unintended reactions c. side effects – consequence reactions d. toxicity – the degree which something is poisonous digoxin = 0.5 – 2.0 ng/mL lithium = 0.5 – 1.5 mEq/L Safety and Efficacy Nursing Principles : 1. Always verify the Five Rights . a. the right medications b. the right client c. the right dosage d. the right form, route and technique e. the right time 2. Chart drug administration only after its been given, never before. 3. Never leave the medication on cart or tray unattended. 4. Chart observed therapeutic and adverse effects accurately and fully. 5. Check history for allergies and potential drug interactions before administering a newly ordered drug. 6. Inform the prescribing physician of any observed adverse effects; if cannot be located, inform the nursing supervisor 7. Question drug orders that are unclear, that appear to contain errors, or that have potential to harm. 8. Take the following actions if an error occurs : a. immediately notify the nursing supervisor, the prescribing physician, and the pharmacist. b. assess the client’s condition and provide any necessary care. 9. For postpartum women, advice to take drugs after breastfeeding. Administration of Drugs : Routes and Nursing considerations: 1. Enteral – oral, sublingual, rectal, gastric tubes

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- capsulated pill, sustained release and enteric coated should not be crushed. 2. Parenteral – IV, IM, SQ, ID, IT, IA, epidural. - vastus lateralis (safest site for IM) 3. Topical – skin, inhalants, mucus membrane. Eye medications : - administer eyedrops first then ointment. - use a separate bottle for each client. - instruct the client to tilt the head backward, open eyes and look up. - avoid contact of medication bottle to the eyeball. - place prescribed dose in the lower conjunctival sac. - instruct the client to press the inner canthus for 30-60 seconds. - instruct the client to close the eye gently. Ear drops - in infant and children younger than 3 y.o, pull pinna downward and backward. - in older children and adult, upward and backward. - direct the solution on the wall of the ear canal, not directly on the ear drum.

CLASSIFICATIONS OF DRUGS DRUGS AFFECTING THE CENTRAL AND AUTONOMIC SYSTEM Cholinergic Agents (Parasympathomemitics) Prototype : - synthetic acetylcholine, pilocarpine, carbachol, bethanecol (Urocholine), edrophonium (Tensilon), neostigmine (Prostigmine), pyridostigmine (Mestinon). Mechanism of action : - stimulates cholinergic receptors by mimicking acetylcholine or inhibition of enzyme cholinesterase. Indications : - glaucoma, urine retention, Myasthenia Gravis - antidote to neuromuscular blocking agents : tricyclic antidepressants and atropine Adverse effects : - blurring of vision, miosis - increase in salivation, intestinal cramps - bronchoconstriction, wheezing, DOB - hypotension and bradycardia Nursing considerations : 1. Warn & monitor clients of the side effects. 2. Have atropine available for use as antidote.

Cholinergic Blocking Agents (Parasympatholytics, Anticholinergics) Prototype : ______________________________________________________________

atropine, scopalamine (Triptone), dicyclomine (Bentyl), propantheline (Pro-Banthine). Mechanism of actions : - block the binding of acetylcholine in the receptors of parasympathetic nerves. Indications : - use preoperatively to dry up secretions. - treat spasticity of GI or urinary tract. - use for treatment of bradycardia, asthma, parkinsonism. - use for antidote in organophosphate poisoning. Adverse effects : - dry mouth , dilatation of pupils, tachycardia - urinary retention, ileus, heat stroke Nursing considerations : 1. Keep client’s in cool environment. 2. Watch out for signs of heatstroke and dehydration. 3. Encourage clients to increase fluid intake and use of sugarless gum/candy for dry mouth. 4. For GI spasticity, administer 30 minutes before meals and at bed time. -

Adrenergic Agents (Sympathomimetics) Prototype : - epinephrine, norepinephrine, ephedrine, dopamine, dobutamine, phenylephrine, terbutaline, albuterol, isoproterenol. Mechanism of actions : - stimulate alpha and beta adrenergic receptor directly or trigger the release of catecholamines indirectly causing sympathetic effects. Indications : - cardiopulmonary arrest, hypotension - COPD and asthma, nasal congestions - allergic reaction, anaphylactic shock Adverse effects : - restlessness, insomnia, tremors, nausea - palpitations, angina, tachycardia, HPN Nursing considerations : 1. Contraindicated in clients w/ hyperthyroidism, pheochromocytoma & cardiovascular disease. 2. Monitor vital signs and advice precautions. 3. Should be taken with food.

ADRENERGIC BLOCKING AGENTS Prototype : a. Alpha blockers - phentolamine (Regintine), phenoxybenzamine, prazosin (Minipress), reserpine (Serpasil), terazosin (Hytrin) - clonidine (Catapress), methyldopa (Aldomet) b. Beta blockers - atenolol (Tenormin), esmolol (Brevibloc), metoprolol (Lopressor), nadolol (Corgard), propanolol (Inderal), timolol ( Blocadren) Mechanism of actions : a. alpha blockers ______________________________________________________________

- inhibits action of a-receptors in vascular smooth muscle to cause vasodilatation. b. beta blockers - compete with epinephrine in b-receptors in heart, pulmonary airways, peripheral circulation and CNS. Indications : - Raynaud’s disease, hypertension, pheochromocytoma. - angina, arrhythmias, mitral valve prolapse, glaucoma Adverse effects : - orthostatic hypotension, bradycardia, CHF - depression, insomnia and vertigo - bronchospasm and dyspnea, nasal stuffiness, cold extremities Nursing considerations : 1. Administer oral alpha-blockers with milk to minimize GI side effects. 2. Administer oral beta-blockers before meals and at a.m. if insomnia occurs. 3. Check client’s apical pulse rate before drug administration, refer if below 60 bpm. 4. Hypotensive precautions. 5. Warn clients not to drive or operate dangerous machinery until he/she has adjusted to medications.

Skeletal Muscle Relaxants Agents Prototype : - methacarbamol (Robaxin), baclofen (Lioresal), dantrolene (Dantrium), metaxalone (Skelaxin), orphanedrine (Norgesic), chlorzoxazone Mechanism of actions: - depress CNS - inhibit calcium ion release in the muscle - enhance the inhibitory action of GABA (gamma-amino butyric acid) Indications : - for acute musculoskeletal pain - for muscle spasticity associated with multiple sclerosis, cerebral palsy, CVA, and spinal cord injury. Adverse effects : - hypotonia, ataxia, hypotension, drowsiness - blurred vision, bradycardia, depression, urine retention Nursing considerations : 1. Caution clients that mental alertness may be impaired. 2. Monitor neuromuscular status, bowel and bladder functions. 3. Inform clients that maximum benefit of baclofen is attained for 1-2 months. 4. Reduce baclofen dosage gradually because of associated withdrawal symptoms : Confusion, hallucinations, paranoia & rebound spasticity.

