Elevated · ATI Pharmacology Book

TL;DR · One-glance summary

Pharmacokinetics = ADME: Absorption (route-dependent), Distribution (blood flow + protein binding), Metabolism (mostly hepatic via P450), Excretion (mostly renal). First-pass effect reduces oral bioavailability. Half-life guides dosing interval. Therapeutic index (TI) — low TI drugs (digoxin, lithium, warfarin) need close monitoring.

The four phases (ADME)

Absorption: GI tract, IM, SC, IV, etc. — IV is 100% bioavailable
Distribution: lipid solubility, blood flow, plasma protein binding (albumin)
Metabolism: liver enzymes (CYP450) — first-pass effect with oral route
Excretion: primarily kidneys — adjust dose for renal impairment

Key concepts

Half-life: time for drug concentration to drop by 50%
Steady state: reached after 4–5 half-lives
Peak/trough: monitor for low-TI medications
Onset, peak, duration: nurse times assessments accordingly

Important kinetic concepts

Bioavailability: Fraction of dose reaching systemic circulation; IV = 100%; PO varies widely
First-pass effect: Hepatic metabolism on first GI absorption — reduces oral bioavailability (e.g., nitroglycerin given SL/IV/patch to bypass)
Loading dose: Higher initial dose to rapidly reach therapeutic level (faster than waiting 4–5 half-lives)
Prodrug: Inactive until metabolized (e.g., codeine → morphine; enalapril → enalaprilat)
Routes ranked by absorption speed: IV (instant) > inhaled > SL > IM/SC > PO > topical
Z-track IM injection: For irritating meds (iron dextran, hydroxyzine) — pull skin laterally, inject, hold 10 sec, release
Enterohepatic recirculation: Prolongs half-life of some drugs (digoxin, OCPs); antibiotics that disrupt gut flora can decrease this

Absorption & Routes of Administration

Absorption is the transmission of medication from the site of administration to the bloodstream. The rate determines onset; the amount determines intensity. Route choice depends on the medication's properties, the urgency of effect, and client factors.

Oral (PO) and enteral

Most common

Tablets, capsules, liquids, suspensions, elixirs, lozenges. Convenient and inexpensive but absorption is variable.

Absorption pattern

Varies greatly with stability, solubility, GI pH, emptying time, food presence
Enteric-coated tablets and sustained-release forms — do not crush or chew
First-pass effect through the liver reduces oral bioavailability

Nursing considerations

Hold for NPO, dysphagia, vomiting
Verify swallowing ability
Check for crushing/splitting compatibility

Sublingual / Buccal

Rapid systemic action

Dissolves under tongue (SL) or against cheek (buccal). Bypasses first-pass effect — rapid systemic absorption.

Pattern

Quick absorption through highly vascular mucous membranes
Swallowing before dissolution allows gastric pH to inactivate the medication
Common examples: nitroglycerin (SL), buprenorphine (buccal)

Teaching

Do not swallow until fully dissolved
Avoid eating, drinking, or smoking during dissolution

Other mucous membranes (rectal, vaginal)

Suppositories and vaginal applications produce both local and systemic effects depending on the medication.

Absorption

Easy absorption with both local and systemic effects
Stool in the rectum or infectious material in the vagina limits tissue contact

Uses

Rectal: antiemetics (promethazine), laxatives, hemorrhoid preparations
Vaginal: antifungals (miconazole), hormonal therapy

Inhalation

Direct delivery to lungs

Medication delivered via metered-dose inhaler (MDI), dry powder inhaler (DPI), or nebulizer. Local effect for respiratory conditions; some systemic absorption.

Absorption pattern

Rapid absorption through alveolar capillary network
Barrier: inadequate inspiratory effort
Use a spacer with MDI to ↑ drug delivery to lungs, ↓ deposition in oropharynx

MDI with spacer technique

Remove cap; shake inhaler 5–6 times
Insert MDI into spacer end
Exhale completely; seal lips around mouthpiece
Press inhaler and begin slow, deep inhalation (3–5 sec)
Hold breath for 10 seconds; exhale slowly through pursed lips

Intradermal, topical, transdermal

Local and slow systemic

Topical creams/ointments treat skin conditions; transdermal patches deliver steady systemic medication over hours to days.

Patterns

Slow, gradual absorption
Effects primarily local, but systemic possible with lipid-soluble drugs (passes through SC fat)

Transdermal patch teaching

Apply to clean, dry, hairless skin (do not shave — use scissors if needed)
Rotate sites; do not place on same site as old patch
Remove old patch before applying new — never two patches at once
Wash hands after applying
Avoid direct heat (heating pads, hot tubs) — accelerates absorption (especially dangerous with fentanyl)

Subcutaneous (SC) and intramuscular (IM)

Parenteral

Injection into subcutaneous fat (SC) or muscle (IM). Bypasses GI tract; useful when oral route unavailable or for medications inactivated by GI environment (insulin).

Absorption

Capillary walls have large gaps — no significant barrier
Highly soluble medications absorb in 10–30 min; poorly soluble drugs absorb slowly
↑ blood perfusion at injection site = ↑ rate of absorption

IM sites & technique

Vastus lateralis: Preferred for infants < 1 year
Ventrogluteal: Preferred for IM injections and volumes > 2 mL
Deltoid: Smaller muscle; max 1 mL typically; common for vaccines
Z-track method for irritating drugs (iron dextran): pull skin laterally, inject, hold 10 sec, release

Intravenous (IV)

Most rapid and complete

Direct infusion into the vein. 100% bioavailability and immediate onset. Carries the highest risk for adverse effects and toxicity.

Properties

No barriers — immediate and complete
Enters blood directly; reaches systemic circulation in entirety
Allows precise titration and rapid effect

Risks

Cannot be reversed easily once given
Risk of infiltration, extravasation, phlebitis, infection, air embolism, fluid overload
Some medications are vesicants (chemo, dopamine, vasopressors) — extravasation causes tissue necrosis
Always verify patency; flush before/after med administration per protocol

Distribution

Distribution is the transportation of medication to sites of action by bodily fluids. Three primary factors affect distribution: circulation, cell membrane permeability, and plasma protein binding.

Circulation

Conditions that inhibit blood flow or perfusion delay distribution.

Conditions that impair distribution

Peripheral vascular disease
Cardiac disease (heart failure, shock)
Edema and inflammation in target tissue

Permeability of cell membranes

The medication must cross tissues and membranes to reach its target. Lipid solubility and transport systems determine penetration.

What crosses easily

Lipid-soluble medications (cross blood-brain barrier and placenta)
Small uncharged molecules
Medications with active transport systems

Implications

Pregnancy: assume the medication crosses the placenta unless proven otherwise
CNS effects: lipid-soluble drugs (most psychotropics, opioids) cross BBB

Plasma protein binding

Medications compete for protein binding sites in the blood — primarily albumin. Only the unbound (free) fraction is active.

Key concepts

Two medications competing for the same binding site → ↑ free fraction → ↑ effect/toxicity
Low albumin (malnutrition, liver disease, older adults) → ↑ free drug → ↑ effect
Highly protein-bound drugs (warfarin, phenytoin) are most affected by displacement

Metabolism (biotransformation)

Metabolism converts medications into more active, less active, or inactive forms via enzymatic action. Occurs primarily in the liver but also kidneys, lungs, intestines, and blood.

Factors affecting metabolism

Multiple factors alter the rate at which the body metabolizes medications, requiring dosage adjustments.

Factors that ↓ metabolism (require ↓ dose)

Liver failure — decreased enzyme activity
Aging — hepatic metabolism declines, accumulation possible
Concurrent medications metabolized by the same enzyme pathway
Infants — immature liver enzymes

Factors that ↑ metabolism (require ↑ dose)

Concurrent enzyme-inducing medications (carbamazepine, phenytoin, rifampin, St. John's wort)
Increased medication-metabolizing enzymes
Smoking ↑ metabolism of theophylline

First-pass effect

Oral medications absorbed in the GI tract pass through the liver before reaching systemic circulation. The liver metabolizes a portion, reducing the amount that reaches systemic circulation (oral bioavailability).

Routes that bypass first-pass effect

IV, IM, SC, sublingual, buccal, transdermal, inhaled
Example: Nitroglycerin is given SL, IV, transdermal, or buccal — never PO standard tablet (almost completely destroyed in first pass)

Prodrugs

Inactive medications that become active after metabolism.

Examples

Codeine → morphine (CYP2D6)
Enalapril → enalaprilat
Levodopa → dopamine
Clopidogrel requires CYP2C19 activation

Excretion

Excretion is the elimination of medication from the body, primarily via the kidneys. Other routes include bile/feces, lungs (volatile substances), sweat, saliva, and breast milk.

Renal excretion

The kidneys filter most medications and their metabolites. Renal function determines elimination rate.

Key points

↓ glomerular filtration rate (GFR) → ↑ medication accumulation → ↑ risk of toxicity
Renal impairment: ↓ dose for renally-cleared drugs (digoxin, aminoglycosides, vancomycin, lithium, metformin)
Older adults: assume some degree of reduced renal function
Monitor creatinine clearance (CrCl) and BUN/creatinine for renally-cleared drugs

Other routes of excretion

Some medications use additional or alternative routes.

Routes

Bile/feces — enterohepatic recirculation prolongs effect of some drugs
Lungs — volatile drugs and gases (anesthetics, alcohol)
Breast milk — drugs may transfer to nursing infant
Sweat, saliva, tears — small amounts

Half-life, Steady State, and Therapeutic Index

Half-life determines dosing frequency. Steady state determines when full effect is reached. Therapeutic index determines how closely the drug must be monitored.

Half-life (t½)

The time required for the medication concentration to decrease by 50%. Determines dosing frequency.

Implications

Short half-life → multiple daily doses (e.g., ibuprofen QID)
Long half-life → once daily dosing (e.g., phenobarbital, levothyroxine)
Time to clear drug: approximately 4–5 half-lives
Time to reach steady state: approximately 4–5 half-lives with regular dosing

Steady state

When the amount of medication entering the body equals the amount eliminated. Therapeutic effect plateaus.

Loading dose

A larger initial dose to reach therapeutic level quickly
Used when waiting 4–5 half-lives is impractical (e.g., digoxin, amiodarone, antiretrovirals)
Followed by smaller maintenance doses

Therapeutic index (TI)

The ratio of toxic to therapeutic dose. A high TI means a wide safety margin; a low TI means a narrow margin where toxicity is close to therapeutic levels.

Low-TI medications (require monitoring)

Digoxin — therapeutic 0.5–2.0 ng/mL
Lithium — therapeutic 0.6–1.2 mEq/L
Warfarin — monitored via INR (2–3 standard)
Phenytoin — therapeutic 10–20 mcg/mL
Theophylline — therapeutic 10–20 mcg/mL
Aminoglycosides (gentamicin, tobramycin, amikacin) — peak and trough levels
Vancomycin — trough levels

Peak vs trough monitoring

Peak: Highest concentration — typically drawn 30 min after IV finishes (or per drug-specific timing)
Trough: Lowest concentration — drawn immediately before the next scheduled dose
Trough below the toxic threshold confirms safe dosing interval

Active Learning Scenario

From the book — uses the ATI Active Learning Template: Therapeutic Procedure. Practice answering before reviewing the key.

Scenario

A nurse is showing a client how to use a metered-dose inhaler (MDI) with a spacer. What should the nurse include in the instructions? Use the ATI Active Learning Template: Therapeutic Procedure to complete this item.

Show key

Indications

Medication absorption pattern: Rapid absorption through the alveolar capillary network. A spacer keeps the medication in the device longer, increasing the amount delivered to the lungs and decreasing the amount deposited in the oropharynx.
Barrier to absorption: Inadequate respiratory effort.

