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1. On admission, the patient’s A1C level was 10%. What does this lab value indicate?

2. The provider states the discharge plan is to initiate Lantus insulin therapy at home, based on the admitting A1C level. What patient teaching should the nurse plan to provide before discharge?

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The nurse is providing care for a patient who has new orders to start amiodarone (Pacerone) PO 400 mg BID. Which of the following orders should the nurse anticipate and why? Select all that apply.

A. Monitor vital signs every 4 hr.

B. Telemetry monitoring.

C. Liver function tests every morning for the next 3 days.

D. Initiate seizure precautions.

E. Notify physician of visual changes.

F. Do not serve grapefruit juice.

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While caring for a 31-year-old female client who is initiating therapy with thalidomide (Thalomid), the nurse recognizes the need for further teaching by which of the following statements.

What pregnancy class is this drug?

What are the possible effects to the fetus classified as?

A. “I can’t start the medication until I’ve had a negative pregnancy test.”

B. “I must have a pregnancy test every month for the first 3 months I take this medication.”

C. “I must use two methods of birth control while I am taking this medication.”

D. “I will not be able to donate blood while taking this medication.”

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Published 10:52 AM EDT, Sat September 1, 2012

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Mr. Johnson is a 92-year-old male admitted to the medical-surgical unit for severe pneumonia, and the provider prescribed gentamicin antibiotic therapy.

Upon review of the order, you notice the initial dose is ordered at less than the standard recommended dose. What is the rationale behind the decreased starting gentamicin dose for this patient?

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Which of the following are NOT classified as potassium-sparing diuretics? Select all that apply. Which classes are they?

A. Lasix (furosemide)

B. Aldactone (spirinolactone)

C. Dyrenium (triamterene)

D. Diuril (chlorothiazide)

E. Midamor (amiloride)

F. Microzide (hydrochlorothiazide)

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A patient with high blood pressure is prescribed propranolol.

How will propranolol help to lower his blood pressure?

What will the nurse assess before administering the propranolol?

The nurse listens to the patient’s lungs a few hours after administering propranolol and notices new wheezing.

What  could be a potential cause of this new finding?

What is the nurse’s next best response?

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The nurse is counseling a patient who will begin taking buspirone. Which of the following statements indicates further teaching is required?

A. “I might feel dizzy or sleepy with this medication.”

B. “I shouldn’t drive until I know how I’m going to respond to this medication.”

C. “It’s all right to take most over-the-counter medications and things with this medication.”

D. “I should avoid alcohol or other medications that depress my nervous system.”

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What is Afrin?

How does it work?

What patient teaching would you want to include for this drug?

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GIFs Of The 80s — Dristan Nasal Spray - 1983

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Found on Google from gifsofthe80s.tumblr.com

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A patient has a new order to receive vancomycin (Vancocin) to treat a systemic infection.

What class of antibiotics is this?

The nurse anticipates the order would indicate which route for optimal administration?

A. Peripheral venous access

B. Central venous access

C. Intramuscular

D. Oral

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The nurse prepares to provide ondansetron (Zofran) in orally disintegrating tablet. Which of the following instructions should the nurse provide?

A. “Simply suck on the pill like a lozenge, and it will dissolve over a few minutes.”

B. “Place the tablet on your tongue; it will melt in seconds and then you can swallow.”

C. “Take this with a full swallow of water.”

D. “I will dissolve this in some water, and you can drink it in one sip.”

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Your 82-year-old postoperative patient is hard to arouse 30 minutes after you administered IV morphine. Their BP is 102/72, respirations are 8 and shallow and SpO2 is 88% on room air. Which of the following (with health care provider orders) are priority nursing actions? Select all that apply.

a) Administer oxygen

b) Administer naloxone

c) Insert a foley catheter

d) Increase IV fluid rate

e) Raise the head of the bed

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1. When the nurse enters the room around 4 p.m., she discovers that the patient has become irritable and is shaky. The nurse performs a bedside blood glucose and obtains a value of 60. What is the nurse’s best response?

2. What is the likely cause of the patient’s condition? Explain using the onset and peak actions of the insulin orders.

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A nurse is preparing to administer medications to a patient. While reviewing the chart, the nurse notices two medications with similar mechanisms of action have been prescribed by two different providers.

What is the nurse’s best response?

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What is chronic kidney disease?

What might some causes be?

How does this disease impact medication excretion?

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Which of the following are classified as potassium-sparing diuretics? Select all that apply.

A. Lasix (furosemide)

B. Aldactone (spirinolactone)

C. Dyrenium (triamterene)

D. Diuril (chlorothiazide)

E. Midamor (amiloride)

F. Microzide (hydrochlorothiazide)

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A patient with asthma is taking albuterol to help when she feels increased shortness of breath.

How will albuterol assist in her breathing?

The patient states, “After I take albuterol, it feels like my heart is racing.”

What is the likely cause of this symptom?

What is the nurse’s best response to the patient’s concern?

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Which of the following would cause the nurse to suspect that a patient taking escitalopram (Lexapro) may be developing serotonin syndrome?

Select all that apply.

What is this syndrome?

What are risk factors for it?

A. Pulse = 122 bpm

B. Patient reports seeing blue spiders on the wall.

C. Patient’s blood glucose = 93 g/dL.

D. Patient complains of nausea and diarrhea.

E. White blood cell count = 5,500 cell/mm³.

F. Urinary output = 600 mL in 8 hr.

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Part 1: A nurse is counseling the parent of a 15-year-old adolescent with chronic ear infections and fluid in the ears. The physician recommends pseudoephedrine (Silfedrine Children’s or Sudafed) as a decongestant.

Which of the following statements, made by the parent, indicate that teaching has been effective?

Select all that apply. Provide rationale for why the correct answers are correct and the incorrect answers are incorrect.

A. “The decongestant will help clear the fluid from his ears.”

B. “I should give this medication at bedtime to help him sleep.”

C. “I should call the doctor if I notice he is having any difficulty breathing.”

D. “This medication will kill the bacteria causing the infection in his ears.”

E. “Too much of this medication can alter his heart rate, so I need to keep it out of his reach

Part 2: Which comorbid conditions, if present, is a contraindication to this class of medication?

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Gentamicin (Garamycin) therapy is to be initiated.

What class of medication is this antibiotic?