ANTICONVULSANTS ______________________________________________________________

Prototype : a. Hydantoins - phenytoin (Dilantin) b. Barbiturates - phenobarbital ( Luminal) c. Miscellaneous - carbamazepine (Tegretol), diazepam, clorazepate (Tranxene), valproic acid (Dapakene), ethosuximide (Zarontin). Mechanism of action : - treat seizures by depressing abnormal neuronal activity in motor cortex. Adverse effects : - sedation & drowsiness, gingival hyperplasia - diplopia, nystagmus, vertigo, dizziness - thrombocytopenia, aplastic anemia Nursing considerations : 1. Advise female clients to use contraceptives. 2. Inform clients taking phenytoin that harmless urine discoloration is common. 3. Warn clients with diabetes that hydantoins may increase blood sugar level and that valproic acid may produce a false positive result in urine ketone test. 4. Teach clients receiving carbamazepine to identify symptoms of bone marrow depressions. 5. Reassure that barbiturates are not addictive at a low dosage. 6. Avoid taking alcohol with barbiturates. 7. Administer IV phenytoin slowly to avoid cardiotoxicity. 8. Avoid mixing other drugs in same syringe with phenytoin.

ANTIPARKINSONIAN AGENTS

Prototype : a. Anticholinergic agents - trihexyphenidyl (Artane), benztropine (Congentin) b. Dopaminergic agents - Levodopa, carbidopa-levodopa (Sinemet), amantidine (Symmetrel), pergolide (Permax), selegiline (Eldepryl), bromocriptine. Mechanism of actions : a. anticholinergic agents - inhibit cerebral motor centers. b. dopaminergic agents - increasing dopamine concentrations or enhancing neurotransmitter functioning. Adverse effects of dopaminergic agents: a. levodopa – nausea, vomiting, anorexia, orthostatic hypotension, dark-colored urine and sweat b. amantidine – ankle edema, constipation c. bromocriptine – palpitations, tachycardia Nursing considerations : 1. Give dopaminergic agents after meals to reduce GI symptoms. ______________________________________________________________

2. Reassure client that levodopa may cause harmless darkening of urine and sweat. 3. Avoid taking Vit B6 (pyridoxine) with levodopa because it speed up metabolism. 4. Educate clients to minimize orthostatic hypotension. 5. Elevate leg to reduce ankle edema.

CENTRAL NERVOUS SYSTEM STIMULANTS Prototype : - amphetamines, methylphenidate (Ritalin) Mechanism of actions : - increase excitatory CNS neurotransmitter activity and blocks inhibitory impulses. Indications : - for obesity (amphetamines) - attention deficit hyperactivity disorders - narcolepsy - drug-induced respiratory depressions. Adverse effects : - nervousness, insomnia, restlessness - hypertension, tachycardia, headache - anorexia, dry mouth. Nursing considerations : 1. Should be given at morning. 2. Don’t stop amphetamine abruptly to avoid withdrawal symptoms. 3. Monitor blood pressure and pulse. 4. Ice chips or sugarless gum for dry mouth. 5. Watch out for growth retardation in children taking methylphenidate.

DRUGS AFFECTING MENTAL FUNCTIONING Sedatives, Hypnotics, and Anxiolytics Prototype : a. Benzodiazepines - diazepam (Valium), lorazipam (Ativan), alprazolam (Xanax), flurazepam (Dalmane) b. Barbiturates - amobarbital, phenobarbital, secobarbital c. Miscellaneous - chloral hydrate (Noctec), buspirone (Buspar), paraldehyde (Paral) Mechanism of actions : a. Benzodiazepines - increase the effect of inhibitory neuro transmitter GABA (gamma-amino butyric acid) b. Barbiturates and Miscellaneous agents - depress CNS Indications : - induce sleep, sedate and calm clients Adverse effects : - hangover-effect, dizziness, CNS depression - respiratory depression, drug-dependence Nursing considerations : ______________________________________________________________

1. Warn clients of injuries and falls. 2. Brief period of confusion and excitement upon waking up is common with benzodiazepines. 3. Warn clients not to discontinue medications abruptly without consulting a physician. 4. Avoid alcohol while taking these drugs. 6. Rotate and don’t shake the ampules of barbiturates. Don’t mix with other drugs. 7. Warn female clients that diazepam is associated with cleft lip.

ANTIDEPRESSANTS AND MOOD DISORDER DRUGS Prototype : a. Tricyclic antidepressants - amitriptyline (Elavil), protriptyline (Vivactil), - imipramine (Tofranil), desipramine b. MAO (monoamine oxidase inhibitors ) - isocarboxazid (Marplan), phenelzine (Nardil), tranylcypromine (Pernate) c. Second-generation antidepressants - fluoxetine (Prozac), trazodone (Desyrel) d. Lithium Mechanism of actions : a. Tricyclic antidepressants - increase receptor sensitivity to serotonin and/or norepinephrine. b. MAO inhibitors - inhibit the enzyme MAO that metabolize the neurotransmitters norepinephrine and serotonin. c. Second – generation antidepressants - inhibits the reuptake of serotonin. d. Lithium - increase serotonin & norepinephrine uptake Adverse effects : - dry mouth, blurred vision, urine retention, constipation (anticholinergic effects) - orthostatic hypotension, insomnia - hypertensive crisis (MAO) - dehydration (Lithium). Nursing considerations : 1. Caution client to rise slowly to reduce the effects of orthostatic hypotension. 2. Take antidepressant with food to enhance absorption 3. Explain to client that full response may take several weeks (2 weeks). 4. Assess client for constipation resulting from tricyclic antidepressant use. 5. Client taking MAO inhibitors should avoid tyramine-rich foods to avoid hypertensive crisis. - aged cheese, sour cream, yogurt, beer, wine, chocolate, soy sauce and yeast - pentholamine (Regintine) is the drug of choice for hypertensive crisis. ______________________________________________________________

6. Inform physician and withhold fluoxetine if client develop rashes. 7. Take lithium with food to reduce GI effects - > 1.5 mEq/L blood level may cause toxicity manifested by: confusion, lethargy, seizures,hyperreflexia. - maintain salt and adequate fluid intake - tremors may occur but it is temporary - monitor white blood cell count (increase).

ANTIPSYCHOTIC DRUGS (NEUROLEPTICS) Prototype : a. Phenothiazines - chlorpromazine (Thorazine), - trifluoperazine (Stelazine), - thioridazine (Mellaril) b. Other Agents - clozapine (Clozaril), haloperidol (Haldol) Mechanism of action : - block dopamine receptor in the limbic system, hypothalamus, and other regions of the brain. Adverse effects : - Extra pyramidal symptoms such as dystonia, pseudoparkinsonism, and an irreversible tardive dyskinesia as manifested by : a. lip smacking b. fine wormlike tongue movement c. involuntary movements of arms and leg. - Neuroleptic malignant syndrome a. fever, tachycardia, tachypnea, diaphoresis, cardiovascular collapse b. muscle rigidity, seizures. - orthostatic hypotension Nursing considerations : 1. Teach family members the signs of EPS and NMS, and report to physician immediately. 2. Normalization of symptoms may not occur for several weeks after beginning of therapy . 3. Avoid administering haloperidol intravenously 4. Watch out of neutropenia with clozapine. 5. Watch out for orthostatic hypotension and photosensitivity with phenothiazine. 6. Be sure that oral doses are swallowed, and not hoarded.

DRUGS USED IN PAIN

MANAGEMENT

General Anesthetics Prototype : a. Inhalation anesthetics - enflurane (Ethrane), halothane - isoflurane (Forane), nitrous oxide b. Injection anesthetics - fentanyl (Sublimaze), ketamine (Ketalar), thiopental Na (Penthotal), etomidate (Amidate) Mechanism of actions : ______________________________________________________________

- cause CNS depression, by producing loss of consciousness, unresponsiveness to pain stimuli, and muscle relaxation. Nursing considerations : 1. Instruct client NPO for 8 hours before administration. 2. Monitor cardio pulmonary depression and hypotension. 3. Monitor urinary retention. 4. Monitor body temperature - malignant hyperthermic crisis : dantrolene (antidote) 5. Avoid alcohol or CNS depressants for 24 hours after anesthesia. 6. In patient who received halothane, monitor signs of hepatic fatal side effects : - rash, fever, nausea, vomiting - jaundice and altered liver function.