Client Education — Steps for MDI with Spacer

Remove the covers from the mouthpieces of the inhaler and of the spacer
Insert the MDI into the end of the spacer
Shake the inhaler five or six times
Exhale completely, then close your mouth around the spacer's mouthpiece
Tilt your head back slightly, press the inhaler, and at the same time begin a slow, deep inhalation
Continue to breathe in slowly and deeply for 3 to 5 seconds to facilitate delivery to the air passages
Hold your breath for 10 seconds to allow the medication to deposit in your airways
Take the mouthpiece out of your mouth and slowly exhale through pursed lips
Resume normal breathing

Practice · Application Exercises

5 NCLEX-style questions covering Ch 1 core content. Click each exercise to reveal rationales and NCLEX category.

Q1

A provider prescribes phenobarbital for a client who has a seizure disorder. The medication has a long half-life of 4 days. How many times per day should the nurse expect to administer this medication?

A. One
B. Two
C. Three
D. Four

Show rationale ▾

A. CORRECT. Medications with long half-lives remain at their therapeutic levels between doses for long periods. The nurse should expect to administer this medication once a day.

B. A medication administered twice a day would have a shorter half-life. An example is vancomycin.

C. A medication administered three times a day would have a shorter half-life. An example is zidovudine.

D. A medication administered four times a day would have a shorter half-life. An example is ibuprofen.

NCLEX · Pharmacological & Parenteral Therapies · Medication Administration

Q2

A nurse educator is reviewing medication metabolism at an in-service presentation. Which of the following factors should the educator include as a reason to administer lower medication dosages? (Select all that apply.)

A. Increased renal excretion
B. Increased medication-metabolizing enzymes
C. Liver failure
D. Peripheral vascular disease
E. Concurrent use of medication that the same pathway metabolizes

Show rationale ▾

A. Increased renal excretion decreases the concentration of the medication, requiring an INCREASED dosage.

B. Increased metabolism decreases the concentration of the medication, requiring an INCREASED dosage.

C. CORRECT. Liver failure decreases metabolism and thus increases the concentration of a medication. This requires decreasing the dosage.

D. PVD impairs distribution, but the medication remains in circulation longer at lower levels, often requiring an INCREASED dosage to reach target tissues.

E. CORRECT. When the same pathway metabolizes two medications, they compete for metabolism, thereby increasing the concentration of one or both medications. This requires decreasing the dosage.

NCLEX · Pharmacological & Parenteral Therapies · Adverse Effects/Contraindications/Side Effects/Interactions

Q3

A nurse is preparing to administer eye drops to a client. Which of the following actions should the nurse take? (Select all that apply.)

A. Have the client lie on one side
B. Ask the client to look up at the ceiling
C. Tell the client to blink when the drops enter the eye
D. Drop the medication into the client's conjunctival sac
E. Instruct the client to close the eye gently after instillation

Show rationale ▾

A. The client should be sitting or in a supine position to facilitate the instillation of eye drops.

B. CORRECT. The client should look upward to keep the drops from falling onto the cornea.

C. Ideally, the client should not blink so that they do not eject the eye drops. If they do blink, repeat the instillation.

D. CORRECT. Dropping medication into the conjunctival sac promotes distribution.

E. CORRECT. Closing the eye gently promotes distribution of the medication.

NCLEX · Pharmacological & Parenteral Therapies · Medication Administration

Q4

A nurse is teaching a client about transdermal patches. Which of the following statements should the nurse identify as an indication that the client understands?

A. "I will clean the site with an alcohol swab before I apply the patch."
B. "I will rotate the application sites weekly."
C. "I will apply the patch to an area of skin with no hair."
D. "I will place the new patch on the site of the old patch."

Show rationale ▾

A. The site should be clean and dry, but alcohol swabs are not necessary and can irritate the skin.

B. Rotation should occur with each new patch application — typically every 24–72 hours depending on the patch — not weekly.

C. CORRECT. A hairless area allows good adhesion and consistent absorption. If hair is present, use scissors to trim — do not shave (causes skin trauma → variable absorption).

D. Sites should be rotated to prevent skin irritation and ensure consistent absorption.

NCLEX · Pharmacological & Parenteral Therapies · Medication Administration

Q5

A nurse reviewing a client's medical record notes a new prescription for verifying the trough level of the client's medication. Which of the following actions should the nurse take?

A. Obtain a blood specimen immediately prior to administering the next dose of medication
B. Verify that the client has been taking the medication for 24 hr before obtaining a blood specimen
C. Ask the client to provide a urine specimen after the next dose of medication
D. Administer the medication, and obtain a blood specimen 30 min later

Show rationale ▾

A. CORRECT. Trough levels reflect the lowest concentration of medication in the blood, which is just before the next dose. This is used to verify the medication has not accumulated to toxic levels.

B. Trough levels are obtained once steady state has been reached, which typically takes 4–5 half-lives — usually longer than 24 hours.

C. Medication levels are measured in blood (serum), not urine.

D. This would measure the peak level, not the trough level.

NCLEX · Pharmacological & Parenteral Therapies · Pharmacological Pain Management

TL;DR · One-glance summary

Six rights: right patient, drug, dose, route, time, documentation (plus reason, response). Verify by checking three times against the MAR. Use two patient identifiers. High-alert medications (insulin, opioids, heparin, KCl) require independent double-check. ISMP do-not-use abbreviations cause errors.

Rights of medication administration

Right patient (two identifiers)
Right medication (read label 3 times)
Right dose (calculate, verify with another nurse for high-alert)
Right route
Right time
Right documentation
Right reason and right response

Error prevention

Use barcode scanning (BCMA)
Compute calculations independently
Question unclear or unusual orders
Never crush enteric-coated or sustained-release tablets
Do not leave meds at bedside (unless ordered)
Report all errors per facility policy

Controlled substances, errors & reporting

Controlled substance schedules (DEA):
• Schedule I: No accepted medical use (heroin, LSD, marijuana federally)
• Schedule II: High abuse potential, accepted medical use — morphine, oxycodone, fentanyl, methylphenidate, amphetamines
• Schedule III: Moderate potential — buprenorphine, ketamine, anabolic steroids
• Schedule IV: Lower potential — benzodiazepines, tramadol, zolpidem
• Schedule V: Lowest potential — pregabalin, low-dose codeine cough preparations
Controlled substance documentation: Count at every shift change with another nurse; document discrepancies immediately
Wasting: Two licensed staff witness disposal of unused portions
ISMP do-not-use abbreviations: U/u (use "units"), IU (use "international units"), Q.D./QD (use "daily"), Q.O.D./QOD (use "every other day"), MS/MSO4/MgSO4 (use full name), trailing zero (10.0 mg → 10 mg), leading zero (.5 mg → 0.5 mg)
Tall-man lettering distinguishes look-alike drug names (hydrOXYzine vs hydrALAzine; predniSONE vs predniSOLONE; vinBLAStine vs vinCRIStine)
Medication reconciliation required at admission, transfer, and discharge — compare current meds with new orders
Error reporting: Complete incident/occurrence report per facility policy — used for system improvement, NOT punishment; near-misses also reported
Just culture: Distinguishes human error, at-risk behavior, and reckless behavior; supports learning from errors

Six Rights of Medication Administration

The foundational checks performed every time a medication is given. Use them at three checkpoints: when removing the medication, when preparing it, and at the bedside before administration.

The 6 (or 8) Rights

Verify every dose

The classic six rights protect against medication errors. Many facilities now add right reason, right response, and right documentation.

Core six rights

Right patient — verify with two identifiers (name, DOB, MR#); scan barcode
Right medication — read label three times: when removing, when preparing, before administering
Right dose — verify calculation; independent double-check for high-alert (insulin, heparin, opioid drips, chemo)
Right route — confirm the prescribed route; never assume
Right time — within 30 minutes of scheduled time (per facility); first-dose and STAT promptly
Right documentation — after administration, not before; include any deviations

Additional rights

Right reason — understand why this client needs this medication now
Right response — assess for therapeutic effect and adverse reactions
Right to refuse — clients can decline; document and notify provider

Two patient identifiers

Use two unique identifiers before administering any medication. Room number is NOT an identifier.

Acceptable identifiers

Full name and date of birth
Medical record number
Hospital armband barcode (scan)
Government-issued photo ID (outpatient)

Special situations

Unconscious/non-verbal: armband + family confirmation
Children: ask the parent to state the child's name and DOB
Cognitively impaired adults: armband + family member or caregiver

Error Prevention

Medication errors are preventable. Use technology, double-checks, and standardized practices to reduce risk. Errors are reported as part of a Just Culture — focus is on system improvement, not punishment.

Technology safeguards

Bedside technology has substantially reduced errors but is not a substitute for nursing vigilance.

Tools

Barcode medication administration (BCMA): Scan client armband and medication; system flags mismatches
Smart pumps: Built-in drug libraries with dose-range limits; flag potentially unsafe rates
eMAR (electronic medication administration record): Real-time updates; allergy alerts
Override functionality should be used cautiously and documented

Communication safeguards

Many errors trace back to communication breakdowns.

Best practices

Read back verbal/telephone orders; have the prescriber repeat
SBAR communication for handoffs (Situation, Background, Assessment, Recommendation)
Bedside handoff with the off-going nurse
Question any unclear or unusual orders before administering
Never accept a verbal order in a non-emergency situation if avoidable

Special formulation cautions

Certain medication forms have administration restrictions that prevent errors.

Do NOT crush or chew

Enteric-coated tablets
Sustained-release / extended-release (ER, XR, XL, SR, CR)
Sublingual or buccal tablets
Capsules (unless specifically labeled to open)
Crushing changes pharmacokinetics — can cause toxicity (release entire dose at once) or therapeutic failure

Other cautions

Never leave medication at bedside (unless ordered, e.g., nitroglycerin within client reach)
Never administer a medication someone else prepared (except pharmacy)
Never recap needles routinely
Dispose of sharps in approved containers

Tall-man lettering

A system of mixed-case letters that highlights distinguishing letters in look-alike drug names. Prevents wrong-drug errors.

Common tall-man pairs

hydrOXYzine (antihistamine, anxiolytic) vs hydrALAzine (antihypertensive)
predniSONE (oral) vs predniSOLONE (different potency)
vinBLAStine vs vinCRIStine (chemotherapy — fatal if confused)
DAUNOrubicin vs DOXOrubicin
cycloSERINE vs cycloSPORINE

ISMP Do-Not-Use abbreviations

The Institute for Safe Medication Practices (ISMP) maintains a list of dangerous abbreviations that should not be used. The Joint Commission requires elimination of these from prescribing.

Common forbidden abbreviations

U or u → use "units" (mistaken for 0, 4, or cc)
IU → use "international units"
QD or Q.D. → use "daily"
QOD or Q.O.D. → use "every other day"
Trailing zero (10.0 mg) → use 10 mg (decimal point can be missed)
Missing leading zero (.5 mg) → use 0.5 mg (decimal point can be missed)
MS, MSO4, MgSO4 → use full name (morphine sulfate vs magnesium sulfate confusion)
SC, SQ → use "subcut" or "subcutaneously"

Controlled Substances

The DEA classifies certain medications with abuse potential into five Schedules. Schedule I has no accepted medical use; Schedules II–V are prescribed but require special handling, documentation, and security.

DEA Schedules

Schedule classification determines prescribing restrictions, refills allowed, and storage requirements.