Which laboratory test would indicate to the nurse that the patient is manifesting a common adverse effect?

A.    Elevated liver enzymes

B.    Increased prothrombin time (PT)

C.    Increase serum creatinine

D. Hypokalemia

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Kidney Dance GIF - Dumb Ways To Die - Discover & Share GIFs

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A patient who recently underwent surgery has a medication order for daily pantoprazole. The nurse reviews the patient’s medical history and finds no history of GERD or peptic ulcer disease. The patient does not report any symptoms of heartburn, stomach pain, or sour stomach. The nurse reviews the physician orders for an indication for this medication before calling the provider to clarify.

What is the likely indication for this drug therapy for this patient?

What two comorbid conditions might manifest due to long-term use of a proton pump inhibitor (ppi)?

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Oral morphine was administered to a patient for rib pain (rated as “6”) from metastatic lung cancer.

When should the effectiveness of the medication be evaluated?

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1. The patient’s blood sugar before breakfast is 223 and he eats 3 carbs at breakfast. What types and amounts of insulin will the nurse administer?

2. The nurse reviews the patient’s morning lab results and finds a creatinine of 1.8. She plans to call the provider to discuss the impact of the results on the medications ordered. Which medication may require a dosage adjustment based on these results?

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While responding to a rapid response called on the cardiac step-down unit, the nurse from intensive care observes the unit nurse massaging a patient’s neck and instructing the patient to bear down.

Which of the following medications will most likely be used if the patient’s pulse does not return to normal? How does is work?

A. Adenosine (Adenocard)

B. Epinephrine (Adrenaline)

C. Atenolol (Tenormin)

D. Asenapine (Saphris)

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A nurse is disciplined by the Wisconsin Board of Nursing for an incident reported by her employer that she arrived at her shift intoxicated.

The nurse shares with a nursing colleague, “I love taking care of patients. I worked so hard to obtain my nursing license – I don’t want to lose it. I know my drinking has gotten out of control, but I don’t know where to turn.”

What is the best advice by the nursing colleague for this nurse with a drinking problem?

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Metabolism can be influenced by many factors within the body. If a patient has liver damage, the patient may not be able to breakdown (metabolize) medications as efficiently. Dosages are calculated according to the liver’s ability to metabolize and the kidney’s ability to excrete.

When caring for a patient with cirrhosis, how does this condition impact the dosages prescribed for the patient?

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While providing care for a patient who receives Lasix (furosemide) 20 mg IV push twice daily, the nurse would include which of the following in the plan of care and why? Select all that apply.

A. Change the patient’s incontinence brief 30–60 min after medication administration.

B. Check patient’s platelet count prior to medication administration.

C. Schedule the first dose at 11 a.m. and the second dose at 11 p.m.

D. Provide the dose undiluted.

E. Give the medication over 30 seconds

F. Institute high fall risk protocol interventions.

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A patient with benign prostatic hyperplasia (BPH) has a new order for Tamsulosin.  He asks, “How will Tamsulosin help me? I already take so many pills.”

What is the nurse’s best response?

What does the nurse plan to monitor carefully, especially after administering the first dose of tamsulosin?

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A patient with an acute episode of heart failure is admitted and is prescribed dobutamine.

How will dobutamine improve the patient’s condition?

What will the nurse monitor carefully during administration?

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Part 1: While working with a patient who takes flurazepam (Dalmane), the nurse should be most concerned by which of the following patient statements?

A. “I usually take the medication at 10 pm.”

B. “I have to take it every night or I won’t get any sleep.”

C. “I work out at the gym 3–4 times per week.”

D. “I stopped drinking coffee at dinner now.”

Part 2: What class is this medication and what should patient teaching include?

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Sleep Time GIF - Sleep Time - Discover & Share GIFs

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The nurse receives a call from the parent of an 8-year-old boy who is home sick from school with a headache, sinus congestion, and a cough. The parent asks, “Can I give him some Benadryl to help him breathe easier?” Which of the following statements by the nurse is best?

Provide rationale for why the correct answers are correct and the incorrect answers are incorrect.

A. “How long has your child been ill?”

B. “It should be fine if he weighs more than 50 pounds.”

C. “What other over-the-counter medications have you given him?”

D. “That might make him sleepy, so it is best to give it at night.”

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What side effect is displayed here?

Which class of antibiotic would have caused this side effect?

What can the nurse do to help prevent this side effect?

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A child, aged 6, has diarrhea. The mother asks the nurse what OTC medications she can provide to her child to help resolve the diarrhea.

What is the nurse’s best response?

Why wouldn't the nurse suggest Pepto Bismol?

What is the link between Pepto Bismol and Aspirin?

Why can't children receive aspirin products?

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A post-operative patient just received naloxone for respiratory depression.

What class of medication is naloxone and how does it work?

When should the patient’s respiratory status be reassessed?

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1. Explain the difference between type 1 and type 2 diabetes.

2. The patient states that he usually does not take insulin at home. What is the likely rationale for insulin therapy while hospitalized?

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Why must the nurse monitor serum potassium levels as well as digoxin levels?

A nurse enters a patient’s room and the patient complains “My vision seems strange and I feel nauseated.” What is the nurse’s next best action?

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Ken Jeong What Is This GIF - Ken Jeong What Is This I Cant See - Discover & Share GIFs

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A nurse begins a new job on a medical surgical unit. One of the charge nurses on this unit is highly regarded by her colleagues and appears to provide excellent care to her patients.

The new nurse cares for a patient that the charge nurse cared for on the previous shift. The new nurse asks the patient about the effectiveness of the pain medication documented as provided by the charge nurse during the previous shift.

The patient states, “I didn’t receive any pain medication during the last shift.” The nurse mentions this incident to a preceptor who states, “I have noticed the same types of incidents have occurred with previous patients, but didn’t want to say anything.”

What is the new nurse’s best response?

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Julia is a 56-year-old patient admitted to the cardiology unit with new-onset atrial fibrillation. She has been prescribed amiodarone for her irregular heartbeat and is set to receive her first dose with her morning breakfast tray.

When you arrive in the room, you notice that she has grapefruit juice on her breakfast meal tray.

Is this a concern? Why or why not? What is the nurse’s next action?

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Which of the following examples should be provided as food to include with dietary intake when taking Lasix (furosemide) and why?