LOCAL AND TOPICAL ANESTHETIC Prototype : local : bupivacaine, lidocaine, tetracaine, procaine, mepivacaine, prilocaine topical : benzocaine, butacaine, dibucaine,lignocaine Mechanism of action : - block transmission of impulses across nerve cell membrane. Adverse effects : - cardiac dysrhythmias Nursing considerations : - lignocaine + prilocaine (EMLA cream) should be applied topically 60 minutes before procedure. - administer cautiously to the areas of large broken skin. - observe for fetal bradycardia in pregnant clients.

ANALGESICS Prototype : a. Narcotic analgesics - codeine, meperidine (Demerol) morphine, butorphanol (Stadol) nalbuphine (Nubain) b. Non – narcotic analgesic NSAIDs – aspirin (aminosalicylic acid), mefenamic acid (Ponstan), ibuprofen (Motrin), naproxen, ketoprofen (Orudis), ketorolac. paracetamol and acetaminophen (Tylenol) Mechanism of actions : a. Narcotic analgesics - alter pain perception by binding to opiod receptors in CNS. b. Non- narcotic analgesic - relieves pain and fever by inhibiting the prostaglandin pathway. Nursing considerations : 1. Monitor respiratory depression & hypotension in clients taking narcotic analgesic. 2. Injury and accident precautions in clients taking narcotic analgesic. 3. Warn clients about possibility of dependency,and do not discontinue narcotics ______________________________________________________________

abruptly in the narcotic-dependent clients. 4. Naloxone is antidote for narcotic overdose. 5. Advice clients to take NSAIDs with food and monitor bleeding complications. 6. Aspirin is contraindicated in clients below 18 years old with flu-like symptoms. 7. Monitor hearing loss in clients taking aspirin. 8. Monitor liver function in clients taking acetaminophen. 9. N-acetylcysteine is antidote for paracetamol overdose.

DRUGS AFFECTING THE CARDIOVASCULAR

SYSTEM

ANTICOAGULANTS Prototype : - Heparin (SQ and IV) Warfarin (Orally) Mechanism of actions : a. Heparin - prevents thrombin from converting fibrinogen to fibrin. b. Warfarin - suppress coagulation by acting as an antagonist of vitamin K after 4-5 days. Indications : - thrombosis, pulmonary embolism, myocardial infarction Adverse effect : - bleeding Nursing considerations : 1. HEPARIN sodium - if given SQ don’t aspirate or rub the injection site (above the scapula - best site). - therapeutic level 1.5-2.5 times normal PTT; normal PTT is 20-35 sec. = 50-85 sec. - antidote : (protamine sulfate) 2. WARFARIN sodium (coumadin) - warfarin is used for long-term .

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HEMOSTASIS : Bleeding/injury I Vasoconstriction Plasminogen I I Platelet aggregation Plasmin ( temporary plug) I I I Clotting factor activation -------------I I I I Intrinsic pathway (8,9,10,11,12) Extrinsic pathway (3,7,10) I (PTT ) (PT) Vit K dep. I I I I I Prothrombin activation I I I I Thrombin I I I Fibrinogen ------------Fibrin threads ------------- Fibrin split products (coagulation) ( Removed by liver & spleen )

- onset of action is 4-5 days. - therapeutic level is 1.5-2.5 times normal PT; normal PT = 9.6 -11.8 sec. = 25 - 30 sec. INR = 2 - 3 - should be taken at the same time of the day to maintain at therapeutic level. - reduce intake of green leafy vegetables. - antidote : Vitamin K ( Aquamephyton)

THROMBOLYTICS Prototype : Streptokinase, Urokinase Mechanism of actions : - activates plasminogen to generates plasmin (enzyme that dissolve clots). Indications : - use early in the course of MI (within 4-6 hours of the onset) Nursing considerations : - monitor bleeding - antidote : Aminocarpic acid Antiplatelet Medications Prototype: aspirin, Dipyridamole (Persantin) Clopidoigrel (Plavix), Ticlopidine Mechanism of action : - inhibit the aggregation of platelet thereby prolonging bleeding time. Indications : - used in the prophylaxis of long-term complication following M.I, coronary revascularization, and thrombotic CVA. Nursing considerations : ______________________________________________________________

- Monitor bleeding time ( NV = 1-9 mins) - Take the medication with food.

CARDIAC GLYCOSIDES Prototype: - digoxin (Lanoxin) and digitoxin (Crystodigin) Mechanism of actions : - increase intracellular calcium, which causes the heart muscle fibers to contract more efficiently, producing positive inotropic & negative chronotropic action. Indications : - use for CHF, atrial tachycardia and fibrillation Nursing considerations : - Monitor for toxicity as evidence by : nausea, vomiting, anorexia, halo vision, confusion, bradycardia and heart blocks . - Do not administer if pulse is less than 60 bpm. - Should be caution in patient with hypothyroidism and hypokalemia. - Antidote : Digi-bind - Phenytoin is the drug of choice to manage digitalis-induced arrhythmia. Nitrates Prototype : - isosorbide dinitrate (Isordil) - nitroglycerine (Deponit, Nitrostat) Mechanism of action : - produce vasodilatation including coronary artery. Indications : - angina pectoris, MI, peripheral arterial occlusive disease. Adverse effects: - headache, orthostatic hypotension . Nursing Considerations : 1. Transdermal patch - apply the patch to a hairless area using a new patch and different site each day. - remove the patch after 12-24 hours, allowing 10-12 hours “patch free” each day to prevent tolerance. 2. Sublingual medications : - note the BP before giving the medication. - offer sips of water before giving because dryness may inhibit absorption. - one tablet for pain and repeat every 5 mins. for a total of three doses; if not relieved after 15 mins., seek medical help. - stinging or burning sensation indicates that the tablet is fresh. - instruct patient not to swallow the pill - sustained release medications should be swallowed and not to be crush. - protect the pills from light.

ANTI-ARRHYTHMIC DRUGS Class I (block Na channels) ______________________________________________________________

IA - quinidine, procainamide IB - lidocaine IC - flecainamide Class II (Beta-blockers) propanolol, esmolol Class III (block K channels) amiodarone, bretylium Class IV (block Ca channels) verapramil, diltiazem Nursing considerations : 1. Watch out for signs of CHF. 2. Have client weigh themselves and report weight gain. 3. Watch out for signs of lidocaine toxicity : - confusion and restlessness

ANTILIPEMICS Prototype : a. cholesterol-lowering agents - cholestyramine, colestipol, lovastatin b. triglyceride-lowering agents - gemfibrozil, clofibrate Mechanism of actions : - interfere with cholesterol synthesis as well as decreasing lipoprotein & triglyceride synthesis. Nursing considerations : - monitor liver functions while using statins. - prevent constipation, flatulence, cholelithiasis - encourage increase fluid and fiber intake.