Schedule II — high abuse potential, accepted medical use

No refills allowed; written or electronic prescription required (some states allow phone for emergency, with written follow-up)
Examples: morphine, oxycodone, hydromorphone, fentanyl, methadone, methylphenidate, amphetamines, cocaine

Schedule III — moderate abuse potential

Refills allowed (up to 5 in 6 months)
Examples: buprenorphine, ketamine, anabolic steroids, codeine combination products, testosterone

Schedule IV — lower abuse potential

Refills allowed (up to 5 in 6 months)
Examples: benzodiazepines (alprazolam, diazepam, lorazepam), tramadol, zolpidem, eszopiclone, modafinil

Schedule V — lowest abuse potential

Some available OTC (state-dependent); refills similar to Schedule IV
Examples: pregabalin, low-dose codeine in cough preparations, diphenoxylate/atropine (Lomotil)

Handling and documentation

Controlled substances require strict accountability to prevent diversion.

Nursing responsibilities

Count at every shift change with another licensed nurse — both sign
Any discrepancy: investigate immediately; do not give the next dose until resolved
Document on the controlled substance record at the time of administration
Wasting: Two licensed staff witness disposal of unused portions (e.g., a partial vial of morphine) and both sign
Lock storage in a double-locked cabinet or automated dispensing machine (e.g., Pyxis)
Report suspected diversion through facility chain of command

Medication Reconciliation & Pregnancy Categories

Reconciliation prevents discrepancies between what the client takes and what is prescribed. Pregnancy categories (now replaced by detailed labeling) guide safety decisions.

Medication reconciliation

A formal process required at every transition of care to prevent omissions, duplications, dosing errors, and interactions.

When to reconcile

On admission to a healthcare facility
At each transfer (e.g., ICU to floor, ED to admission)
At discharge
After each provider visit

What to include

Prescription medications (name, dose, route, frequency, last dose)
Over-the-counter medications
Herbal supplements and vitamins
Recreational substances if disclosed
Compare with new orders; reconcile any discrepancies with the provider

Pregnancy categories (older FDA system)

The FDA pregnancy categories (A, B, C, D, X) were the standard until 2015. The newer Pregnancy and Lactation Labeling Rule (PLLR) replaces these with narrative summaries, but the letter categories still appear on many references.

FDA letter categories

A — adequate human studies show no fetal risk (rare; example: levothyroxine, prenatal vitamins)
B — animal studies show no risk OR animal toxicity not confirmed in humans (acetaminophen, most penicillins, metformin, ondansetron)
C — animal studies show harm OR no adequate studies; use only if benefits outweigh risks (most drugs)
D — evidence of human fetal harm; may be used if benefit outweighs risk in serious illness (phenytoin, lithium, paroxetine)
X — contraindicated; risks clearly outweigh any benefit (warfarin, isotretinoin, methotrexate, statins, thalidomide, misoprostol)

PLLR (current) sections

Pregnancy: includes risk summary and clinical considerations
Lactation: information on drug transfer to milk and infant effects
Females and Males of Reproductive Potential: contraception requirements, fertility effects

Active Learning Scenario

From the book — uses the ATI Active Learning Template: Nursing Skill. Practice answering before reviewing the key.

Scenario

A nurse is preparing to administer a medication to a client. List the steps a nurse should take to verify the right client. Use the ATI Active Learning Template: Nursing Skill to complete this item.

Show key

Description of Skill — Verifying the Right Client

Use two unique identifiers before each medication administration
Acceptable identifiers: full name, date of birth, medical record number
Compare the medication administration record (MAR) against the client's identification armband
Scan the client's armband and the medication barcode when available
Ask the client to state their name and date of birth (when able)
For unconscious/non-verbal clients, verify with armband and a family member

Indications for Use of Two Identifiers

Reduces wrong-patient errors
Required by The Joint Commission National Patient Safety Goal
Used at every medication administration, blood transfusion, specimen collection

Considerations

Never use room number or location as an identifier
If barcode scanning fails, do not bypass — re-verify manually and troubleshoot
Document any deviation from standard process per facility policy

Practice · Application Exercises

5 NCLEX-style questions covering Ch 2 core content. Click each exercise to reveal rationales and NCLEX category.

Q1

A nurse is preparing to administer medications. Which of the following actions should the nurse take to prevent medication errors?

A. Read the medication label three times: when removing the container, when preparing the medication, and at the bedside before administering it
B. Crush the enteric-coated tablet to make it easier to swallow
C. Leave the medication at the bedside for the client to take when they are ready
D. Document medication administration immediately before giving the medication

Show rationale ▾

A. CORRECT. Reading the label three times is the standard safety practice that catches errors at each handling step. This is a foundational principle of medication safety.

B. Crushing enteric-coated tablets destroys the protective coating and can cause GI irritation, drug instability, or release of the entire dose at once.

C. Medications should not be left at the bedside (unless specifically ordered, like nitroglycerin) — they may be missed, misplaced, or taken by another person.

D. Documentation should occur AFTER the medication is administered, not before. Documenting first risks omission if the client refuses or the medication is held.

NCLEX · Safety and Infection Control · Medication Administration · Error Prevention

Q2

A nurse is reviewing the ISMP list of error-prone abbreviations. Which of the following abbreviations should the nurse identify as appropriate to use in a medication order? (Select all that apply.)

A. "units" instead of "U"
B. "daily" instead of "QD"
C. "morphine sulfate" instead of "MS"
D. "0.5 mg" instead of ".5 mg"
E. "5.0 mg" instead of "5 mg"

Show rationale ▾

A. CORRECT. CORRECT — "U" can be misread as "0," "4," or "cc," leading to massive overdose. Always write out "units."

B. CORRECT. CORRECT — "QD" can be misread as "QID" (four times a day) or "QOD" (every other day). Write out "daily."

C. CORRECT. CORRECT — "MS" or "MSO4" can be confused with "MgSO4" (magnesium sulfate). Always write the full name.

D. CORRECT. CORRECT — Always use a leading zero before a decimal point so the decimal is not missed. ".5 mg" can look like "5 mg" (10× overdose).

E. INCORRECT — Trailing zeros should be removed. "5.0 mg" can be misread as "50 mg" if the decimal point is missed.

NCLEX · Safety and Infection Control · Reporting of Incident/Event

Q3

A nurse on a medical unit is signing out a controlled substance for administration. Which of the following actions is the priority?

A. Wait until the end of shift to count and verify with another nurse
B. Document the dose on the MAR before administering it
C. Verify the count with another licensed nurse before removing the dose
D. Discard any unused portion in the sharps container

Show rationale ▾

A. Controlled substance counts occur at shift change, but discrepancies for a current dose must be addressed immediately, not at the end of shift.

B. Document AFTER administering, not before. This is true for all medications, but especially important for controlled substances where wasted doses must be accounted for.

C. CORRECT. CORRECT — Controlled substance counts must be verified by two licensed staff. Discrepancies must be investigated immediately, before continuing administration.

D. Unused portions must be wasted in front of a second licensed witness who co-signs the wasting documentation. Discarding alone or in the wrong container does not provide accountability.

NCLEX · Pharmacological & Parenteral Therapies · Medication Administration

Q4

A nurse is performing medication reconciliation for a newly admitted client. Which of the following should the nurse include?

A. Only prescription medications taken regularly
B. Prescription medications, OTC products, and herbal supplements
C. Only medications the client took in the past 24 hours
D. Medications listed in the discharge summary from the previous admission

Show rationale ▾

A. Reconciliation must include ALL substances the client takes — prescription, OTC, herbal, vitamins — because all can interact.

B. CORRECT. CORRECT — Complete reconciliation includes all medications and supplements. Herbals especially can have major interactions (e.g., St. John's wort with antidepressants, antiretrovirals, anticoagulants).

C. A 24-hour window misses medications taken every other day, weekly, or as needed. Reconciliation looks at the client's full current regimen.

D. Discharge summaries are a useful reference but the client's current regimen may differ. Confirm with the client and/or caregiver.

NCLEX · Management of Care · Continuity of Care

Q5

A nurse is teaching a group of nursing students about FDA pregnancy categories. Which of the following medications should the nurse identify as Category X (contraindicated in pregnancy)? (Select all that apply.)

A. Warfarin
B. Acetaminophen
C. Isotretinoin
D. Methotrexate
E. Insulin

Show rationale ▾

A. CORRECT. CORRECT — Warfarin is a known teratogen causing fetal warfarin syndrome (skeletal abnormalities, CNS defects). Use heparin or LMWH in pregnancy instead.

B. Acetaminophen is Category B and considered safe at therapeutic doses throughout pregnancy. It is the first-line analgesic/antipyretic in pregnancy.

C. CORRECT. CORRECT — Isotretinoin (Accutane) is a potent teratogen causing severe craniofacial and cardiac defects. Requires the iPLEDGE program with strict contraception requirements.

D. CORRECT. CORRECT — Methotrexate is an abortifacient and teratogen. Used to terminate pregnancy in some cases; contraindicated when continued pregnancy is desired.

E. Insulin is Category B and is the preferred treatment for diabetes in pregnancy. Most oral antidiabetic agents are avoided.

NCLEX · Pharmacological & Parenteral Therapies · Adverse Effects/Contraindications

TL;DR · One-glance summary

Three methods: ratio-proportion, formula method (Desired/Have × Volume), dimensional analysis. Pediatric doses: mg/kg/day (always weight-based). IV flow rates: gtt/min = (mL × gtt/mL) ÷ min. Always double-check calculations for high-alert drugs.

Standard formulas

Tablet/capsule: Desired ÷ Have = number of units
Liquid: (Desired ÷ Have) × Volume = mL
IV rate: mL/hr = total volume ÷ time in hours
IV drip: (mL × drop factor) ÷ minutes = gtt/min

Pediatric calculations

Doses always based on weight (kg)
Verify safe range: dose × weight = total daily dose
Compare to recommended dose range — call provider if outside range
Use age-appropriate measurement devices (oral syringes)

Common calculation formulas

Tablets: Desired ÷ Have = number of tablets
Liquid: (Desired ÷ Have) × Volume on hand = mL
Pediatric weight-based: Convert lb to kg (lb ÷ 2.2); then mg/kg × kg = total daily dose; divide by # of doses/day
IV continuous: mL/hr = total volume (mL) ÷ time (hr)
IV drip (gtt/min): (Volume × drop factor) ÷ time in minutes
Drop factors (gtt/mL): Macrodrip 10/15/20; microdrip = 60 (1 mL = 60 gtt; mL/hr = gtt/min for micro)
Safe dose verification: Calculate dose × weight = expected; compare to ordered; hold and call provider if outside safe range
Round per facility policy; pediatric — usually to nearest tenth; high-alert (insulin, heparin) — independent double-check

Three Methods of Dosage Calculation

Three commonly-taught methods produce the same answer: ratio-proportion, formula method (desired over have), and dimensional analysis. Choose the method you find clearest — what matters is accurate calculation.

Ratio-proportion method

Universal applicability

Set up known and unknown ratios as equivalent fractions, then solve for the unknown.

Steps

Step 1: Write the known ratio (what you have)
Step 2: Write the unknown ratio (what you want)
Step 3: Cross-multiply and solve for x
Example: Order = 750 mg; on hand = 500 mg/tab → 500/1 = 750/x → x = 1.5 tabs

Formula method (Desired ÷ Have × Quantity)

Most common

Use when the units match. Quantity is the volume or number of units per dose.

Formula

(Desired ÷ Have) × Quantity = amount to administer
Example: Desired = 25 mg; have = 100 mg/2 mL → (25 ÷ 100) × 2 = 0.5 mL
Always check that units cancel correctly — if not, conversions are needed

Dimensional analysis

Best for multi-step conversions

Set up a chain of conversion factors so unwanted units cancel and only the desired unit remains. Particularly useful for weight-based and IV drip calculations.