A. Cauliflower, cabbage, and yogurt

B. Macaroni and cheese, deli meat, and buttermilk

C. Clams, oysters, and broccoli

D. Potatoes, milk, and prune juice

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A patient begins a nicotine patch in an attempt to stop smoking. The patient reports feelings of nausea, weakness, and a rapid heartbeat.

What is the likely cause of these symptoms, and what is the nurse’s best response?

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Part 1: A student nurse is taking care of patients on a medical unit and receives new orders for eszopiclone (Lunesta) 2 mg orally each evening. In transcribing this order, the student should take which of the following actions?

A. Schedule the medication routinely at 6 pm.

B. Schedule the medication 1 hr prior to the evening meal.

C. Call the pharmacy to ask what time the medication should be given.

D. Schedule the medication at bedtime.

Part 2: What are major patient safety issues associated with this class of medication?

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The nurse receives a call from a patient who recently began taking cetirizine (Zyrtec) 5 mg daily. The patient reports that her mouth frequently feels dry.

Which of the following responses by the nurse is best?

Provide rationale for why the correct answer is correct and the incorrect answers are incorrect.

A. “Dry mouth is a common side effect of Zyrtec. Rinse your mouth frequently, and try using sugarless chewing gum or candy for relief.”

B. “You may be taking too strong of a dose. You should take half a pill each day to reduce the risk of side effects.”

C. “You might be having an allergic reaction to the medication. Are you able to come to the doctor’s office today?”

D. “It is important that you take the medication with a full meal and drink at least 12 glasses of water each day.”

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What side effect is displayed here?

Which class of antibiotic would have caused this side effect?

Which populations should this medication be avoided in due to the above side effect?

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A patient has been prescribed loperamide for diarrhea associated with gastroenteritis. The patient begins to complain of “heart palpitations.” What might be the cause of these symptoms? What is the nurse’s next best response?

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Your patient is admitted to the hospital with acute liver failure due to acetaminophen toxicity. Your patient reveals that they have had a cold for several days and have been taking over-the-counter cold medications and acetaminophen for a headache. They also mention that every night after work they drink a “few” beers.

What patient education about acetaminophen should be provided?

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Discuss what hyperglycemia is, signs/symptoms, treatment, and nursing priorities.

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Why should a nurse assess the apical pulse for 1 full minute before administering digoxin?

How does a nurse evaluate if digoxin is effective?

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A nurse is providing discharge education to a patient who recently had surgery and has been prescribed hydrocodone/acetaminophen tablets to take every four hours as needed at home.

The nurse explains that when the medication is no longer needed when the post-op pain subsides, it should be dropped off at a local pharmacy for disposal in a collection receptacle.

The patient states, “I don’t like to throw anything away. I usually keep unused medication in case another family member needs it.”

What is the nurse’s best response?

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Your patient is prescribed NPH insulin to be given at breakfast and supper.  As a student nurse, you know that insulin is used to decrease blood sugar levels in patients with diabetes mellitus.

During report, you hear that the patient has been ill with GI upset during the night, and the nursing assistant just informed you he refused his breakfast tray.

While reviewing this medication order, you consider the purpose of the medication and information related to the medication’s onset, peak, and duration. When reviewing the drug reference,  you find the NPH insulin has an onset of about 1 – 3 hours after medication administration.

What should you consider in relation to the administration and timing of the patient’s insulin?

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What assessments should a nurse do before and after administering a diuretic?

What are the signs and symptoms of digoxin toxicity? What can happen to a patient who has toxic levels of digoxin?

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The nurse is counseling a patient who has been given a prescription for fluoxetine (Prozac). Which of the following statements should the nurse include in the patient’s teaching? Select all that apply.

A. “The medicine can cause some dizziness, so you should change position slowly.”

B. “Sugarless gum or candy may help the feeling of dry mouth that some patient’s experience with this medicine.”

C. “Most likely you will notice a huge change in your mood immediately.”

D. “You may experience a decrease in your sex drive while on this medication.”

E. “It is important to wear protective clothing and sunscreen since the drug can cause increased sensitivity to the sun.”

F. “This medicine should always be taken on an empty stomach.”

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Doubledougs Side Effects GIF - Doubledougs Side Effects Engineer - Discover & Share GIFs

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The nurse is caring for a patient with bronchitis and prepares to provide benzonatate (Tessalon) as ordered. The patient states, “I don’t think I’ve had this before. What is it for?”

Which of the following responses by the nurse is best?

How does this medication work?

Provide rationale for why the correct answer is correct and the incorrect answers are incorrect.

A. “This helps thin the mucus so it is easier for you to cough it up.”

B. “It is a cough suppressant and will help reduce your coughing.”

C. “This helps dilate the small airways in your lungs to help you breathe.”

D. “It is a muscle relaxer so you can rest more comfortably.”

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What is the name of this syndrome?

Describe what happens to your patient with this syndrome.

What will you do as the nurse if your patient develops this syndrome?

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What other preventative measures for constipation should the nurse teach the patient?

If docusate is not effective within 24 hours, what other medications can the nurse anticipate to be ordered?

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A patient has been prescribed celecoxib for their arthritic pain.

What patient teaching does the nurse plan to provide?

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Discuss what hypoglycemia is--signs/symptoms, treatment, and nursing priorities.

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The nurse caring for a patient taking hydrochlorothiazide and digoxin (Lanoxin) instructs the patient to notify the physician with which of the following symptoms and why? Select all that apply.

A. Systolic blood pressure less than 150

B. Anorexia, nausea, and vomiting

C. Muscle cramps

D. Confusion

E. Numbness and tingling in extremities

F. Nocturia

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Levofloxacin is an antibiotic that received FDA approval. However, after the drug was on the market, it was discovered that some patients who took levofloxacin developed serious, irreversible adverse effects such as tendon rupture. The FDA issued a Black Box Warning with recommendations to reserve levofloxacin for use in patients who have no alternative treatment options for certain indications: uncomplicated UTI, acute exacerbation of chronic bronchitis, and acute bacterial sinusitis.[4]

A nurse is preparing to administer medications to a patient and notices that levofloxacin has been prescribed for the indication of pneumonia. There is no other documentation in the provider’s notes related to the use of this medication.

What is the nurse’s best response?