ANTI – HYPERTENSIVE Angiotensin-Converting Enzyme (ACE) Inhibitors Prototype : captopril (Capoten), enalapril (Vasotec), quinapril, lisinopril Mechanism of actions : - prevent peripheral vasoconstriction by blocking conversion of angiotensin I to angiotensin II decreasing peripheral resistance. Adverse effect : - it cause hyperkalemia - induce chronic cough Nursing considerations : - not to discontinue medications because it can cause rebound hypertension. - avoid using K+ sparing diuretics.

CALCIUM-CHANNEL BLOCKERS Prototype : - Nifedipine (calcibloc, adalat), Amlodipine (norvasc), Felodipine (Plendil) Verapramil (Isoptin) Mechanism of action : - decrease cardiac contractility and the workload of the heart, thus decreasing the ______________________________________________________________

need for O2. - it also promote vasodilatation of the coronary and peripheral vessels. Indications : - hypertension, angina, arrhythmia Adverse effects : - bradycardia, hypotension, headache - reflex tachycardia, constipation Nursing considerations : - Administer between meals to enhance absorption. - Take client’s pulse rate before each dose, withhold if pulse is below 60 bpm. - Refer for signs of congestive heart failure.

DIURETICS - usually given at morning CARBONIC ANHYDRASE INHIBITORS - Acetazolimide (Diamox) - increase Na+, K+, & HCO3 secretion, along with it is H2O - metabolic acidosis OSMOTIC DIURETIC - Mannitol - Increase osmotic pressure of the glomerular filtrate. - hypotension THIAZIDE DIURETICS - hydrochlorothiazide - blocks Na and K reabsorption; reabsorb Ca - hypercalcemia LOOP DIURETICS - Furosemide (Lasix) - blocks Na, K, and Ca reabsorption - hypocalcemia POTASSIUM SPARING DIURETICS - Spironolactone (Aldactone) - excrete Na and water but it reabsorb K - hyperkalemia

RESPIRATORY MEDICATIONS Bronchodilators Prototype : Symphatomimetic Xanthines - albuterol, salbutamol - aminophylline - isoproterenol, salmeterol - theophylline - terbutaline Mechanism of actions: - sympathomimetic (b-receptor agonist) bronchodilators, dilate airways. - xanthine bronchodilators, stimulate CNS for respiration. ______________________________________________________________

Indications : - bronchospasm, asthma, bronchitis, COPD. Adverse effects : - palpitations and tachycardia - restlessness, nervousness, tremors - anorexia, nausea and vomiting, headache, dizziness. Nursing considerations : - Contraindicated hyperthyroidism, cardiac dysrhythmia, or uncontrolled seizure disorder. - Should be used with caution in patient with HPN and narrow-angle glaucoma.

GLUCOCORTICOIDS (CORTICOSTEROIDS) Prototype : - dexamethasone, budesonide, fluticasone, prednisone, beclomethasone. Mechanism of actions : - act as anti-inflammatory agents and reduce edema of the airways, as well as pulmonary edema. Adverse effects : - Cushing’s syndrome, neutropenia. osteoporosis Nursing considerations : - Take drugs at meal time or with food. - Eat foods high in potassium, low in sodium. - Instruct client to avoid individuals with RTI. - Instruct client not to stop medication abruptly, it should be tapered to prevent adrenal insufficiency - Avoid taking NSAID while taking steroids. - Take inhaled bronchodilators first before taking inhaled steroids, and rinse mouth after using.

MAST CELL STABILIZERS Prototype : cromolyn sodium (Intal) Mechanism of action : - stabilize mast cells that release histamine triggering asthmatic attacks. Nursing Consideration: - Should be given before asthmatic attacks. - Administer oral capsule at least 30 mins before meals for better absorption. - Drink a few sips of water before & after inhalation to prevent cough & unpleasant taste - Assess for lactose-intolerance.

ANTI-HISTAMINES (H-1 BLOCKERS) Protoytype : - Astemizole (Hismanal), Loratidine (Claritin), ______________________________________________________________

Brompheniramine (Dimetapp), Diphenhydramine (Benadryl), Cetirizine (Iterax), Celestamine (Tavist). Mechanism of action : - decrease nasopharyngeal secretions and decrease nasal itching by blocking histamine in H1-receptor. Indications : - common colds, rhinitis, nausea and vomiting, urticaria, allergies and as sleep aid. Nursing Considerations : - Administer with food and drink. - Given IM via Z-track method or orally. - Precautions in handling machine and driving while taking these drugs. - Ice chips or candy for dry mouth

ANTI-TUBERCULOSIS Prototype : First line - Isoniazid (INH) - Rifampicin (Rifadin) - Ethambutol - Pyrazinamide - Streptomycin

Second line - Cycloserine - Kanamycin - Ethonamide - Para-aminosalicylic acid

- active tuberculosis are treated with drug combination for 6-9 mos. - multidrug-resistant strain (MDR-TB) are medicated for 1 year up to 2 years - given before meals Isoniazid - should be given 1 hr before or 2 hrs after meals because food may delay absorption. - should be given at least 1 hr before antacids. - instruct to notify physician for signs of hepatoxicity (jaundice), and neurotoxicity numbness of extremities. - administer with Vitamin B6 to counteract the neurotoxic side effects. - avoid alcohol. Rifampicin - given on an empty stomach with 8 0z. of water, 1 hour before or 2 hours after meals and avoid taking antacids with medications. - hepatotoxic thus avoid alcohol. - instruct the client that urine, feces, sweat, and tears will be redorange in color. Pyrazinamide - given for 2 months. - increase serum uric acid and cause photosensitivity. ______________________________________________________________

Ethambutol - contraindicated in children under 13 years old. - obtain a baseline visual acuity because it can cause optic neuritis. - Instruct the client to notify the physician immediately if any visual problems occurs. Streptomycin - aminoglycoside antibiotic given IM. - nephrotoxic and ototoxic. - obtain baseline audiometric test and repeat every 1-2 months because the medications impairs the CN VIII.

DRUGS AFFECTING GASTROINTESTINAL SYSTEM Antacids Prototype : - aluminum/magnesium compounds (Maalox) - sodium bicarbonate (Alka-Seltzer) - calcium carbonate (Tums) - magnesium hydroxide (Milk of Magnesia). Mechanism of actions : - neutralize the stomach acidity. Adverse effects : - metabolic alkalosis, stone formation - electrolyte imbalance - diarrhea (magnesium), constipation (aluminum). Nursing considerations : - Give 1 hr after meals. - Avoid giving medications within 1-2 hrs of antacid administration (decreases absorption). - Take fluids to flush after intake of antacid suspensions. - Monitor for changes of bowel patterns.

HISTAMINE – 2 BLOCKERS Prototype : - cimetidine (Tagamet), ranitidine (Zantac), famotidine (Pepcid), nizatidine (Axid). Mechanism of action: - blocks H2 receptors in the stomach, reducing acid secretions. Nursing considerations : - Given before or with meals - Avoid giving other drugs with cimetidine - Gynecomastia may developed with chronic use of cimetidine.