Steps

Step 1: Write the desired unit (left side of equation = X with appropriate unit)
Step 2: Find a factor with the same unit on top (right side starts there)
Step 3: Add factors so unwanted units cancel diagonally (numerator-denominator)
Step 4: Multiply across; the only remaining unit should be the desired unit
Example: 8 mg/kg/day × 10 kg × 1 day = 80 mg/day total

Key Formulas

Memorize these common formulas. They cover the majority of clinical dosage calculations: tablets, liquids, IV continuous rates, IV drip rates, and pediatric doses.

Tablets and capsules

Solid oral dosage forms. Always confirm whether the tablet can be cut, crushed, or split.

Formula

Number of tablets = Desired dose ÷ Available dose per tablet
Example: Order = 750 mg; on hand = 250 mg tabs → 750 ÷ 250 = 3 tabs
Avoid splitting tablets when possible (uneven doses); never split capsules or sustained-release

Liquid medications

Oral suspensions, solutions, and parenteral medications. Always verify with marked oral syringe (oral) or appropriate volumetric measure.

Formula

Volume = (Desired dose ÷ Available concentration) × Volume of one dose
Example: Order = 40 mg; on hand = 100 mg/5 mL → (40 ÷ 100) × 5 = 2 mL
Always use oral syringe for oral liquids (never a parenteral syringe)
Never use household teaspoons — they vary widely

IV continuous infusion

Calculate the rate for IV pump programming. Pumps deliver in mL/hr.

Formula

mL/hr = Total volume (mL) ÷ Time (hours)
Example: 1000 mL over 8 hr → 125 mL/hr
Verify with pump programming; double-check high-alert infusions

IV drip rate (gtt/min) — gravity infusion

For gravity drips without a pump. Requires the drop factor (gtt/mL), found on the tubing package.

Formula

gtt/min = (Volume × Drop factor) ÷ Time in minutes
Example: 1000 mL over 8 hr, drop factor 15 gtt/mL → (1000 × 15) ÷ 480 min ≈ 31 gtt/min
Drop factors: Macrodrip = 10, 15, or 20 gtt/mL; Microdrip = 60 gtt/mL
Microdrip shortcut: mL/hr = gtt/min (one-to-one)

IV bolus / push

Direct injection of a medication into an IV line.

Considerations

Verify drug-specific push rate (per pharmacy or drug reference) — many drugs over 1–5 minutes
Hold timer; do not exceed maximum rate (e.g., furosemide ≤ 20 mg/min, vancomycin not given as push)
Flush before and after with appropriate solution

Pediatric Dose Calculations

Children's doses are ALWAYS weight-based (mg/kg or mg/kg/day) because they vary so dramatically by age and size. Verify the calculated dose is within the safe range for the medication and the child's weight.

Weight-based dosing

Always convert pounds to kilograms first: kg = lb ÷ 2.2. Some medications use mg/m² (body surface area) but most pediatric drugs use mg/kg.

Standard process

Step 1: Convert weight to kg (lb ÷ 2.2)
Step 2: Calculate total daily dose (mg/kg/day × weight in kg)
Step 3: Divide total daily dose by number of doses per day to get per-dose amount
Step 4: Convert from mg to mL using the available concentration
Step 5: Verify against safe dose range — if outside range, hold and call provider

Example

Order: cefixime 8 mg/kg/day PO divided q12h to toddler weighing 22 lb
22 lb ÷ 2.2 = 10 kg
8 mg/kg/day × 10 kg = 80 mg/day total
80 mg ÷ 2 doses = 40 mg per dose
On hand: 100 mg/5 mL → (40 ÷ 100) × 5 = 2 mL per dose

Safe dose verification

Critical safety check

Before administering ANY pediatric medication, verify the order is within the safe dose range. Hold the medication and call the provider if outside the range.

Verification steps

Look up the recommended dose range (mg/kg/day) from a drug reference
Calculate the safe range for this client (range × weight in kg)
Compare the ordered dose to the safe range
Within range: Administer
Outside range: Hold medication, call provider, document

Rounding rules

Follow facility policy and the medication's package insert.

Common pediatric rounding

Most pediatric oral liquids: round to nearest 0.1 mL (1/10)
Many IV medications: round to nearest 0.01 mL for small infants
Tablets: avoid splitting beyond scored lines; choose liquid form when available
Use appropriate measurement device (oral syringe for liquids — never household teaspoon)

High-Alert Medications & Verification

High-alert medications cause significant harm when used in error. They require additional safety measures even when used correctly.

High-alert medication classes

These categories have the highest risk profile. ISMP maintains the official list.

Examples

Insulin (all forms — especially U-500 concentration)
Anticoagulants (heparin IV, warfarin, DOACs)
Opioids (especially IV; concentrated forms)
Concentrated electrolytes (KCl, NaCl > 0.9%, MgSO4)
Chemotherapy (all forms)
Neuromuscular blockers (succinylcholine, rocuronium, vecuronium)
Digoxin, lithium, sedatives (moderate sedation)

Independent double-check

Two qualified individuals separately calculate and verify the medication and dose. Each person performs the calculation independently — not just "looks over" the other's work.

When required (per ISMP and facility policy)

Insulin IV infusions and bolus doses
Heparin IV infusions and bolus
Opioid IV continuous infusions, PCA programming
Chemotherapy preparations
IV potassium and other concentrated electrolytes
Neonatal and pediatric high-alert medications

Process

Each nurse independently calculates the dose
Each nurse independently verifies the medication, concentration, pump settings, line tracing
Both sign documentation only after agreement
If disagreement: stop, recalculate, involve a third party if needed

Active Learning Scenario

From the book — uses the ATI Active Learning Template: Nursing Skill. Practice answering before reviewing the key.

Scenario

A nurse is preparing to administer cefixime 8 mg/kg/day PO divided every 12 hours to a toddler who weighs 22 lb. Available is cefixime suspension 100 mg/5 mL. How many mL should the nurse administer per dose? Use the ATI Active Learning Template: Nursing Skill to complete this item.

Show key

Description of Calculation Steps

Step 1: Convert weight — 22 lb ÷ 2.2 = 10 kg
Step 2: Calculate total daily dose — 8 mg/kg/day × 10 kg = 80 mg/day
Step 3: Divide by doses per day — 80 mg ÷ 2 doses (q12h) = 40 mg per dose
Step 4: Calculate volume — (40 mg ÷ 100 mg) × 5 mL = 2 mL per dose
Answer: 2 mL per dose

Safety Considerations

Verify the order is within the safe dose range (5–10 mg/kg/day for cefixime in pediatrics — 8 mg/kg/day is within range)
Use an oral syringe — not a household teaspoon
Independent double-check is not required for cefixime but is good practice for any pediatric calculation
Document administration on the MAR after giving

Practice · Application Exercises

5 NCLEX-style questions covering Ch 3 core content. Click each exercise to reveal rationales and NCLEX category.

Q1

A nurse is preparing to administer digoxin 0.125 mg PO to a client. The medication is available in scored 0.25 mg tablets. How many tablets should the nurse administer?

A. 0.25 tablet
B. 0.5 tablet
C. 1 tablet
D. 2 tablets

Show rationale ▾

A. Incorrect calculation — this would deliver only 0.0625 mg, not 0.125 mg.

B. CORRECT. CORRECT — (0.125 ÷ 0.25) × 1 tablet = 0.5 tablet. The tablet is scored, so it can be safely split.

C. One tablet would deliver 0.25 mg — twice the ordered dose. This would be a serious medication error in a narrow-therapeutic-index drug.

D. Two tablets would deliver 0.5 mg — four times the ordered dose. Digoxin toxicity is dangerous.

NCLEX · Pharmacological & Parenteral Therapies · Dosage Calculation

Q2

A provider prescribes 1000 mL 0.9% NaCl to infuse over 8 hours. The IV tubing drop factor is 15 gtt/mL. How many gtt/min should the nurse set the infusion at? (Round to the nearest whole number.)

A. 21 gtt/min
B. 31 gtt/min
C. 42 gtt/min
D. 125 gtt/min

Show rationale ▾

A. This would be too slow — would not deliver the volume in 8 hours.

B. CORRECT. CORRECT — (1000 mL × 15 gtt/mL) ÷ (8 hr × 60 min/hr) = 15,000 ÷ 480 = 31.25 ≈ 31 gtt/min.

C. Too fast — would deliver the volume in less than 8 hours.

D. 125 is the mL/hr rate, not gtt/min. Confusing the two leads to massive over-infusion.

NCLEX · Pharmacological & Parenteral Therapies · Dosage Calculation

Q3

A nurse is preparing to administer amoxicillin 50 mg/kg/day PO divided every 8 hours to a child who weighs 33 lb. Available is amoxicillin suspension 250 mg/5 mL. How many mL should the nurse administer per dose? (Round to the nearest whole number.)

A. 3 mL
B. 5 mL
C. 7 mL
D. 10 mL

Show rationale ▾

A. Recalculate. 33 lb ÷ 2.2 = 15 kg; 50 mg × 15 = 750 mg/day; ÷ 3 doses = 250 mg/dose; (250 ÷ 250) × 5 = 5 mL.

B. CORRECT. CORRECT — 33 lb ÷ 2.2 = 15 kg → 50 mg/kg/day × 15 kg = 750 mg/day → 750 ÷ 3 doses = 250 mg/dose → (250 mg ÷ 250 mg) × 5 mL = 5 mL.

C. Too high — recheck the conversion and division by 3 doses per day.

D. This would deliver double the prescribed dose. Recalculate carefully.

NCLEX · Pharmacological & Parenteral Therapies · Pediatric Dosage Calculation

Q4

A nurse is administering heparin IV bolus 80 units/kg to a client who weighs 154 lb. Heparin is available 5,000 units/mL. How many mL should the nurse administer? (Round to the nearest tenth.)

A. 0.8 mL
B. 1.1 mL
C. 1.6 mL
D. 2.0 mL

Show rationale ▾

A. Recalculate the bolus dose and the volume.

B. CORRECT. CORRECT — 154 lb ÷ 2.2 = 70 kg → 80 units/kg × 70 kg = 5,600 units → 5,600 ÷ 5,000 × 1 mL = 1.12 mL ≈ 1.1 mL.

C. Recheck the conversion to kg and the multiplication.

D. Recheck — would be approximately 10,000 units, much higher than the prescribed dose.

NCLEX · Pharmacological & Parenteral Therapies · Parenteral/Intravenous Therapies

Q5

A nurse is reviewing strategies to prevent calculation errors with high-alert medications. Which of the following actions should the nurse take? (Select all that apply.)

A. Perform an independent double-check with another qualified nurse before administration
B. Use a calculator rather than mental math for all dose calculations
C. Avoid leading zeros on decimal doses (e.g., write ".5 mg" instead of "0.5 mg")
D. Confirm the dose is within the safe range for the client
E. Use trailing zeros on whole-number doses (e.g., write "5.0 mg" instead of "5 mg")

Show rationale ▾

A. CORRECT. CORRECT — Independent double-checks for insulin, heparin, opioids, chemotherapy, and concentrated electrolytes catch errors before they reach the client.

B. CORRECT. CORRECT — Mental math is a common source of error. A calculator (with the result verified) is safer and faster for complex calculations.

C. INCORRECT — Always include a leading zero before a decimal (0.5 mg, not .5 mg). The decimal point can be missed without a leading zero.

D. CORRECT. CORRECT — Verifying the calculated dose against the safe range is a fundamental check, especially for pediatric and high-alert medications.