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At 0500, your patient who had a total knee replacement yesterday rates his pain while walking as 7 out of 10.  Physical therapy is scheduled at 0900.

The patient has acetaminophen (Tylenol) 625 mg ordered every four hours as needed for discomfort.

What should you consider in relation to the administration and timing of the patient’s pain medication?

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What is the normal range for serum potassium level?

What classification of medication is furosemide (Lasix)?

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While providing care for an adolescent patient newly prescribed amitriptyline (Elavil), the nurse should be most concerned by which of the following patient statements?

What class of medication is this?

A. “My mouth seems really dry and I’m thirsty all the time.”

B. “I take a nap most afternoons now because I feel sleepy sometimes.”

C. “I’m not sure why we should even bother anymore; everything seems so pointless.”

D. “I drink a cup of coffee most days with breakfast.”

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Directed GIF - Directed - Discover & Share GIFs

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The nurse is caring for a patient receiving treatment for viral pneumonia. The nurse notes the patient has a persistent cough that is interfering with the patient’s ability to sleep. Which of the following medications should the nurse provide?

What patient teaching should be done with this medication?

How is the correct medication different from a mucolytic?

A. Lorazepam (Ativan) 1 mg orally prn

B. Guaifenesin (Guiatuss) 200 mg every 4 hr prn

C. Acetaminophen (Tylenol) 325 mg orally prn

D. Granisetron (Sustol) 2 mg orally prn

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What type of reaction might be occurring based on the above signs and symptoms?

Which antibiotic classes might cause this reaction?

Which substance, when ingested along with the antibiotic, is necessary to cause this type of reaction?

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What are the potential causes of constipation that should be addressed for this patient?

What is the mechanism of action for docusate?

The patient asks how quickly the medication will work. What is the nurse’s best response?

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The nurse prepares to provide colchicine (Colcrvs) to a patient. The nurse should assess which of the following prior to administration of the medication?

A. Blood pressure

B. Complete blood count

C. Triglyceride level

D. Oxygen saturation

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A patient has been diagnosed with hypothyroidism and receives a prescription for levothyroxine.

What patient education should the nurse provide regarding taking this medication?

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The nurse is caring for a 56-year-old patient with a history of atrial fibrillation who takes digoxin (Lanoxin) 0.5 mg/day. Which of the following assessments should cause the nurse to hold the patient’s dose? Why?

A. BP = 112/70 mmHg

B. Lung sounds with fine bibasilar crackles

C. Urine output = 300 mL in 3 hr

D. P = 58 bpm

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A nurse is performing medication reconciliation for an elderly patient admitted from home. The patient does not have a medication list and cannot report the names, dosages, and frequencies of the medication taken at home.

What other sources can the nurse use to obtain medication information?

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Mr. Parker has been receiving gentamicin 80 mg IV three times daily to treat his infective endocarditis. He has his gentamicin level checked one hour after the end of his previous gentamicin infusion was completed.  The result is 30 mcg/ml. Access the link below to determine the nurse’s course of action.

View information on Therapeutic Drug Levels

(Within the activity link, be sure to select “click to keep reading” in order to view drugs that are commonly checked, their target levels, and what abnormal results mean).

Based on the results in the above patient scenario, what action will the nurse take based on the result of the gentamicin level of 30 mcg/mL?

# data[].attributes.attachment_link.readable_text
Bluth MH, Pincus MR, Abraham NZ. Toxicology and therapeutic drug monitoring. In: McPherson RA, Pincus MR, eds. Henry's Clinical Diagnosis and Management by Laboratory Methods. 24th ed. Philadelphia, PA: Elsevier; 2022:chap 24.

Clarke W. Overview of therapeutic drug monitoring. In: Clarke W, Dasgupta A, eds. Clinical Challenges in Therapeutic Drug Monitoring. Cambridge, MA: Elsevier; 2016:chap 1.

Diasio RB. Principles of drug therapy. In: Goldman L, Schafer AI, eds. Goldman-Cecil Medicine. 26th ed. Philadelphia, PA: Elsevier; 2020:chap 26.

Nelson LS. Acute poisoning. In: Goldman L, Schafer AI, eds. Goldman-Cecil Medicine. 26th ed. Philadelphia, PA: Elsevier; 2020:chap 102.

# data[].attributes.attachment_link.title
Therapeutic drug levels: MedlinePlus Medical Encyclopedia

# data[].attributes.attachment_link.description
Bluth MH, Pincus MR, Abraham NZ. Toxicology and therapeutic drug monitoring. In: McPherson RA, Pincus MR, eds. Henry's Clinical Diagnosis and Management by Laboratory Methods. 24th ed. Philadelphia, PA: Elsevier; 2022:chap 24. Clarke W. Overview of therapeutic drug monitoring. In: Clarke W, Dasgupta A, eds. Clinical Challenges in Therapeutic Drug Monitoring.

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Is dehydration a risk for patients on furosemide (Lasix)? Why or why not?

How would you assess for dehydration?

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A nurse working in an outpatient psychiatric clinic is assessing a 39-year-old patient with a history of schizophrenia who started taking haloperidol (Haldol) 3 mg PO TID last week. Which of the following should be reported to the physician immediately and why?

A. The patient is smacking his lips and chewing while the nurse is asking questions.

B. The patient says, “I heard the angels talking again last night.”

C. The patient reports he is staying at a homeless shelter downtown.

D. The patient tells the nurse he forgot to bring in his pills but that he needs more.

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The nurse is caring for a patient with a long history of asthma. Which of the following medications should the nurse question and why?

A. Propanolol (Inderal LA)

B. Albuterol (Proventil)

C. Salmeterol (Serevent)

D. Budesonide (Pulmacort)

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What condition is represented by yellowing of the skin and the sclera?

Which organ system is involved?

Which classes of antibiotics can cause this condition?

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The nurse recognizes that the treatment plan for which of the following individuals would likely include psyllium (Metamucil)? Select all that apply.

A. A 72-year-old patient who drinks prune juice on a daily basis and has a soft brown stool daily

B. A 61-year-old patient hospitalized for an anterior myocardial infarction

C. A 29-year-old patient with the flu who reports having diarrhea

D. A 57-year-old patient reporting increased difficulty with constipation since the onset of menopause

E. A 65-year-old patient who recently had a hemorrhoidectomy

F. An 84-year-old patient who reports walking 3 miles every day in the mall

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Ketorolac IV was administered to a patient for severe pain (rated as “8”) due to a back injury.