Proton – Pump Inhibitors (PPI) Prototype : - omeprazole (Losec), Lansoprazole (Lanz), pantoprazole (Pantoloc). Mechanism of action : - inhibit the proton H+ to combine with Cl- toform hydrochloric acid. ______________________________________________________________

Nursing considerations : - Given before meals preferably at morning. Mucosal Barriers Prototype : - sucralfate (Carafate), misoprostol (Cytotec). Mechanism of action : - coats the mucosa to prevent ulcerations. Nursing consideration : - Given before meals. - Misoprostol is contraindicated for pregnants. - Sucralfate cause constipation. Anti-diarrheal Agents Prototype : - diphenoxylate (Lomotil), loperamide (Imodium), kaolin/pectin mixture (Kaopectate). Mechanism of actions : - decrease stomach motility and peristalsis. Nursing considerations : - Monitor for rebound constipation. - Be cautious taking if with infectious diarrhea. - Monitor atropine toxicity with diphenoxylate. - Clay, white or pale stool is common with kaopectate. Laxatives a. lactulose (Cephulac), Na biphosphate (Fleet enema) & magnesium salt (Milk of Magnesia) - retain fluid and distend intestine b. ducosate (Dialose) - emulsify fecal fat and water c. bisacodyl (Dulcolax) & senna (X-prep) - irritates intestinal mucosa and stimulate intestinal smooth muscles d. bulk-forming laxative (Metamucil) - increase fecal bulk and water content e. mineral oil - lubricates & prevent colon absorption

EMETICS Prototype : ipecac syrup, apomorphine Mechanism of actions : - induce vomiting through stimulation of vomiting center of medulla. Indications : - ingestion of poisonous or toxic substances. Nursing considerations : - Consult poison control center before induction of vomiting. - Administer ipecac syrup with large amount of fluid.

DRUGS AFFECTING THE

ENDOCRINE SYSTEM

THYROID AGENTS ______________________________________________________________

Prototype : - Proloid (thryroglobulin ) - Synthroid (levothyroxine) - Cytomel ( liothyronine). Mechanism of action : - function as natural or synthetic hormones. Nursing considerations : - Taken in the morning. - Caution with coronary artery disease. - Monitor for signs of hyperthyroidism and refer for decreasing the dose.

PARATHYROID AGENTS Prototype : a. calcitonin (Calcimar), etidronate (Didronel), b. calcitrol (Rocaltrol), calcifediol (Calcedrol) Mechanism of action : a. reduce bone resorption b. promotes calcium absorption Nursing considerations : - Monitor signs of calcium imbalance - Report for bone pains. - Remain sitting upright after taking etidronate.

Oral Hypoglycemic Agents (OHA) 1. Sulfonylureas - stimulate insulin secretions and increase tissue sensitivity to insulin. First Generation : Chlorpropamide (Diabenese) - disulfiram precautions Tolbutamide (Orinase) - congenital defect Second Generation : Glypizide, Glymepiride 2. Biguanides - facilitates insulin action on the peripheral receptor site. Metformin and Glucophage (Glucovance) - side effect is lactic acidosis 3. Alpha-glucosidase inhibitors ______________________________________________________________

- delay carbohydrate absorption in the intestinal system. Acarbose (Precose) – side effect is diarrhea 4. Thiazolinidine - increase tissue sensitivity of insulin. Rosiglitazone (Avandia) 5. Meglitinides - stimulate insulin release in pancreatic B-cells. Repaglinide (Prandin) Nursing considerations : - Effective only for type II DM. - Contraindicated to pregnant & breastfeeding. - Given before meals. - Monitor for signs of hypoglycemia.

Insulin Insulin

Onset

Peak

Duration

Immediate-acting 0.15h 0.5–1h 5 h (lispro) Short-acting 0.5-1 h 2-4 h 5-7h (regular, semilente) Intermediate-acting 1-3 h 6-12 h 18-24 h (NPH, lente) Long-acting 4-6h 10-30 h 24-36 h (ultralente) Mixed 0.5 h 4-8 h 25 h (regular 30%, NPH 70%) Nursing considerations : - Usually given before meals. - Roll the bottle in palm of hands, don’t shake. - Inject amount of air that is equal to each dose into the bottle – short acting last (clear). - Aspirate short acting first, then long or intermediate (cloudy). - Alcohol is recommended for cleansing bottle but not with skin. - Pinch skin, avoid I.M, don’t aspirate. - Rotate the injection site an inch a part. - Prefilled syringes are stored vertically, needle-up. - May increase dose during illnesses. - Used bottles stored in room temperature, unused bottle stored in refrigerator. - Monitor for acute hypoglycemia : a. 3-4 commercially prepared glucose tablet b. 4-6 ounce of fruit juice or regular soda c. 2-3 teaspoon or honey d. Glucagon 1 gm SQ or IM e. D50-50 IV.

ESTROGENS AND PROGESTINS Prototype : ______________________________________________________________

- conjugated estrogen (Premarin), estrone (Bestrone), estradiol (Estrace), diethylstilbestrol (DES). Indications : - prostate cancer, contraceptions - estrogen replacement Adverse effects : estrogen - endometrial CA, gallbladder disease, HPN, migraine, breast tenderness progesterone - altered menstrual flow, risk of thrombo embolism Nursing considerations : 1. Mix estrogen or progestins prior to IM administration by rolling vials between palms. 2. Monitor blood pressure 3. Teach patient how to perform BSE. 4. Regular follow-up examination is required to detect associated risk of acquiring CA

DRUGS AFFECTING LABOR and LACTATION Uterine Stimulating Agents Protoytpe : a. Oxytocin (Pitocin), ergonovine (Ergotrate), methylergonovine (methergine) b. carbopost (Prostin), dinoprostone (Prostin E2) Mechanism of actions : a. stimulates uterine smooth muscles b. ripening of cervix Adverse reactions : - fetal bradycardia (oxytocin), - hypertension (ergonovine), palpitations - allergic reactions (Prostaglandins)

Uterine Inhibiting Agents (Tocolytic) Prototype : - ritodrine (Yutopar), terbutaline (Brethine) Mechanism of actions : - relaxes the uterus by stimulating the B2- adrenergic receptors Adverse effects : - tremors, nausea, vomiting and tachycardia

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Lactation Suppressants Prototype : - bromocriptine (Parlodel) Mechanism of action : - decrease serum prolactin levels Adverse effects : - drowsiness, headache, nausea, palpitations

DRUGS FOR TREATING INFECTION Antibacterial Agents 1. Cell wall inhibitors a. penicillins - pen G, amoxicillin, cloxacillin b. cephalosphorins - cephalexin, cefaclor c. glycopeptide - vancomycin 2. Protein synthesis inhibitors a. aminoglycosides - amikacin, gentamycin b. macrolide - erythromycins, roxithromycin c. lincosamides - clindamycins d. chloramphenicol, tetracyclines 3. Antimetabolites - blocks folic acid synthesis a. Sulfonamides - cotrimoxazole 4. DNA synthesis inhibitors a. quinolones - ciprofloxacin, ofloxacin b. metronidazole Adverse effects : 1. Aminoglycoside - nephrotoxicity & ototoxicity 2. Sulfonamides - Steven-Johnson’s syndrome, photosynsetivity 3. Quinolones - insomnia 4. Tetracyclines - bone problems 5. Chloramphenicol - Gray syndrome, bone marrow depression 6. Erythromycin - hepatitis Nursing considerations : 1. Collect appropriate specimen for C & S before starting antibiotics. 2. Check client’s history of allergies. 3. Avoid administering erythromycin and quinolones with food. 4. Pregnant precautions. 5. Report for diarrhea - pseudomembranous colitis (clindamycin) 6. Monitor adverse effects. Antiviral Agents Prototype : - acyclovir (Zovirax), ganciclovir (Cytovene), vidarabine (Vira-A), amantidine (Symmetrel), ribavirin (Virazole), zidovidine (Retrovir). Mechanism of actions : - inhibits virus specific enzymes involve in DNA synthesis. They only control the growth of virus but it does not cure. Adverse effects : - granulocytopenia, thrombocytopenia, nausea, nervousness, headache, nephrotoxicity. ______________________________________________________________