E. INCORRECT — Trailing zeros should be avoided. "5.0 mg" can be misread as "50 mg" if the decimal point is missed.

NCLEX · Safety and Infection Control · Reporting of Incident/Event

TL;DR · One-glance summary

Crystalloids (isotonic NS/LR, hypo 0.45% NS, hyper D5NS) treat dehydration and maintenance. Colloids (albumin, dextran) expand volume. Check site for infiltration, phlebitis, infection. Central lines for irritants, vesicants, TPN, hyperosmolar solutions. IV push: always over correct time.

IV solution types

Isotonic (0.9% NS, LR) — fluid replacement, blood compatible
Hypotonic (0.45% NS) — cellular hydration
Hypertonic (D5NS, 3% NS) — pulls fluid into vascular space
Add electrolytes (KCl) carefully — never IV push K+

Complications

Infiltration: cool, swelling, no blood return
Phlebitis: redness, warmth, pain along vein
Extravasation: leakage of vesicant → tissue damage
Infection: site redness, fever, purulent drainage
Air embolism, fluid overload: assess regularly

IV complications & monitoring

Infiltration (non-vesicant solution leaks into tissue): Swelling, cool, blanched/pale, decreased flow, fluid leakage; stop IV, remove catheter, elevate limb, warm compress (cool for some); restart at different site
Extravasation (vesicant solution — chemo, dopamine, vasopressors leaks): Tissue damage/necrosis possible; stop infusion immediately, try to aspirate residual from catheter, give antidote per protocol, do NOT remove catheter until done
Phlebitis (vein inflammation): Redness, warmth, pain along the vein, possible palpable cord; remove IV, warm compress, may need culture; common with peripheral IV > 72–96 hr
Air embolism: Sudden chest pain, dyspnea, hypotension; turn client left side, Trendelenburg (keeps air in right ventricle); O2
Catheter embolism: Tip of catheter breaks off; emergency — tourniquet above site, X-ray to locate
Circulatory overload (TACO): Crackles, dyspnea, hypertension, JVD; slow rate, sit client up, O2, diuretic
Central line complications: CLABSI (bloodstream infection); pneumothorax (after subclavian/jugular insertion); air embolism; thrombosis
Tubing change: Continuous IV q96h; intermittent/secondary q24h; TPN q24h; blood/blood products with each unit; lipids q24h
IV bag/bottle: Maximum hang time 24 hr (less for blood, TPN, lipids); date and time when hung
Site rotation: Peripheral IV typically rotated q72–96h per CDC; can be longer if needed

IV Solutions

IV fluids are categorized by tonicity (osmolality compared to plasma). Choosing the right tonicity for the clinical situation prevents dangerous fluid shifts. Crystalloids contain water-soluble solutes; colloids contain larger molecules that pull fluid into the vascular space.

Isotonic solutions

Same osmolality as plasma

Fluid stays in the vascular space — used for volume expansion and replacement. No fluid shift between compartments.

Examples & uses

0.9% sodium chloride (NS, normal saline) — fluid replacement; compatible with blood products
Lactated Ringer's (LR) — surgical and trauma resuscitation; contains K+, Ca++, lactate (becomes bicarbonate); avoid in liver failure (impaired lactate metabolism), hyperkalemia
D5W (5% dextrose in water) — technically isotonic in the bag, but becomes hypotonic once dextrose is metabolized; treats hypernatremia, vehicle for medications
Uses: Hypovolemia, shock, blood/blood product administration (NS only), surgical fluid replacement

Cautions

Risk of fluid overload — circulatory overload, CHF, pulmonary edema
Monitor lung sounds, weight, JVD, edema

Hypotonic solutions

Lower osmolality than plasma

Fluid shifts from the vascular space into cells — rehydrates cells. Used carefully — too much can cause cellular swelling and cerebral edema.

Examples & uses

0.45% NS (half-normal saline) — most common hypotonic; cellular dehydration, hypernatremia, DKA after initial resuscitation
0.225% NS, 0.33% NS — less common

Risks

Do NOT give: Increased ICP (worsens cerebral edema), burns, trauma, liver disease
Monitor closely; can cause hypotension if vascular space depletes

Hypertonic solutions

Higher osmolality than plasma

Pulls fluid from cells into the vascular space. Used for severe hyponatremia and to reduce cerebral edema.

Examples & uses

3% NS, 5% NS — severe symptomatic hyponatremia, cerebral edema (raises serum osmolality, reduces brain swelling)
D5NS, D5LR, D5 ½ NS — provides calories with electrolytes; post-op
D10W, D20W, D50W — concentrated dextrose; hypoglycemia (D50W IV push)

Cautions

Risk of fluid overload and pulmonary edema
Risk of cellular dehydration and crenation
Hypertonic saline (3%) requires central line for prolonged administration; intensive monitoring
Rapid sodium correction can cause osmotic demyelination syndrome (central pontine myelinolysis)

Colloids

Volume expanders

Large molecules that remain in the vascular space, pulling fluid in by osmotic pressure. Useful when blood products are not available or appropriate.

Examples & uses

Albumin (5% and 25%) — burns, hypovolemia, hypoalbuminemia, large-volume paracentesis
Dextran, hetastarch — synthetic plasma expanders; trauma
Blood products (whole blood, PRBCs, FFP, platelets, cryoprecipitate)

Cautions

Risk of fluid overload
Hetastarch and dextran: bleeding risk, possible renal effects
Albumin: anaphylaxis (rare), fluid overload

IV Access

Peripheral IV catheters are the standard short-term access. Central venous catheters allow long-term access, irritating medications, TPN, and frequent blood draws.

Peripheral IV

Standard short-term

Catheter inserted in a peripheral vein, usually in the hand or forearm. Limited to short courses (typically < 5–7 days) and non-vesicant solutions.

Site selection

Use most distal site that will accept the catheter (preserves proximal sites for future use)
Avoid: areas of flexion (antecubital limited), affected side post-mastectomy, dialysis fistula limb, paralyzed limb
Hand veins for shorter dwell times; forearm veins for longer dwell times
Avoid lower extremity in adults (risk of DVT, infection)

Catheter sizing

18 gauge: Blood/blood products, surgery, trauma
20 gauge: Standard adult IV fluids and most medications
22 gauge: Older adults, fragile veins, pediatric
24 gauge: Neonates, infants, fragile veins

Rotation

Per CDC: peripheral IV may stay in place if functioning and site shows no complications
Per facility policy: typically replaced every 72–96 hours; sooner if complications

Central venous access

Long-term, irritant, TPN

Catheter terminates in the superior vena cava (or other large central vein). Allows infusion of irritants, vesicants, hyperosmolar solutions, TPN, and frequent blood draws.

Types

PICC (peripherally inserted central catheter): Inserted in upper arm, threads to SVC; weeks to months; nurse-inserted with proper certification
Tunneled catheter (Hickman, Broviac, Groshong): Surgically tunneled under skin; long-term (months to years); chemotherapy, TPN
Implanted port (Port-a-cath): Subcutaneous reservoir; longest-term; accessed with Huber needle
Non-tunneled central line: Inserted in jugular, subclavian, or femoral; short-term ICU use

Maintenance

Sterile technique for all dressing changes, access
Confirm placement with X-ray before initial use
Flush per facility protocol (often heparin lock for ports; NS for PICC/CVC)
Change dressing per protocol (typically q7d for transparent; q2d for gauze)
CLABSI prevention bundle: Hand hygiene, max sterile barriers at insertion, chlorhexidine skin prep, optimal site selection, daily review of necessity

IV Complications

Early recognition of IV complications prevents tissue damage and systemic harm. Inspect the site at every assessment.

Infiltration

Non-vesicant leak

Solution leaks into surrounding tissue (extravascular). Most common IV complication.

Signs

Swelling, coolness, pallor at the site
Slowed or stopped flow
Tenderness without erythema
Possible fluid leakage at insertion site

Interventions

Stop the infusion immediately
Remove the IV catheter
Elevate the extremity
Apply warm compress (for most solutions) or cool compress (per facility protocol/specific medication)
Restart IV at a different site, preferably proximal to original site
Document size of affected area, appearance, intervention

Extravasation

Vesicant leak — emergency

A VESICANT solution (chemotherapy, dopamine, vasopressors, calcium chloride, hypertonic saline) leaks into surrounding tissue, causing severe tissue damage and necrosis.

Signs

Severe burning or pain at site
Swelling and erythema
Skin discoloration
Tissue necrosis can develop over days

Interventions (emergency)

Stop the infusion immediately — but leave the IV catheter in place initially
Attempt to aspirate residual fluid through the catheter
Administer the antidote through the catheter (if available — e.g., hyaluronidase, phentolamine, sodium thiosulfate depending on vesicant)
Remove catheter only after antidote given
Apply warm or cold compress per the vesicant's protocol
Mark and measure affected area; photograph if facility policy
Notify provider and follow protocol for tissue specialist consult

Phlebitis / Thrombophlebitis

Vein inflammation

Inflammation of the vein wall, often with thrombus formation. Caused by chemical irritation, mechanical movement of catheter, or infection.

Signs

Redness and warmth along the vein
Pain or tenderness
Palpable cord along the vein course
Possible fever, purulent drainage (if infectious)

Interventions

Stop infusion and remove IV
Apply warm compress
Elevate extremity
Culture site/catheter tip if infectious phlebitis suspected
Restart IV in opposite extremity if possible
Document grade per facility scale (0–4)

Air embolism

Life-threatening

Air enters the circulation through the IV line.

Signs

Sudden dyspnea, chest pain
Hypotension, tachycardia
Confusion, anxiety
Wheezing, cyanosis

Interventions (emergency)

Position client on left side in Trendelenburg (traps air in right atrium/ventricle apex)
Administer 100% oxygen
Call rapid response / provider
Monitor vital signs continuously
Prevent: prime tubing fully; secure all connections; avoid letting bags run dry

Circulatory overload (TACO)

Volume overload

Too much IV fluid given too quickly overwhelms cardiovascular system.

Signs

Dyspnea, crackles (rales), tachypnea
Hypertension
Jugular vein distention (JVD)
Bounding pulse, S3 heart sound
Productive cough with pink frothy sputum (pulmonary edema)

Interventions

Slow the infusion to a keep-vein-open (KVO) rate
Position client upright (Fowler's or high Fowler's)
Administer oxygen
Notify provider; expect order for diuretic (furosemide IV)
Risk factors: older adults, infants, renal impairment, heart failure — use slower rates and smaller volumes

Catheter embolism

Catheter fragment travels

Tip of catheter breaks off and travels in the bloodstream.

Recognition & response

Suspect when partial catheter is withdrawn during removal
Apply tourniquet above insertion site
Notify provider immediately
X-ray to locate fragment; possible surgical retrieval
Prevention: never reinsert needle/stylet into a catheter; remove catheter intact

Infection / CLABSI

Bloodstream infection

Central line-associated bloodstream infection. Significant morbidity and mortality risk.

Signs

Fever, chills, elevated WBC
Erythema, warmth, purulent drainage at site
Positive blood cultures (especially from line vs peripheral)
Signs of sepsis: hypotension, tachycardia, altered mental status

Prevention bundle (CLABSI bundle)

Hand hygiene before all line interactions
Maximum sterile barriers at insertion
Chlorhexidine skin antisepsis
Optimal site selection (subclavian preferred over femoral)
Daily review of line necessity — remove ASAP

Active Learning Scenario

From the book — uses the ATI Active Learning Template: Nursing Skill. Practice answering before reviewing the key.