When should the effectiveness of the medication be evaluated?

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A patient who was treated in the hospital for DVT in his left leg has been prescribed warfarin.

The patient asks, “Will the warfarin dissolve the clot in my leg?” What is the nurse’s best response?

The nurse plans to assess the patient’s lab work before administering the warfarin.

What blood test(s) are important to monitor for patients taking warfarin, and what is the therapeutic range?

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While providing care for a 45-year-old woman client who has been started on methimazole (Tapazole) 15 mg every 4 hr, the nurse would include which of the following in the plan of care? Select all that apply.

A. Teach client self-injection techniques.
B. Monitor for signs and symptoms of hyper- or hypothyroidism.
C. Place client in protective isolation.
D. Assess white blood cell and differential counts.
E. Strain all urine.
F. Monitor for signs or symptoms of bleeding.

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A nurse is preparing to administer morphine, an opioid, to a patient who recently had surgery.

Explain the 6 rights that the nurse will check before administering this medication to the patient

Outline 3 methods the nurse can confirm patient identification.

What if the dose of morphine required a partial package and there is leftover opioid medication? What should the nurse do?

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Sara is a nurse working on the medical-surgical floor. She is reviewing her patient’s chart and notes her patient has a 0600 vancomycin infusion; however, the trough level is not available.

The nurse phones the lab, and they state they will not be available to draw the trough level for an hour. What actions should the nurse take?

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What electrolyte imbalance(s) can occur in patients taking furosemide (Lasix)?

What relationship exists between this patient’s furosemide, digoxin, and potassium levels?

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What are the 4 features/symptoms of this syndrome and what are a few nursing considerations if you thought your patient were experiencing this?

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CONTENTS

As its name implies, NMS is often related to neuroleptic agents (i.e., antipsychotic medications) and is manifest by mental status changes, hyperthermia, rigidity, and autonomic dysfunction. It can present as a life-threatening emergency, and is often challenging to diagnose.

Neuroleptic malignant syndrome seems to result from a deficiency of signaling via D2 dopamine receptors in the brain:

Dopamine deficiency within striatal dopamine pathways in the basal ganglia may cause Parkinsonian-type symptoms (e.g., lead-pipe rigidity).

Dopamine deficiency in the hypothalamus may cause autonomic dysfunction.

Dopamine alterations within the reticular activating system may cause alterations in consciousness (e.g., mutism, coma).

A combination of excess motor tone plus dysautonomia may precipitate other features of neuroleptic malignant syndrome, including rhabdomyolysis and hyperthermia.

Treatment involves both augmentation of D2 signaling in the brain, as well as providing muscle relaxants to reduce peripheral muscle tone.

causative agents

Antipsychotics are the most common cause:

NMS can occur with typical or atypical agents (especially clozapine).

⏰ NMS usually presents within a month of initiating treatment (most often within two weeks), but it can emerge during chronic therapy (often triggered by another illness).

Antiemetics that block the dopamine receptor:

Prochlorperazine.

Promethazine.

Metoclopramide.

Withdrawal of dopaminergic Parkinson's medications.

risk factors

Personal or family history of NMS.

Aspects of antipsychotic therapy:

Rapid up-titration of neuroleptic.

Higher doses of antipsychotic.

First-generation ("typical") antipsychotics have greater risk than atypical antipsychotics. Clozapine and quetiapine have the lowest risk.(Shutter, 2019)

Multiple antipsychotic agents, coadministration with lithium.

Underlying dopamine deficiency:

Parkinson's disease or Lewy body dementia.

Active withdrawal of dopaminergic stimulation (e.g., cessation of chronic cocaine use).

Other medications that deplete dopamine (e.g., tetrabenazine).(Frucht 2022)

epidemiology

The risk of NMS is on the order of ~0.01-0.04% among people exposed to antipsychotics.

There doesn't appear to be any dramatic age or sex predominance.Historical trends towards higher rates among young men may simply represent patients treated with higher doses of neuroleptics.

There are a few case reports of NMS arising within the ICU, as a nosocomial complication of antipsychotic administration. Diagnosis of nosocomial NMS is challenging (e.g., the development of fever and altered mental status may initially be attributed to sepsis).

Symptoms usually develop gradually over 1-3 days, but timing is extremely variable. NMS likewise takes a while to improve, with resolution usually occurring over two weeks.

four features classically present in order
Clinical presentations vary. Mental status changes and extrapyramidal symptoms often precede hyperthermia and autonomic instability. Initially, many patients will only have mental status changes and extrapyramidal features - which may render early diagnosis challenging.
#1/4: mental status changes in ~70%

These may be variable. Agitation may occur initially, with later evolution into mutism, catatonia, and coma.

These symptoms may be obscured in patients who are intubated and sedated, or in patients with poorly controlled schizophrenia (in whom these symptoms may blend into the symptoms of schizophrenia).

#2/4: extrapyramidal symptoms, which may include:

Tremor (similar to Parkinson's disease), chorea.

Oculogyric crises (gaze may be fixated upwards).

Dystonia (which may be refractory to anticholinergic therapies).

Dysphagia or dysarthria may occur.

Rigidity is the most common and hallmark extrapyramidal symptom:
The most severe manifestation is lead-pipe rigidity (stable resistance throughout the range of motion; see video below). However, patients may also have a superimposed tremor on top of the lead pipe rigidity, which creates a pattern of cogwheel rigidity.

Not all patients have hyperthermia:

~87% of patients have temperatures >38C.

~40% of patients have temperatures >40C (so frank hyperthermia is often absent).

Delayed onset of hyperthermia may promote diagnostic confusion.

Similar to other forms of hyperthermia, this is usually not associated with chills, nor responsive to antipyretic therapy.

#4/4: autonomic instability with sympathetic activation

These features seem to be the least frequent:

Sinus tachycardia and other arrhythmias (~62%).

Labile hypertension (~42%).

Diaphoresis (~44%).

Urinary incontinence.

complications are responsible for the ~10% mortality associated with NMS

Most common complications:

Aspiration, pneumonia, and respiratory failure may occur. This may relate in some cases to dysphagia and hypersalivation caused by NMS.