Nursing consideration : - Pregnant and breastfeeding precautions. - Administer IV antivirals to avoid crystallization in renal tubules. - Give ribavirin only with aerosol generator. - Monitor CBC and creatinine level. - Refer for signs of bleeding. - Take amantidine after meals. Antifungal Agents Prototype : - amphotericin B (Fungisone), nystatin, fluconazole (Diflucan), ketoconazole (Nizoral). Mechanism of actions : - inhibit the synthesis of fungal sterol. Adverse effects : - nephrotoxicity and neurotoxicity - bone marrow depression - chills, fever, joint pains, abdominal pain and headache. Nursing considerations : - Dilute amphotericin B with sterile water solution not with electrolyte solution. - Tell clients that fever, chills, GI upset, joint and muscle pain will subside as amphotericin B continues. - With oral candidiasis, let nystatin tablet dissolve in mouth rather than swallowing it. - Refrain ketoconazole with antacids. - Report for signs of bleeding, infection & fatigue.

ANTIPARASITIC AGENTS Prototype : a. Antimalarial - chlroquine, mefloquine, primaquine, quinine, pyrimethamine b. Antiamebiasis - metronidazole (Flagyl), iodoquinol, furozolidone (Furoxone). Mechanism of actions : a. antimalarial – alters protozoal DNA, depleting folates, & reducing nucleic acid production b. antiamoeba – block protein synthesis. Nursing considerations : 1. Administer anti-malarial drugs with food. 2. Take seizure precautions while administering antimalarial drugs. 3. Refer cinchonism during quinine treatment: - tinnitus, headache, vertigo, fever, and visual changes. 4. Inform clients that iodoquinol falsify thyroid function test for up to 6 months.

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ANTIHELMINTIC Prototype : - mebendazole (Vermox), thiabendazole, niclosamide (Niclocide), piperazine (Antepar), praziquantel (Biltricide). Mechanism of actions : - paralyze larva and adult helmints by acting on parasite microtubules. Adverse effects : - GI upset, urinary odor (thiabendazole) - headache, dizziness, fatigue Nursing considerations : 1. Treat all the family members for nematodes infection to prevent recurrence. 2. Praziquantel must swallowed rapidly because of its bitter taste to avoid gagging. 3. Other antihelmintics should be chewed.

ANTI-NEOPLASTIC DRUGS General considerations : - kills or inhibit the reproduction of neoplasmic cells but as well as normal cells. - it could be cell cycle phase specific or cell cycle non-specific. - preferably given through IV route. Prototype : 1. Alkylating Agents - inhibits cell production by causing cross linking of DNA a. Busulfan – hyperuricemia b. Chlorambucil – gonadal suppression c. Cisplatin – ototoxicity and nephrotoxicity d. Cyclophosphamide – hemorrhagic cystitis. 2. Antitumor Antibiotic Agents - interfere in DNA and RNA synthesis a. Plicamycin – affects bleeding time b. Doxurubicin – cardiotoxicity c. Bleomycin – pulmonary toxicity. 3. Antimetabolites - replace normal proteins required for DNA synthesis by inhibiting the S phase a. Cytarabine – hepatotoxicity b. 5-flourouracil – phototoxicity reaction and cerebellar dysfunctions c. 6-marcaptopurine – hyperuricemia d. Methotrexate – photosensitivity - given with leucoverin to lessen its toxicity. 4. Mitotic Inhibitors (Vinca Alkaloids) - prevent mitosis acting on the M phase causing cell death a. Vincristine sulfate – neurotoxicity, numbness 5. Hormonal Medications and Enzymes ______________________________________________________________

- block the normal hormones in hormone sensitive tumors a. Tamoxifen citrate – visual problems – elevate cholesterol & triglycerides level b. Diethylstilbestrol – impotence and gynecomastia in men. Side Effects: stomatitis - bland diet, avoid strong mouthwash - soft tooth brush, ice chips diarrhea, nausea and vomiting - anti-emetic, replace fluids and electrolytes alopecia - reassure that it is temporary - encourage o wear wigs, hats and head scarf skin pigmentation - inform that it is only temporary tumor lysis syndrome - hyperuricemia & hyperkalemia - force fluids infection - notify physician if WBC is <2000/mm3 - monitor for signs of infection - reverse isolation - low bacteria diet anemia - iron, B-12, folic acid rich food - provide rest periods bleeding - avoid NSAIDs - minimize invasive procedures - use soft toothbrush and electric razor menstrual changes - reassure that menstruation will resume. THE END

REVIEW QUESTIONS SITUATION: Mr. Hero Fernando, a 60 year-old bank manager had experienced a sensation of chest tightness, chest pain, sweating and a feeling of apprehension. A diagnosis of CAD with angina pectoris was established 1. The physician orders for nitroglycerin tablet. The nurse knows that the pharmacological action of the drug is: a. To dissolve the atheromatous plaque in the coronary artery b. Constrict the venous vessels and capillaries c. Dilate the coronary arteries d. Decrease the myocardial consumption of oxygen 2. The nurse gave instructions to the patient on nitroglycerin intake. He remarked, “I think I will try not to take too many of these pills.” At this instance, the nurse’s BEST reply would be: a. “I agree, nitroglycerin can cause drug addiction, that is why you must not take too many of the pills” b. “I must inform you that nitroglycerin is non-habituating and you should take the pills many times to relieve the pain” c. “You will be needing only three tablets to ease the pain and if unrelieved, you must seek medical attention”

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d. “ There is no problem with continuous daily intake because nitroglycerin does not cause a tolerance effect” 3. The nurse must emphasize to the patient which ONE of the following sideeffects of nitroglycerin: a. Headache c. Nausea and vomiting b. Hypertension d. Visual changes 4. What other information must the nurse provide to the patient taking the nitroglycerin? a. Keep the tablet in a clear container b. Take the tablet with meals c. Continue to take as many tablets of nitroglycerin until chest pain subsides d. A burning sensation under the tongue is expected

5. The nurse applies the ordered nitroglycerin ointment on the patient’s chest wall. Which nursing action is considered inappropriate? a. The nurse chooses a hairless area b. She spreads the ointment with her fingers c. She removes the ointment on the skin from the previous dose d. She rotates the sites of ointment application 6. The nurse gives which of the following discharge instructions to this patient with angina regarding nitroglycerin therapy? a. Only take the nitroglycerin as desired b. The drug should be taken before engaging in exertional activities c. The tablet should be taken only in the morning d. If the drug does not relieve the pain, increase the frequency of the dose 7. Hero asked the nurse what he could do about his concern about sex activity. The nurse best suggests: a. Tell him to avoid sex for several months while his heart is on therapy b. Suggests that his wife assume the top position c. Tell him to avoid sex on days when he is anxious d. Advise that he should have sex only once a month 8. The nurse understands that her discharge teaching is effective regarding life style modification when the patient says: a. “I know that I will need to eat less, so I will eat once a day only” b. “I will stay on bed most of the time so I wont experience chest pain” c. “I will stop what I’m doing whenever I have pain and take the pill” d. “I need to enroll in a gym class to have a vigorous exercise to condition my heart” SITUATION: Manny is admitted to the medical ward with the diagnosis of essential hypertension. He had hypertensive emergency 2 hours ago and was hospitalized for further observation. 9. The nurse administers prescribed anti-hypertensive meds. If it can be any of the following, she will check the pulse prior to giving: a. Nifedipine b. Metoprolol c. Clonidine d. Captopril 10. After administering a blood-pressure lowing agent, the nurse must caution the patient: a. To avoid straining during defecation b. To avoid low-sodium and potassium diet c. To avoid abrupt change of positions d. To take warm shower immediately after taking the drug