Scenario

A nurse is caring for a client who has an IV infusion and notes that the IV site is cool, swollen, and pale, with decreased flow. What actions should the nurse take? Use the ATI Active Learning Template: Nursing Skill to complete this item.

Show key

Description of Complication — Infiltration

Infiltration is the leakage of a non-vesicant solution into the tissue surrounding the IV catheter
Signs: coolness, swelling, pallor, decreased flow, possible fluid leakage
Caused by catheter displacement, vein wall puncture, or vein fragility

Nursing Actions

Stop the IV infusion immediately
Remove the IV catheter
Elevate the extremity to promote venous return
Apply warm compress to most non-irritant solutions (or cool compress per specific solution protocol)
Restart IV in a different site, preferably proximal to or in the opposite extremity
Document site appearance, size, intervention, and time
Notify provider if significant infiltration

Differentiation from Extravasation

Infiltration = non-vesicant solution; manage with stop/remove/warm compress
Extravasation = vesicant solution (chemo, dopamine, vasopressors) — emergency; leave catheter in place to administer antidote first

Practice · Application Exercises

5 NCLEX-style questions covering Ch 4 core content. Click each exercise to reveal rationales and NCLEX category.

Q1

A nurse is preparing to administer 0.9% NaCl IV to a client who is hypovolemic. Which of the following statements describes 0.9% NaCl?

A. It is a hypotonic solution that shifts fluid into cells
B. It is an isotonic solution that expands intravascular volume
C. It is a hypertonic solution that pulls fluid from cells
D. It is a colloid solution containing large molecules

Show rationale ▾

A. 0.9% NaCl is isotonic, not hypotonic. It has the same osmolality as plasma and does not shift fluid between compartments.

B. CORRECT. CORRECT — 0.9% NaCl (normal saline) is isotonic. Fluid stays in the intravascular space, expanding circulating volume — making it ideal for hypovolemia and shock.

C. 0.9% NaCl is isotonic. Hypertonic saline (3% or 5%) pulls fluid from cells.

D. 0.9% NaCl is a crystalloid (small dissolved solutes), not a colloid (large molecules like albumin).

NCLEX · Pharmacological & Parenteral Therapies · Parenteral/Intravenous Therapies

Q2

A nurse is monitoring a client who is receiving IV fluids and notices the insertion site is swollen and cool with decreased flow. Which of the following actions should the nurse take first?

A. Apply warm compresses to the site
B. Stop the IV infusion
C. Administer the antidote
D. Elevate the client's arm

Show rationale ▾

A. Warm compresses are an appropriate eventual intervention, but the first action is to stop the infusion.

B. CORRECT. CORRECT — The signs (swelling, coolness, decreased flow) indicate infiltration. The first action is to stop the infusion to prevent further leakage into tissue.

C. Administering an antidote is for extravasation of a vesicant solution. This appears to be infiltration of a non-vesicant.

D. Elevation helps after stopping the infusion, but is not the priority first action.

NCLEX · Reduction of Risk Potential · System-Specific Assessments

Q3

A nurse is caring for a client who develops sudden dyspnea, chest pain, and hypotension during IV fluid administration. The nurse suspects air embolism. Which of the following positions should the nurse place the client in?

A. High-Fowler's position
B. Left lateral Trendelenburg
C. Right lateral position
D. Supine with head of bed flat

Show rationale ▾

A. High-Fowler's is appropriate for fluid overload but worsens air embolism.

B. CORRECT. CORRECT — Positioning the client on the LEFT side in Trendelenburg traps air in the apex of the right atrium/ventricle, preventing it from entering the pulmonary circulation. This is the priority intervention for suspected air embolism.

C. Right lateral position would allow air to enter the pulmonary circulation, worsening the embolism.

D. A simple supine position is insufficient. The left Trendelenburg position is required.

NCLEX · Reduction of Risk Potential · Therapeutic Procedures

Q4

A nurse is monitoring a client receiving IV chemotherapy via a peripheral IV. The nurse notes severe burning at the site, swelling, and erythema. Which of the following actions should the nurse take first?

A. Discontinue the IV catheter immediately
B. Stop the infusion and aspirate residual vesicant from the catheter
C. Apply ice and elevate the extremity
D. Document the findings and continue monitoring

Show rationale ▾

A. For chemotherapy extravasation (vesicant), the catheter should remain in place initially to attempt aspiration of residual vesicant and to administer the antidote.

B. CORRECT. CORRECT — Chemotherapy is a vesicant; this is an extravasation emergency. Stop infusion, attempt to aspirate any residual vesicant through the catheter, and prepare to administer the antidote. The catheter stays in place until the antidote has been given.

C. Cold or warm compresses depend on the specific vesicant — not the first action. Stop the infusion and aspirate first.

D. This is a tissue-threatening emergency. Documentation occurs after intervention.

NCLEX · Pharmacological & Parenteral Therapies · Adverse Effects/Contraindications

Q5

A nurse is preparing to administer IV fluids to a client. Which of the following are appropriate uses for lactated Ringer's (LR)? (Select all that apply.)

A. Surgical fluid replacement
B. Trauma resuscitation
C. Treating hyperkalemia
D. A client with severe liver failure
E. Co-infusing with blood products

Show rationale ▾

A. CORRECT. CORRECT — LR is commonly used for surgical and post-operative fluid replacement because of its balanced electrolyte composition.

B. CORRECT. CORRECT — LR is preferred for trauma resuscitation because it more closely matches body fluids than NS and reduces risk of hyperchloremic acidosis.

C. INCORRECT — LR contains potassium (4 mEq/L); avoid in clients with hyperkalemia.

D. INCORRECT — LR contains lactate, which is converted to bicarbonate by the liver. In severe liver failure, lactate accumulates and worsens acidosis.

E. INCORRECT — LR contains calcium, which can cause clotting when co-infused with citrated blood products. Use 0.9% NaCl with blood transfusion.

NCLEX · Pharmacological & Parenteral Therapies · Parenteral/Intravenous Therapies

TL;DR · One-glance summary

Adverse effects range from minor (nausea) to severe (anaphylaxis, organ toxicity). Allergic reaction = immune-mediated; side effect = predictable, dose-related. Anaphylaxis: epinephrine first, then antihistamine + steroid. Drug interactions: check before adding any new med. Grapefruit + many CYP450 substrates = danger.

Types of adverse reactions

Side effects: predictable, dose-related (nausea, drowsiness)
Adverse effects: harmful, unintended responses
Toxic effects: from accumulation, overdose, or low-TI drug
Idiosyncratic: unexpected (genetic factor)
Allergic: immune-mediated, can escalate to anaphylaxis
Carcinogenic / teratogenic: long-term harm

Anaphylaxis management

Epinephrine IM first (lateral thigh)
Call for help, position supine, elevate legs
Oxygen, IV access, fluids
Diphenhydramine, methylprednisolone
Monitor for biphasic reaction (4–24 hr after)

Adverse effects — additional concepts

Black Box Warning: FDA strongest warning — review before administration; common examples: NSAIDs (CV), antipsychotics (death in dementia), SSRIs (suicide < 25 yo), LABA monotherapy in asthma
Stevens-Johnson Syndrome (SJS) / TEN: Life-threatening skin reaction — fever, blisters, mucosal involvement; STOP drug immediately; common culprits: sulfa drugs, anticonvulsants (carbamazepine, lamotrigine, phenytoin), allopurinol
Naranjo scale: Tool to determine probability that an adverse drug reaction is actually caused by the suspected drug
Pregnancy categories (older system, being phased out): A (safe), B (probably safe), C (caution — animal harm or unknown), D (evidence of human harm but benefits may outweigh), X (contraindicated)
2015 FDA Pregnancy and Lactation Labeling Rule: Replaced letter categories with narrative summaries for pregnancy, lactation, and reproductive potential
Drug-drug interaction mechanisms: Pharmacokinetic (absorption, distribution, metabolism, excretion) and pharmacodynamic (additive/synergistic/antagonistic effects)
CYP450 inducers (↓ levels of substrates): Carbamazepine, phenytoin, rifampin, St. John's wort, smoking
CYP450 inhibitors (↑ levels of substrates): Erythromycin, clarithromycin, ketoconazole, fluconazole, grapefruit juice, cimetidine

Types of Adverse Reactions — Overview

Not all adverse events are the same. Recognizing the type guides nursing response — some require dose adjustment, others require stopping the drug and never giving it again.

Side effect

Predictable

An expected, dose-related effect at therapeutic doses. Usually mild; often resolves with continued use or dose reduction.

Examples

Nausea with opioids
Drowsiness with antihistamines
Dry mouth with anticholinergics

Nursing actions

Educate client to expect
Offer comfort measures (mints, fluids, slow position changes)
Notify provider if intolerable

Adverse effect

Unintended, harmful

Noxious, unintended response at normal doses. More serious than side effects; may require dose adjustment or discontinuation.

Examples

Aplastic anemia with chloramphenicol
Pulmonary fibrosis with amiodarone
Stevens-Johnson syndrome with sulfa drugs

Nursing actions

Monitor for early signs
Stop drug, notify provider
Document and report (MedWatch)

Toxic effect

Dose-related danger

Effect from accumulation, overdose, or low therapeutic index. Watch for in renal/hepatic impairment, drug interactions, and high-alert medications.

High-risk drugs

Digoxin (therapeutic 0.5–2.0 ng/mL)
Lithium (0.6–1.2 mEq/L)
Warfarin (INR 2–3)
Phenytoin (10–20 mcg/mL)
Aminoglycosides (peak/trough)
Theophylline (10–20 mcg/mL)

Nursing actions

Monitor serum drug levels
Renal/hepatic function tests
Recognize early toxicity signs specific to each drug
Know the antidote (Digibind, vitamin K, etc.)

Idiosyncratic effect

Unpredictable

Unusual, unexpected response that cannot be predicted by the drug's pharmacology. Often genetic basis (e.g., CYP450 polymorphism).

Examples

Hemolytic anemia in G6PD deficiency with sulfa drugs, nitrofurantoin, primaquine
Paradoxical excitation in older adults with benzodiazepines
Carbamazepine hypersensitivity in HLA-B*1502 (Asian descent)

Allergic reaction

Immune-mediated

Hypersensitivity reaction from prior sensitization. Severity ranges from mild rash to fatal anaphylaxis.

Types

Type I (immediate): IgE-mediated — anaphylaxis, urticaria, bronchospasm (PCN, latex, contrast)
Type II: Cytotoxic — hemolytic anemia, thrombocytopenia (PCN, methyldopa)
Type III: Immune complex — serum sickness, glomerulonephritis
Type IV (delayed): Cell-mediated — contact dermatitis, drug rash (sulfa, anticonvulsants)

Nursing actions

Always ask about allergies and the SPECIFIC REACTION
Document; alert band
Severe reaction = stop drug, support airway/breathing/circulation
Anaphylaxis: epinephrine IM first

Teratogenic, carcinogenic, mutagenic

Long-term harm

Effects on fetal development, cancer risk, or DNA. Most relevant for pregnancy planning and chronic therapy.

Known teratogens (avoid in pregnancy)

Warfarin (fetal bleeding, malformation)
ACE inhibitors, ARBs (renal damage)
Isotretinoin (severe defects)
Methotrexate (abortifacient, malformation)
Valproate (neural tube defects)
Statins (Category X)
Tetracyclines, fluoroquinolones (bone/teeth)
Lithium (Ebstein anomaly — 1st trimester)

Anaphylaxis — Recognition and Response

A severe, life-threatening allergic reaction that can occur within minutes to hours of drug exposure. Most commonly: penicillins, contrast media, NSAIDs, latex, neuromuscular blockers.