Renal failure due to rhabdomyolysis occurs commonly.

Venous thromboembolic events may result from immobility and systemic inflammation.

Takotsubo cardiomyopathy may result from autonomic instability.

Disseminated intravascular coagulation and multiorgan failure may ultimately evolve, secondary to the above processes.

Creatinine kinase is often >1,000 U/L.

Creatinine kinase may be normal early in the disease course, before rigidity emerges. One literature review found a CK level above 300 IU/L in 94% of patients.

For a differential diagnosis of the causes of elevated creatinine kinase, see the chapter on rhabdomyolysis . There are numerous causes of creatinine kinase elevation, but marked elevation without another explanation might point to NMS in the appropriate clinical context.

Leukocytosis (as high as 40,000), with left shift and elevated neutrophil/lymphocyte ratio. C-reactive protein is often also elevated.

differential diagnosis

Toxicological

Serotonin syndrome, which may be sorted out since:

These two disorders are caused by different medications.

Serotonin syndrome is marked by clonus and hyperreflexia.

If present, nausea, vomiting, diarrhea point towards serotonin syndrome.

Malignant hyperthermia (usually caused by inhalational anesthetics or succinylcholine, more rapid onset than NMS).

Muscle relaxant withdrawal (e.g., intrathecal baclofen, carisoprodol).

Sympathomimetic, anticholinergic, or phencyclidine intoxication.

Ethanol or sedative withdrawal.

Lithium intoxication.

Infection

Meningitis, encephalitis.

Sepsis of any etiology.

Neurologic

Stroke involving the brainstem and basal ganglia.

Nonconvulsive status epilepticus.

Acute Parkinsonism.

Extrapyramidal side effect of a medication (e.g., isolated dystonic reaction or oculogyric crisis).

Hyperthyroidism (may cause tremor, but shouldn't cause extrapyramidal motor abnormalities).

Environmental heat stroke, which can be aggravated by neuroleptics. Heat stroke shouldn't cause rigidity or diaphoresis.

Malignant catatonia - Neuroleptic malignant syndrome is actually one form of malignant catatonia which is triggered by neuroleptics. Thus, neuroleptic malignant syndrome is often indistinguishable from other forms of malignant catatonia. Other potential triggers of catatonia should therefore be considered. Features that may suggest an additional or alternative cause of catatonia may include:

Behavioral prodrome for weeks involving psychosis, agitation, or apathy.

More positive motor symptoms (e.g., waxy flexibility, stereotyped repetitive movements, automatisms).

evaluation will vary, but may involve the following:

Neurological examination and measurement of core temperature.

Creatinine kinase level.

Complete blood count with differential.

Thyroid stimulating hormone (if features of possible thyrotoxicosis).

Evaluation for infection (e.g., blood cultures, chest X-ray).

Depending on the context, neuroimaging and lumbar puncture might be considered.

There's no gold-standard diagnostic test to establish the presence of NMS. Consequently, there is no scientific approach to establish a set of diagnostic criteria. The criteria below were developed by a panel of experts, as a way to predict whether another expert would deem that the patient had NMS. This strategy is bereft with circular logic, so it may well be missing the mark entirely.

Regardless, the criteria are listed below. A validation study found that a cutoff of at least 74 points total (out of 100) could be used to determine the presence of NMS (with 70% sensitivity and 90% specificity, compared to expert adjudication).

Exposure to a dopamine antagonist or withdrawal of a dopamine agonist in the prior 72 hours: 20 points

Hyperthermia (>100.4 F or >38C) on at least two occasions, measured orally: 18 points

Rigidity: 17 points

Mental status alteration (reduced or fluctuating level of consciousness): 13 points

Creatinine kinase elevation at least four times the upper limit of normal: 10 points

Sympathetic nervous system lability, defined as at least two of the below: 10 points

Blood pressure elevation (systolic or diastolic >25% above baseline)

Blood pressure fluctuation (>25% systolic or >20% diastolic change in 24 hours)

Diaphoresis

Urinary incontinence

Hypermetabolic state (defined as heart rate increase >25% above baseline and respiratory rate increase >50% above baseline): 5 points

Negative evaluation for other toxic, metabolic, infectious, or neurologic causes: 7 points

As with many diagnostic scoring systems in critical care, the value of this score to dictate clinical management is dubious. Ideally, we would like to identify NMS and initiate treatment before the full-blown syndrome is present, at a time point when patients might not meet the above criteria.

discontinue offensive medication(s)

Stop any antipsychotics.

Avoid antiemetics that antagonize the dopamine receptor (e.g., metoclopramide, promethazine, prochlorperazine).

If the episode was triggered by withdrawal of Parkinson's medications, restart these medications immediately.
Have a low threshold to consult with a neurologist regarding optimization of Parkinson's medications. Among sicker patients who are unable to take tablets orally, this can get tricky.

supportive care for hyperthermia

General supportive care for the hyperthermic patient is discussed in the chapter on hyperthermia .

Physical cooling measures may be required (e.g., cooling blankets, ice packs, evaporative cooling).

Antipyretics are not helpful.

manage fluid, electrolytes, and rhabdomyolysis

Rhabdomyolysis is common; its treatment is discussed further .

Electrolytes should be monitored and treated appropriately.

There is a high risk of renal failure, so nephrotoxins should be avoided.

Volume depletion may result from insensible losses and inability to tolerate oral intake - monitor and treat this accordingly.

benzodiazepines

Benzodiazepines are widely used in the supportive care of patients with neuroleptic malignant syndrome and malignant catatonia. They may help control agitation and also promote muscle relaxation.

A usual dose may be ~2 mg IV q8hr of lorazepam.

The response to treatment should be noted (in some patients this may cause significant improvement).

There is a risk that benzodiazepines could cause or promote the development of delirium.

management of agitation

This may be challenging in patients with underlying psychosis. Of course, antipsychotics need to be avoided.

Treatment options may include:

Central alpha 2 agonists (e.g., dexmedetomidine or ).

is probably a reasonable treatment for hyperactive delirium in this context. Some case reports have questioned whether valproate might promote NMS, but valproate alone doesn't cause NMS.

general 💊

Bromocriptine is a dopamine agonist, which should reverse the antidopaminergic effect of antipsychotic medications.