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11. The nurse prepares to give a diet appropriate for a hypertensive patient. Which food should the nurse include in the menu? a. Canned meat loaf b. Scallops and shrimps c. Fresh citrus juice and cake d. Butter and pork steaks 12. If the physician orders Captopril as the home medication for the high BP, the nurse must caution that the side-effect of this drug that is disturbing is: a. Rashes b. Cough c. Pruritus d. Ringing of the ears 13. If the client is discharged with home medication of Propranolol hydrochloride, the nurse must include in her medication-teaching plan which one? a. Take the medication on an empty stomach b. Obtain blood pressure readings regularly c. Perform active exercises to prevent Hypotension d. Caution to avoid hazardous activities after taking the drug 14. The nurse determines that the following drugs are calcium channel blockers that can be prescribed by the physician to the patient. One is not included: a. Nifedipine b. Verapamil c. Telmisartan d. Diltiazem SITUATION: Joseph,, 50 y.o. Businessman awakens in the middle of the night with dyspnea, bilateral basilar rales and frothy sputum. He is brought to the Mulawin hospital. His diagnosis is congestive heart failure. 15. The physician gives the patient furosemide and digoxin. The nurse’s main concern is to: a. Take the central venous pressure reading b. Observe for decrease edema c. Observe for signs and symptoms of hypokalemia d. Force fluids 16. The mechanism of action of dioxin that makes it useful in patients with CHF is that it: a. Produces a negative inotropic effect b. Increases cardiac conduction c. Enhances cardiac contractility d. Increases the heart rate 17. The nurse is very vigilant about digoxin overdose. Which one statement below by the patient may alert the nurse of a possible development of toxicity? a. “Nurse, I don’t feel like eating for the past few days” b. “I am having constipation lately” c. “I am developing a nagging cough and night terrors” d. “I am experiencing dryness of the eyes and sandy sensation” 18. The nurse evaluates that the drug digoxin is effective when the patient manifests: a. Decreased bowel sounds b. Increased urine output c. Increased drowsiness d. Decreased sympathetic response of the body 19. The following manifestations must be assessed by the nurse to detect beginning digitalis toxicity, with the exception of: a. Nausea and vomiting b. Palpitations c. Diplopia and visual yellow-green halos d. Hypertension

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20. The nurse instructs the patient on diet modification during digitalis therapy. She is certain that her teaching is effective when the patient will choose all the foods items below, except: a. Fresh orange juice and potato fries b. Dried mangoes and tomato juice c. Broccoli salad with bean sprouts d. Flavored gelatin and iced tea 21. The nurse obtains an apical pulse of 78 beats/min. She is bringing the next dose of digoxin and then proceeds to do which one action below? a. Withhold the drug and notify the physician b. Start IV infusion of Digibind (digoxin antibody) c. Instruct patient to consume more meat and nuts d. Administer the drug SITUATION: Armida, an 18-year-old adolescent is seen in the health center because of easy fatigability and frequent dizziness 22. The health center physician determines that she has iron-deficiency anemia. The nurse will anticipate the doctor to order for: a. Bone marrow aspiration b. Hemoglobin level determination c. Platelet count d. BUN and Creatinine 23. A drug is administered to correct anemia, such as an iron. This drug is classified as: a. Antihelminthic b. Anticoagulant c. Hematinic d. Antihistaminic 24. The nurse administers the oral iron tablet. She will give the medication: a. With milk and dairy products b. With antacids to minimize gastric upset c. With fruit juices like calamansi and orange d. With a full glass of coffee or tea 25. The nurse instructs the patient to eat iron-rich foods. She determines that her teaching is effective when the client will choose: a. Pomelo juice and hamburger b. Gelatin and marshmallows c. Lean meat and buttered corn d. Liver and eggyolk 26. The doctor decides to order Iron dextran one ampoule. The nurse prepares to administer the drug: a. Intravenously. Slow IV push b. Intamuscular, Z-track method c. Subcutaneous d. Intrathecal 27. The nurse must warn the patient taking oral iron preparations that it can cause which side effect/s? a. Yellowish discoloration of the skin and mucus membrane b. Darkening of stool color c. Anorexia and loss of hair d. Ulceration of the skin and cough 28. The patient remained pale and weak, upon further examination, it was determined that she has pernicious anemia. The pathophysiology of this hematological disorder is: a. Absence of Vitamin E in the diet b. Presence of excessive iron in the liver c. Absence of intrinsic factor in the stomach d. Temporary bone marrow depression. DRUGS THAT AFFECT THE HEMATOLOGICAL SYSTEM

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SITUATION: Mrs. Rosalinda Amor, 23 year-old actress is admitted because of a diagnosis of deep vein thrombosis. 29. The nurse employs which of the following non-pharmacological measures in caring for Mrs. Amor? a. Ice compress over the involved leg TID b. Elevate the legs with a pillow c. Maintain on strict bed rest with minimal bathroom privileges d. Massage the involved area 30. The physician orders Heparin sodium for Mrs. Amor. The nurse understands the reason for this therapy is that: a. Heparin will dissolve the clots in the inflamed veins to prevent emobolization b. There is a need to prevent further clot formation in the involved vessels c. Heparin will anticoauglate the blood by inhibiting vitamin K metabolism d. The clot formed in the vein must be lysed by activating plasmin, the action of heparin 31. If the doctor orders for heparin therapy monitoring, the nurse must obtain which laboratory tests from the lab unit? a. Prothrombin time b. Clotting time c. Partial thromboplastin time d. Prothrombin consumption test 32. The above laboratory value must is considered therapeutic if the result is about: a. 3 times the normal b. 2 times the normal c. Equals the normal d. Less than the normal 33. The nurse must administer heparin to Mrs. Amor. She determines that the most common routes of administration are: a. IV and IM b. SC and IV c. ID and IM d. IV and intrathecal 34. When the nurse is monitoring the patient for heparin overdose, she is observing for the following signs/symptoms, except? a. Ecchymoses b. Positive Homan’s sign c. Dark, cola-colored urine d. Epistaxis 35. Which one effect of heparin therapy will cause nursing concern? a. Thrombocytopenia b. Constipation c. Bone marrow depression d. Dizziness 36. In the event of an overdose of heparin injection, the nurse prepares which one antidote for toxicity? a. Phytomenadione b. Atropine Sulfate c. Protamine sulfate d. Deferoxamine chelators 37. The doctor switched from standard heparin to low molecular weight heparin injection. The advantage of LMWH over the standard heparin is: a. The LMWH can be administered IM b. The LMWH does not need frequent laboratory monitoring c. The LMWH has a better potency d. The LMWH does not cause bleeding problems