Recognition

Multi-system

Manifestations

Skin: Generalized urticaria, flushing, pruritus, angioedema (lips, tongue, throat)
Respiratory: Hoarseness, stridor, wheezing, dyspnea, throat tightness
Cardiovascular: Tachycardia, hypotension, shock, dysrhythmias
GI: Nausea, vomiting, cramping, diarrhea
Neuro: Anxiety, sense of impending doom, dizziness, loss of consciousness

Biphasic reaction

Can recur 4–24 hours after the initial reaction resolves
Even without re-exposure to the trigger
Observe for at least 4–6 hours post-event

Treatment sequence

Time-critical

Immediate actions

1. Stop the offending drug immediately
2. Epinephrine IM in the vastus lateralis (anterolateral thigh) — first-line, no contraindications in anaphylaxis
3. Call for help / rapid response
4. Position supine with legs elevated (or sitting if respiratory distress dominates)
5. Oxygen, IV access, IV fluids (crystalloids)

Secondary medications

Diphenhydramine IV (H1 blocker)
Famotidine or ranitidine (H2 blocker)
Methylprednisolone or hydrocortisone IV
Albuterol nebulizer for bronchospasm
Repeat epinephrine every 5–15 min if no improvement
Glucagon if on beta blocker (epinephrine may be less effective)

Drug Interactions — Mechanisms

Two or more drugs taken together can produce effects that neither would produce alone. Categorized by mechanism (pharmacokinetic vs pharmacodynamic) and outcome (synergistic, antagonistic, novel).

Pharmacokinetic interactions

ADME-based

Absorption

Antacids ↓ absorption of fluoroquinolones, tetracyclines (separate by 2 hr)
Bile acid sequestrants bind many drugs — separate by 4 hr
Food affects absorption (levothyroxine, bisphosphonates need empty stomach)

Distribution

Protein-binding competition — sulfonamides displace warfarin → ↑ bleeding
Cleared when drugs are taken concurrently with similar high protein binding

Metabolism — CYP450 inducers (↓ drug levels)

Carbamazepine, phenytoin, phenobarbital
Rifampin, rifabutin
St. John's wort
Smoking
Chronic alcohol use

Metabolism — CYP450 inhibitors (↑ drug levels)

Erythromycin, clarithromycin
Ketoconazole, fluconazole, itraconazole
Cimetidine
Grapefruit juice
Acute alcohol intake
Many antidepressants (fluoxetine, paroxetine)

Excretion

NSAIDs ↓ renal excretion of lithium → toxicity
Probenecid ↓ excretion of penicillins (intentional — prolongs effect)
Loop diuretics ↑ excretion of potassium → hypokalemia

Pharmacodynamic interactions

Effect-based

Additive / synergistic (effects ↑)

CNS depressants (alcohol + benzodiazepine + opioid) — respiratory depression
Multiple antihypertensives — hypotension
NSAID + warfarin — bleeding
SSRI + MAOI — serotonin syndrome

Antagonistic (effects ↓)

Beta blockers + beta agonists (oppose each other)
Vitamin K + warfarin
Naloxone + opioids (overdose reversal)
Flumazenil + benzodiazepines

Pregnancy and Lactation Considerations

All medications cross the placenta to some extent. Risk varies by trimester, dose, and individual drug. The 2015 FDA Pregnancy and Lactation Labeling Rule replaced the older A/B/C/D/X letter categories with narrative summaries — but the letters are still commonly used and tested.

Legacy FDA Pregnancy Categories

Still used clinically

Lactation

Most drugs cross to milk

Generally safe

Acetaminophen, ibuprofen (most NSAIDs)
Most antibiotics (avoid sulfonamides near birth — kernicterus)
Insulin, levothyroxine
Heparin, LMWH (don't cross to milk)
SSRIs (sertraline preferred)

Avoid in lactation

Lithium (high transfer)
Amiodarone (very long half-life)
Ergot alkaloids
Antineoplastics (chemotherapy)
Radioactive iodine
Chloramphenicol (gray baby syndrome)

Active Learning Scenario · Gentamicin + Naproxen

From the book — uses the ATI Active Learning Template: Medication. Practice answering before reviewing the key.

Scenario

A nurse is planning care for a client who is receiving gentamicin IV bolus twice daily. The client has a history of musculoskeletal pain and takes naproxen daily for relief. What information should the nurse include in the client's plan of care? Use the ATI Active Learning Template: Medication to complete this item.

Show key

Therapeutic uses

Gentamicin is a narrow-spectrum aminoglycoside antibiotic prescribed to treat serious infections caused by aerobic bacilli.

Complications

Gentamicin can injure cells of the proximal renal tubules (nephrotoxicity).
Gentamicin is ototoxic — can cause permanent hearing loss and vestibular damage.
Naproxen and other NSAIDs can independently cause renal insufficiency.
The glomerular filtration rate of the kidneys decreases with advanced age, ↑ risk for nephrotoxicity.
Combining gentamicin with naproxen significantly increases the risk of acute kidney injury.

Nursing interventions — labs to monitor

BUN and serum creatinine (baseline and periodically)
Peak and trough gentamicin levels (peak 30 min after IV completion; trough just before next dose)
Specific gravity of urine; urinalysis for proteinuria, casts
Audiometry if long-term therapy (baseline + periodic)

Nursing interventions — actions

Monitor intake and output; report urine output < 30 mL/hr
Daily weights to track fluid status
Encourage adequate fluid intake (unless contraindicated)
Hold naproxen if possible during gentamicin therapy; collaborate with provider
Educate client to report hearing changes, tinnitus, dizziness, decreased urine output

Practice · Application Exercises (Set 1)

5 NCLEX-style questions covering Ch 5 core content. Click each exercise to reveal rationales and NCLEX category.

Q1

A nurse in a clinic is caring for a group of clients. The nurse should contact the provider about a potential contraindication to a medication for which of the following clients? (Select all that apply.)

A. A client at 8 weeks of gestation who asks for an influenza immunization
B. A client who takes prednisone and has a possible fungal infection
C. A client who has chronic liver disease and is taking hydrocodone/acetaminophen
D. A client who has peptic ulcer disease, takes sucralfate, and has started taking OTC aluminum hydroxide
E. A client who has a prosthetic heart valve, takes warfarin, and reports a suspected pregnancy

Show rationale ▾

A. The influenza vaccine is recommended for all clients > 6 months and is NOT contraindicated in pregnancy (the inactivated injection — only the live intranasal is contraindicated).

B. CORRECT. Glucocorticoids (prednisone) are immunosuppressive and should not be given to a client with a possible systemic fungal infection — they can worsen the infection. Notify the provider.

C. CORRECT. Acetaminophen is hepatotoxic and contraindicated in chronic liver disease. Notify the provider to prescribe a non-acetaminophen analgesic.

D. No absolute contraindication exists here. Sucralfate and aluminum hydroxide should be taken 30 min apart for full effect, but both can be used. Verify the provider is aware.

E. CORRECT. Warfarin is Pregnancy Category X — it causes severe fetal defects (warfarin embryopathy). Notify the provider; the client will likely be switched to LMWH (heparin or enoxaparin), which does not cross the placenta.

NCLEX · Pharmacological & Parenteral Therapies · Adverse Effects/Contraindications

Q2

A nurse is preparing to administer an IM dose of penicillin to a client who has a new prescription. The client states when they took penicillin 3 years ago, they developed a rash. Which of the following actions should the nurse take?

A. Administer the prescribed dose.
B. Withhold the medication.
C. Ask the provider to change the prescription to an oral form.
D. Administer an oral antihistamine at the same time.

Show rationale ▾

A. Do not administer. A previous rash with penicillin indicates allergic sensitization. Future doses can produce more severe reactions (anaphylaxis).

B. CORRECT. Withhold the medication and notify the provider. The client has a documented allergic reaction to penicillin. The provider will likely prescribe an alternative antibiotic.

C. Changing the route does not address the allergy — the drug is the issue, not the route.

D. Pretreating with an antihistamine does not prevent anaphylaxis and is not standard practice. The drug must be avoided.

NCLEX · Pharmacological & Parenteral Therapies · Adverse Effects

Q3

A nurse is providing discharge instructions for a client who has a new prescription for an antihypertensive medication. Which of the following statements should the nurse give?

A. "Be sure to limit your potassium intake while taking the medication."
B. "You should check your blood pressure every 8 hours while taking this medication."
C. "Your medication dosage will be increased if you develop tachycardia."
D. "Change positions slowly when you move from sitting to standing."

Show rationale ▾

A. Whether to limit potassium depends on the specific antihypertensive. Loop and thiazide diuretics ↓ K (eat more K-rich foods); K-sparing diuretics, ACE inhibitors, and ARBs ↑ K (limit K-rich foods).

B. Checking BP every 8 hours at home is excessive and not recommended.

C. Tachycardia is not the expected dose-adjustment trigger; reflex tachycardia from some antihypertensives may even suggest the dose is too high or that a beta blocker should be added.

D. CORRECT. Orthostatic hypotension is a common adverse effect of nearly all antihypertensive medications. Teaching slow position changes reduces the risk of falls and syncope.

NCLEX · Pharmacological & Parenteral Therapies · Adverse Effects

Q4

A nurse is reviewing a client's health record and notes that the client experienced permanent extrapyramidal effects caused by a previous medication. The nurse should recognize that the medication affected which of the following systems in the client?

A. Cardiovascular
B. Immune
C. Central nervous
D. Gastrointestinal

Show rationale ▾

A. Extrapyramidal effects (EPS) are not cardiovascular in origin.

B. EPS are not immune-mediated.

C. CORRECT. Extrapyramidal symptoms (acute dystonia, akathisia, parkinsonism, tardive dyskinesia) arise from dopamine blockade in the basal ganglia — part of the central nervous system. Common with first-generation antipsychotics (haloperidol, chlorpromazine) and metoclopramide.

D. EPS affect movement, not the GI tract.

NCLEX · Pharmacological & Parenteral Therapies · Adverse Effects

Q5

A nurse is caring for a client who is taking oral oxycodone. The client is also taking ibuprofen in three recommended doses daily. The nurse should identify that an interaction between these two medications will cause which of the following findings?

A. A decrease in blood levels of ibuprofen, possibly leading to a need for increased doses
B. A decrease in blood levels of oxycodone, possibly leading to a need for increased doses
C. An increase in the expected therapeutic effect of both medications
D. An increase in expected adverse effects for both medications

Show rationale ▾

A. The combination does not decrease ibuprofen levels.

B. The combination does not decrease oxycodone levels.

C. CORRECT. This is a beneficial synergistic interaction. Opioids and NSAIDs work through different mechanisms (opioid receptor activation vs. COX inhibition), so combining them provides greater analgesia than either alone — and often allows lower doses of each, reducing adverse effects.

D. While both medications have adverse effects, this combination is generally used because the synergy allows for LOWER doses of each, often reducing adverse effects.

NCLEX · Pharmacological & Parenteral Therapies · Pharmacological Pain Management

Adverse Reactions — Common Patterns

Adverse effects range from mild side effects to life-threatening reactions. Recognizing the pattern helps decide whether to continue, modify, or stop the medication.

Side effect

Expected, dose-related

An effect that is part of the medication's pharmacological action but is unwanted. Usually predictable, mild, and dose-related.

Examples

Drowsiness with antihistamines
Dry mouth with anticholinergics
GI upset with NSAIDs
Headache with nitrates

Management

Often tolerable — continue medication
Dose reduction may help
Time-related (often improves as body adjusts)
Teach client to expect and report severity

Allergic reaction (hypersensitivity)

Immune-mediated

An immunologic response to a medication. May be immediate (Type I, IgE-mediated, e.g., anaphylaxis) or delayed (Type IV, T-cell mediated, e.g., contact dermatitis).