There is no high-quality evidence for any therapy in NMS. However, enhancing dopamine signaling is a rational strategy that should improve the underlying pathophysiology, and is supported by some case-report level evidence. A systematic literature review suggested that NMS-specific therapy (e.g., bromocriptine and dantrolene) might reduce mortality in severe cases, when compared to purely symptomatic therapy with benzodiazepines.

dosing of bromocriptine

Starting dose is 2.5 mg PO q8hr, may titrate up to 5-10 mg q6-8hr.

Maximal dose is 40 mg/day (10 mg q6hr).

Continue for 10 days after NMS resolution to avoid recurrence, then taper off very gradually.

potential side-effects

Psychosis, including exacerbation of the patient's underlying psychiatric illness.

Dyskinesia.

Hypotension.

Nausea/emesis.

alternative dopaminergic agent: amantadine

Amantadine also has dopaminergic effects and may be used as an alternative dopaminergic agent, if bromocriptine is contraindicated. The initial dose is 100 mg q8-q12hr, with a potential to increase to 200 mg BID.

For severe and refractory NMS, amantadine could be combined with bromocriptine.

other situations where bromocriptine may be useful

Neurogenic fever. 📖

Paroxysmal sympathetic hyperactivity (PSH) 📖

Bromocriptine may be used for refractory hyperthermia.

The starting dose is 1.25 mg PO q12hr, with up-titration to a maximal cumulative dose of 40 mg/day.(Naidech 2022)

general 💊

Dantrolene is a direct-acting muscle relaxant. It should rapidly reduce heat production and rigidity.

Dantrolene shouldn't be used as monotherapy for NMS, but may be helpful in moderate/severe cases in combination with bromocriptine.

One advantage of dantrolene is that if the diagnosis is wrong and the patient has another related form of rigidity, dantrolene may still be beneficial.

dosing

The ideal dose is unclear. The dosing range is 1-2.5 mg/kg q6-8hr hours IV (with a maximal daily dose of 10 mg/kg/day).

Once the patient stabilizes (usually after a few days), IV dantrolene may be transitioned to oral dantrolene (e.g., 1 mg/kg q6hr).

There is disagreement about how rapidly this should be discontinued. Dantrolene may typically be weaned off over several days, to avoid recurrence of NMS.

contraindications, cautions & adverse events

Adverse effects are rare when used for short-term treatment of NMS.

Combination of dantrolene with calcium channel blockers is contraindicated.

Dantrolene can cause liver injury, so it's contraindicated in patients with cirrhosis or acute liver injury.

It's unclear whether dantrolene may reduce diaphragmatic strength, but theoretically higher doses might.

Electroconvulsive therapy (ECT) has been used for NMS, analogous to its use in malignant catatonia in general.

For patients with severe NMS refractory to medical therapy, ECT could be considered. For patients with underlying schizophrenia or psychotic depression, ECT could be particularly helpful (since it may treat the NMS and the underlying disorder).

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To keep this page small and fast, questions & discussion about this post can be found on another page .

Don't assume that absence of fever excludes NMS. There is no single symptom nor laboratory abnormality which is present in 100% of cases, so NMS is a challenging diagnosis. The diagnosis must be based upon recognizing a constellation of features, as well as excluding alternative possibilities.

Among patients with NMS, make sure to avoid any drugs that may inhibit the dopamine receptors (e.g., metoclopramide, promethazine, and prochlorperazine).

NMS may be extremely difficult to diagnose in the context of poorly controlled psychiatric disorders (e.g., it may be extremely difficult to diagnose delirium on the background of a baseline psychotic state).

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CONTENTS Pathophysiology Epidemiology Clinical features Laboratory abnormalities Differential diagnosis & evaluation Diagnostic criteria Management Supportive care Bromocriptine Dantrolene Electroconvulsive therapy Podcast Questions & discussion Pitfalls As its name implies, NMS is often related to neuroleptic agents (i.e., antipsychotic medications) and is manifest by mental status changes, hyperthermia, rigidity, and autonomic dysfunction.

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What is the proper administration when an inhaled corticosteroid and a bronchodilator are scheduled for the same time frame?

A. Take the corticosteroid, allow 1 min to elapse, and then take the bronchodilator.

B. Take bronchodilator, allow 1 min to elapse, and then take the corticosteroid.

C. Take the corticosteroid, allow 5 min to elapse, and then take the bronchodilator.

D. Take bronchodilator, allow 5 min to elapse, and then take the corticosteroid.

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What is going on in this photo?

What causes this?

What class of antimicrobials is used to treat this?

How does this class of antimicrobials work to help?

When should treatment be started?

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Which of the following would cause the nurse to intervene for a patient taking pantoprazole (Protonix)?

A. The client takes the medication an hr before breakfast.

B. The client orders eggs and bacon for breakfast.

C. The client drinks a glass of orange juice when taking the medication.

D. The client chews the medication before swallowing.

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The nurse is caring for a patient who reports long-term use of nonsteroidal anti-inflammatory agents for the treatment of osteoarthritis. Which of the following medications would the nurse also expect as part of the patient’s treatment plan?

A. Misoprostol (Cytotec)

B. Metoprolol (Lopressor)

C. Metronidazole (Flagyl)

D. Mirtazapine (Remeron)

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A patient who was treated in the hospital for DVT in his left leg has been prescribed warfarin.

What dietary instructions should be provided to the patient?

The nurse plans to provide patient education regarding this newly prescribed medication.

Outline the topics to cover with this high-risk medication.

What is the reversal agent for warfarin?

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As part of a new treatment regimen for hypothyroidism, a 48-year-old woman is prescribed levothyroxine (Levoxyl). The nurse should include which of the following statements in the client teaching? Select all that apply.

A. “You should take this medication at roughly the same time each day.”
B. “Once you’ve been taking this medication for a few weeks, you should be cured and the doctor will stop it.”
C. “Let the doctor know if you lose more than 2 pounds per week while taking this medication.”
D. “Do not take this medication at the same time as any other medications.”
E. “Avoid eating beef or pork while taking this medication.”
F. “Some clients experience headaches, nervousness, sweating, and palpitations while taking this medication.”

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A nurse is preparing to administer insulin to a patient. The nurse is aware that insulin is a medication on the ISMP list of high-alert medications.

What is a high-alert medication?