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38. The nurse reads the chart and notes for an order of oral Warfarin sodium, while the patient is on heparin therapy. The nurse will: a. Question the order because of potential excessive bleeding if given simultaneously b. Administer the drug as ordered c. Withhold the heparin and administer the Warfarin orally d. Report the error to the nurse supervisor as the patient may be at risk for toxicity 39. IF Mrs. Amor is discharge with warfarin sodium, the nurse must include in her discharge teaching which one? a. Keep Vitamin A ampule available for injection c/o the health center in case of emergency b. Report any bright red blood in the stool or urine c. Take aspirin to manage the headache side-effect of the drug d. Utilize firm toothbrush when brushing to prevent build up of plaques and gingival hyperplasia 40. The nurse must remind the patient that warfarin therapy is monitored with the use of which laboratory examinations? a. PT and PTT b. PT and INR c. Clotting time and bleeding time d. Platelet count and PT SITUATION: Mrs. Avery had a previous attack of mild stroke and coronary artery disease. She is taking Aspirin. 41. The reason aspirin is utilized as an anti-platelet medication is because: a. Aspirin can prolong the bleeding time b. Aspirin affects the thromboxane production of the platelet c. Aspirin interferes with the receptor binding of the platelets d. Aspirin blocks the degranulation process inhibiting release of histamine 42. The nurse administers aspirin: a. On an empty stomach to increase absorption b. With meals c. In Between meals d. Intramuscularly 43. Mrs. Avery had a sudden severe and prolonged chest pain. Acute MI is suspected. The nurse anticipates the doctor to order a fibrinolytic, and this may be: a. Tranexamic Acid b. Dipyridamole c. Steptokinase d. Coumadin 44. If the above drug is ordered to be given IV drip, the nurse must be aware of which potential effect? a. Hypersensitivity reaction b. Congestive heart failure c. Further damage to the myocardium d. Excessive clot formation 45. If the patient is receiving tissue-plasminogen activator, the nurse must make which one priority intervention? a. Have heparin sodium available b. Monitor closely the renal status c. Observe for psychotic symptoms d. Obtain a stand by Aminocaproic acid SITUATION: A patient is determined to have hypercholesterolemia and is admitted in the hospital for treatment of her condition. The doctor ordered Lovastatin OD. 46. The nurse determines that the BEST time to give the drug is:

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a. In the morning before breakfast to promote absorption b. In the afternoon to promote sleep because it is sedating c. At bedtime d. In between meals 47. The nurse is knowledgeable about the mode of action of lovastatin that it: a. It Inhibits the formation of chylomicrons in the intestinal cells b. It prevents the enzyme that synthesizes cholesterol c. It binds with bile acids and cholesterol promoting excretion d. It promotes cholesterol metabolism in the adipose tissue to lower the plasma cholestero 48. The nurse is prepared to provide comfort measure to the common side effects of the drug. She monitors the patient for: a. Abdominal fullness, flatulence and diarrhea b. Confusion and psychoses c. Palpitations and arrhythmias d. Hypertension and rashes 49. The nurse must monitor for these serious adverse effects of lovastatin. Which one is not included? a. Glaucoma b. Cataract c. Myositis d. Hepatic failure

50. The nurse reads the drug order sheet and is most concern to consult the physician if he orders: a. Paracetamol b. Gemfibrozil c. Vitamin supplements d. Omeprazole 51. The nurse is giving Guaifenesin to a patient. She includes in her teaching which of the following interventions? a. Warn the patient that extreme drowsiness may occur b. Offer a full glass of water c. Nausea and vomiting are potential problems alleviated by small frequent meals d. Suggest to buy a nebulizer machine to be used at home e. Vitamin ADEK supplements because of impaired absorption 52. To be for: a. b. c. d. e.

able to detect the effectiveness of Salbutamol, the nurse should check Blood pressure and CVP readings Urinary output per hour Breath sounds Level of consciousness Pupillary reflexes

53. The patient is receiving theophylline capsule OD. The nurse cautions the patient to avoid foods with components similar to theophyline and they can be: a. Sugar and cream b. Coffee and chocolate c. Spinach and broccoli d. Beans and aged cheese e. Canned goods and wine 54. The patient is receiving theophylline capsule OD. The nurse cautions the patient to avoid foods with components similar to theophyline and they can be: a. Sugar and cream b. Coffee and chocolate c. Spinach and broccoli

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d. Beans and aged cheese e. Canned goods and wine 55. The nurse is administering acetylcysteine nebulization to a patient. It is very much important to keep which item below at bedside? a. Scissors b. Ambu bag c. Suction machine d. Tracheostmy set e. NG tube

56.

After giving diphenhydramine to the patient, the nurse must ensure that the patient understands the teachings below, EXCEPT: a. Refrain from manipulating delicate machines b. Take sugarless candy in the mouth to relieve dryness c. Avoid taking the drug with alcohol d. Check pulse rate before taking the drug e. Manage gastric upset by taking it with food

57. The nurse watches out for a side-effect associated with intake of codeine sulfate and provides appropriate intervention, this can be: a. Constipation- provide liberal fluids b. Excitement- provide less stimulation c. Tachycardia- administer lidocaine d. Polyuria- give the drug in the morning e. Tachypnea- position on semi-fowler’s

58. Terbutaline sulfate is administered to a patient with asthma. If the patient has another disease, the nurse is most vigilant and cautious if this condition exists: a. Hypothyroidism b. Rheumatoid arthritis c. Diabetes mellitus d. Polycystic ovarian disease e. Emphysema

59.

The nurse is administering oxymetazoline nasal decongestant. She includes in her care plan all of the following interventions, EXCEPT? a. Instruct the patient to clear the nasal passage of mucus before instilling b. Remind patient to keep the head tilted for a few seconds after administration c. Advise increased fluid intake d. Encourage the use for one week for better effect e. Caution that tachycardia and urinary retention may occur with systemic absorption

60. The physician asks the nurse for an anticholinergic drug to be used for the asthmatic patient. The nurse obtains from the pharmacy which drug? a. Albuterol b. Terbutaline c. Metaproterenol d. Ipratropium bromide e. Salbutamol 61. The physician orders dextromethorphan for a patient who is complaining of very uncomfortable coughing. The nurse understands that this drug acts to suppress cough by: a. Increasing the secretions of the bronchial glands b. Removing the irritation from the respiratory tract c. Inhibiting the medulla oblongata cough center d. Inhibiting the stretch receptors in the lungs e. Triggering the vagal responses

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62. Inhaled corticosteroid like beclomethasone is administered to the patient with asthma. It is important for the nurse to stress that this drug: a. Acts rapidly to decrease inflammation b. Promotes the secretion of mucus c. May depress the immune function d. Highly effective in terminating acute asthma attack e. Is habituating and addicting 63. The second generation anti-histamines like cetirizine have the advantage over the first generation antihistamines like diphenhydramine because second generation antihistamines: a. Have shorter duration of action that can be reversed rapidly b. Have less sedation and anticholinergic properties c. Posses less drug sensitivity reactions d. Have a greater safety profile e. Have less abuse potential

64.

The nurse cautions the patient taking diphenhydramine (Benadryl) to expect all of the following side effects, except? a. Dry mouth b. Blurred vision c. Urinary frequency d. Drowsiness e. Dizziness

65. The nurse must remember to administer theophylline slowly or with an infusion pump because this drug, if given rapidly can cause: a. Increased alertness b. Severe hypotension c. Tachycardia d. Pallor e. Headache

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