What strategies should the nurse implement to ensure safe administration of this medication to the patient?

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The nurse is caring for a 68-year-old male who is taking doxazosin (Cardura). He denies any history of hypertension. The nurse recognizes this medication can also be used to treat which of the following conditions?

Explain how this drug exerts its effect on the body

A. Psoriasis
B. Gout
C. Lymphoma
D. Benign prostatic hypertrophy

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How to pronounce doxazosin (Cardura) (Memorizing Pharmacology Flashcard)

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Explain the disorder presented and which medications might cause this.

What would you do if you noticed your patient suddenly started exhibiting these symptoms?

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Which of the following should be communicated to a patient who is being prescribed fluticasone and salmeterol (Advair Diskus)? Why?

A. Open capsule and mix with water or juice.

B. Rinse mouth with water after each use.

C. Use a spacer device.

D. Shake medication container prior to administration.

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A nurse is providing discharge teaching to a patient prescribed antitubercular medications for newly diagnosed tuberculosis. Which statement by the patient indicates a need for further teaching?

A. "I will take my medication for at least six months."

B. "I should watch for yellowing of my skin or eyes and report it to my healthcare provider."

C. "I don’t need to use additional birth control because I’m on the pill."

D. "I may have some upset stomach, but I should still take my medication as directed."

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Rick and Morty (2013) - S01E03 clip with quote Tuberculosis coming in fast! Yarn is the best search for video clips by quote. Find the exact moment in a TV show, movie, or music video you want to share. Easily move forward or backward to get to the perfect clip.

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Discuss herbal remedies that can be used during pregnancy for women experiencing nausea and vomiting

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A patient in a long-term care facility who has COPD receives prednisone 10 mg daily to help manage her respiratory status. Upon reviewing the patient’s chart, the nurse notices that the patient was diagnosed with osteoporosis in the past, but is not currently receiving medications indicated for osteoporosis. The nurse is concerned because the patient requires assistance and is a fall risk so the nurse plans to call the provider.

1. What cues in the patient’s medical history cause the nurse to be concerned about the risk for a fracture?

2. What medication(s) may be prescribed concurrently with prednisone to reduce the risk for a fracture?

3. What other patient teaching can the nurse provide to help reduce the patient’s risk for a fracture?

4. Bedside glucose testing with sliding scale insulin is ordered for this patient, although she has no history of diabetes mellitus. What is the rationale for these orders?

5. What cues would cause the nurse to contact the provider with the hypothesis that adrenal suppression is occurring?

6. Why would this patient be more prone to infections?

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The nurse is caring for an 82-year-old woman with superior vena cava syndrome due to a clot formed around the patient’s implanted port.

The patient is on a heparin drip at 12 units/hr.

Which of the following laboratory values will be used to titrate the infusion rate?

How is this lab value measured/obtained?

What does it mean?

A. Hemoglobin (Hgb)

B. Platelet count (Plt)

C. Partial thromboplastin time (aPTT)

D. Clotting time

What is the reversal agent?

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A nurse is administering a new medication and is unsure about the potential side effects. What action should the nurse take according to the ANA Code of Ethics to ensure patient safety?

After choosing an option, which ethical principle does the correct answer represent?

A. Administer the medication as prescribed without delay.

B. Research the medication and validate that it will do more good than harm before administration.

C. Ask a colleague if they have used the medication before and proceed based on their advice.

D. Document the medication in the patient’s chart before administering it.

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While preparing to pass medications on a medical unit, the student nurse notes a client is scheduled to receive Minipress (prazosin). The student recognizes this medication will cause which of the following? Include rationale

A. Decreased gastric acid production
B. Reduced oral and respiratory secretions
C. Dilatation of arteries and veins
D. Increased cardiac preload and afterload

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The nurse is caring for a patient who is to start taking lithium (Lithobid) 300 mg 3 times daily. Which of the following statements should be included in the patient teaching?

Select all that apply.

Please also discuss all appropriate patient teaching regarding Lithium.

A. “You will need to have blood levels checked frequently for the first few months of treatment.”

B. “You should report any muscle twitches or change in coordination since those could be symptoms of too much medication in your system.”

C. “This medication will help level out your mood.”

D. “Please make sure you limit your fluid intake to 3 glasses of liquid per day.”

E. “Avoid dairy products while you are taking this medication.”

F. “You must have a baseline electromyogram before you start this medication.”

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The nurse is providing salmeterol (Serevent Diskus) to a patient on the medical unit who has a long-term history of chronic obstructive pulmonary disease. The nurse would intervene if which of the following were observed?

A. The patient did not attach a spacer prior to inspiration.

B. The patient closes the device after inhalation without washing the mouthpiece.

C. The patient held the diskus level in a horizontal position.

D. The patient exhaled into the diskus device.

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A nursing faculty is observing a student nurse prepare and provide morning medications including delayed-released esomeprazole (Nexium) capsules to a patient with a nasogastric (NG) tube. The nurse should intervene if which of the following is noted?

A. The student asks the patient to state his name and birth date prior to preparing the medication.

B. The student opens the capsule and mixes the granules with 50 mL of water.

C. The student uses a 60 mL cath-tipped syringe to instill the medication into the NG tube.

D. The student waited for the granules to dissolve to prevent clogging of the NG tube.

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Which of the following would cause the nurse to suspect that a client taking metformin (Glucophage) may be developing lactic acidosis? Select all that apply.

A. Client reports chills and muscle aches.
B. Blood pressure = 98/54 mmHg.
C. Client reports profound headache and ringing in the ears.
D. Client complains of dizziness and diarrhea.
E. White blood cell count = 7500 cell/mm³.
F. Pupils are dilated and unresponsive to light.

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The nurse is caring for a patient who had a total hip replacement yesterday.

Based on the patient’s risk of developing deep vein thrombosis or pulmonary emboli, which of the following would the nurse expect to find in the patient’s plan of care?

Select all that apply.

Explain your rationale for the correct ones and also why you didn't choose the other options.

A. Bilateral thigh-high sequential compression stockings

B. Dalteparin (Fragmin) 5,000 IU SQ every day

C. Strict bed rest for 3 days

D. Vital signs and pulse oximetry every 4 hr

E. Enoxaparin (Lovenox) 30 mg IV push—single dose now

F. Aspirin 650 mg every 4 hr while awake