Manifestations (mild → severe)

Itching, hives, rash
Wheezing, dyspnea, swelling of lips/tongue
Anaphylaxis: hypotension, laryngeal edema, bronchospasm, shock

Management

STOP medication immediately
Document allergy with reaction description
Anaphylaxis: epinephrine IM (first), O2, IV fluids, antihistamines, corticosteroids
Update allergy band/list
NEVER re-administer

Idiosyncratic reaction

Unpredictable

An unexpected reaction unique to the individual, often genetic. Cannot be predicted from the medication's known pharmacology.

Examples

Aplastic anemia with chloramphenicol
Malignant hyperthermia with halothane/succinylcholine
Hemolysis with sulfa in G6PD deficiency

Approach

Discontinue medication
Report to FDA MedWatch
Document for future avoidance

Toxic effect

Dose-related serious harm

Damage caused by excessive medication levels — either overdose or accumulation due to impaired metabolism/excretion.

Common examples

Acetaminophen → hepatotoxicity (antidote: acetylcysteine)
Aminoglycosides → nephro/ototoxicity
Digoxin → arrhythmias, visual changes
Vancomycin → red man syndrome, nephrotoxicity

Management

Hold further doses
Antidote if available
Supportive care; monitor levels

Serious & Special Reactions

Certain adverse effects are particularly severe, often requiring immediate intervention and permanent discontinuation.

Stevens-Johnson Syndrome (SJS) / TEN

Dermatologic emergency

A severe mucocutaneous reaction characterized by fever, skin pain, then widespread blistering and sloughing. Toxic Epidermal Necrolysis (TEN) is the most severe form (> 30% body surface).

Common triggers

Sulfa drugs (TMP/SMX)
Anticonvulsants (carbamazepine, lamotrigine, phenytoin)
Allopurinol
NSAIDs, penicillins, nevirapine

Management

STOP medication immediately
Transfer to burn unit (severe cases)
IV fluid replacement, electrolyte correction
Wound care
Genetic testing (HLA-B*1502 in Asian descent before carbamazepine)

Black Box Warning

FDA highest warning

The FDA's strongest warning, indicating a medication has serious or life-threatening risks. Required on the label and prescribing information.

Examples

SSRIs: Suicidal ideation in < 25 yo
NSAIDs: CV thrombotic events, GI bleeding
Antipsychotics: Increased mortality in elderly with dementia
LABA (e.g., salmeterol): Asthma death (monotherapy)
Fluoroquinolones: Tendon rupture, peripheral neuropathy
Methotrexate: Severe toxicities; teratogenic

Nursing responsibility

Review black box warnings before administration
Teach client about specific risks
Monitor for early signs
Document risk-benefit discussion

Teratogenic effects

Pregnancy harm

Medications that can cause fetal malformations or developmental harm. The FDA replaced the A/B/C/D/X categories in 2015 with detailed narrative labeling (PLLR).

Known teratogens (avoid in pregnancy)

Warfarin — fetal warfarin syndrome
ACE inhibitors, ARBs — fetal renal damage (esp. 2nd-3rd trimester)
Isotretinoin — severe craniofacial/cardiac defects
Methotrexate — abortifacient + teratogen
Statins — congenital anomalies
Tetracyclines — teeth/bone effects (also < 8 yo)
Lithium — Ebstein cardiac anomaly (1st trimester)
Valproate — neural tube defects
Thalidomide — limb defects (REMS program)

Nursing actions

Pregnancy test before initiating known teratogen
Contraception counseling for women of childbearing potential
Document pregnancy status
For high-risk drugs (isotretinoin), iPLEDGE program required

Drug Interactions — CYP450 and Foods

Medications can interact with other drugs, foods, and supplements. Interactions may be pharmacokinetic (absorption, distribution, metabolism, excretion) or pharmacodynamic (additive, synergistic, antagonistic effects).

CYP450 enzyme interactions

Major mechanism

The cytochrome P450 enzyme system in the liver metabolizes most drugs. Inducers increase enzyme activity (→ less drug); inhibitors decrease activity (→ more drug).

CYP inducers (↓ substrate levels)

Anticonvulsants: Carbamazepine, phenytoin, phenobarbital
Rifampin
St. John's wort
Smoking (↑ theophylline metabolism)
Chronic alcohol use
Effect: ↓ levels of OCPs, warfarin, antiretrovirals, digoxin

CYP inhibitors (↑ substrate levels)

Macrolides: Erythromycin, clarithromycin (NOT azithromycin)
Azole antifungals: Ketoconazole, fluconazole, voriconazole
Grapefruit juice (calcium channel blockers, statins)
Cimetidine
Protease inhibitors
Effect: ↑ levels of warfarin, statins, digoxin → toxicity

Food interactions

Foods can alter absorption, metabolism, and pharmacological effect of medications.

Common food-drug interactions

Warfarin + vitamin K foods (leafy greens) → ↓ INR; keep intake CONSISTENT
MAOI + tyramine foods (aged cheese, cured meats, wine) → hypertensive crisis
Tetracyclines/quinolones + dairy/calcium → ↓ absorption (separate by 2 hr)
Levothyroxine + food/calcium/iron → ↓ absorption (empty stomach AM, 1 hr before food)
Grapefruit juice + statins/CCBs/many others → ↑ levels (CYP3A4 inhibition)

Pharmacodynamic interactions

When drugs with similar or opposing effects are combined, effects may be additive, synergistic, or antagonistic.

Additive/synergistic (dangerous combinations)

CNS depressants: Opioids + benzodiazepines + alcohol → respiratory depression
Serotonergic agents: SSRI + MAOI/St. John's wort/triptan → serotonin syndrome
Anticoagulants: Warfarin + aspirin/NSAIDs/clopidogrel → bleeding
QT-prolonging drugs: Multiple combined → torsades de pointes

Antagonistic

Naloxone reverses opioids
Flumazenil reverses benzodiazepines
Vitamin K reverses warfarin
Protamine reverses heparin
Therapeutic in overdose; problematic if drugs given together accidentally

Active Learning Scenario · Warfarin + St. John's Wort

From the book — uses the ATI Active Learning Template: Medication. Practice answering before reviewing the key.

Scenario

A nurse is caring for a client who is taking warfarin for atrial fibrillation. The client reports taking St. John's wort for mild depression. What action should the nurse take? Use the ATI Active Learning Template: Medication to complete this item.

Show key

Interaction Identification

St. John's wort is a CYP450 inducer (CYP3A4 and others)
It will ↓ warfarin levels → ↓ anticoagulation effect → ↑ risk of thrombosis/stroke
St. John's wort also interacts with: OCPs, antiretrovirals, digoxin, antidepressants (serotonin syndrome)

Nursing Actions

Notify the provider of the supplement use
Educate client to discontinue St. John's wort or monitor INR closely
Document the interaction
Recheck INR within 1 week of stopping the supplement (may need warfarin dose adjustment)

Client Education

Always inform providers about ALL supplements, including "natural" and herbal products
"Natural" does NOT mean "safe" — supplements have real drug interactions
Read labels; bring all supplements to medication reconciliation visits

Practice · Application Exercises (Set 2)

5 NCLEX-style questions covering Ch 5 core content. Click each exercise to reveal rationales and NCLEX category.

Q1

A nurse is reviewing the medication list of a client and notes they are prescribed warfarin and have just been started on TMP/SMX (Bactrim). Which of the following should the nurse anticipate?

A. No interaction is expected
B. Increased INR and bleeding risk requiring close monitoring
C. Decreased warfarin effectiveness
D. No change to monitoring needed

Show rationale ▾

A. A significant interaction exists: TMP/SMX inhibits warfarin metabolism and displaces it from protein binding, increasing INR and bleeding risk.

B. CORRECT. CORRECT — Sulfamethoxazole inhibits warfarin metabolism (CYP2C9) AND displaces warfarin from albumin → ↑ free warfarin → ↑ INR. Close monitoring with possible warfarin dose reduction is needed.

C. The interaction increases warfarin effect, not decreases it.

D. Closer INR monitoring is essential when starting this combination.

NCLEX · Pharmacological & Parenteral Therapies · Adverse Effects/Contraindications

Q2

A nurse is caring for a client who develops fever, painful red rash, and oral mucosa blistering 1 week after starting a sulfa antibiotic. Which of the following is the priority action?

A. Apply topical hydrocortisone to the rash
B. Stop the antibiotic and notify the provider immediately
C. Continue the antibiotic and treat the rash with antihistamines
D. Decrease the antibiotic dose to reduce the rash

Show rationale ▾

A. Topical steroids do not address the systemic emergency. The medication must be stopped.

B. CORRECT. CORRECT — These signs indicate Stevens-Johnson Syndrome — a life-threatening reaction. Immediately stop the offending drug and notify the provider. SJS may progress to TEN with high mortality.

C. Continuing the offending medication can be fatal in SJS/TEN.

D. Dose reduction does not stop the immunologic reaction. The drug must be discontinued.

NCLEX · Pharmacological & Parenteral Therapies · Adverse Effects/Contraindications

Q3

A nurse is reviewing medications with a client who is pregnant. Which of the following medications should the nurse instruct the client to avoid? (Select all that apply.)

A. Acetaminophen
B. Warfarin
C. Isotretinoin
D. Insulin
E. Lisinopril

Show rationale ▾

A. Acetaminophen is the preferred analgesic in pregnancy (Category B).

B. CORRECT. CORRECT — Warfarin is teratogenic (Category X) — causes fetal warfarin syndrome.

C. CORRECT. CORRECT — Isotretinoin causes severe craniofacial and cardiac defects. Requires the iPLEDGE program.

D. Insulin is Category B and is the preferred treatment for diabetes in pregnancy.

E. CORRECT. CORRECT — ACE inhibitors cause fetal renal damage in 2nd/3rd trimester. Class effect.

NCLEX · Pharmacological & Parenteral Therapies · Adverse Effects/Contraindications

Q4

A client receiving IV penicillin develops sudden onset wheezing, swelling of the lips, and hypotension. Which of the following is the priority intervention?

A. Administer epinephrine IM
B. Administer diphenhydramine IV
C. Administer methylprednisolone IV
D. Slow the rate of penicillin infusion

Show rationale ▾

A. CORRECT. CORRECT — This is anaphylaxis. Epinephrine IM is the first-line treatment. Standard adult dose is 0.3–0.5 mg IM (1 mg/mL concentration) in the anterolateral thigh.

B. Diphenhydramine is given AFTER epinephrine. It is an adjunct, not first-line.

C. Corticosteroids prevent biphasic anaphylaxis but are not first-line and have slower onset than epinephrine.

D. STOP the penicillin entirely — do not slow it. This is a life-threatening allergic reaction.

NCLEX · Pharmacological & Parenteral Therapies · Adverse Effects/Contraindications

Q5

A nurse is teaching a client about food-drug interactions. Which of the following statements by the client indicates understanding? (Select all that apply.)

A. "I should keep my intake of leafy green vegetables consistent while taking warfarin."
B. "I should avoid grapefruit juice while taking my statin."
C. "I can take my levothyroxine with breakfast for better absorption."
D. "I should avoid aged cheese and cured meats while taking my MAOI."
E. "I should take my doxycycline with a glass of milk."

Show rationale ▾

A. CORRECT. CORRECT — Vitamin K (in leafy greens) antagonizes warfarin. Consistent intake — not avoidance — is key so dose can be adjusted appropriately.

B. CORRECT. CORRECT — Grapefruit juice inhibits CYP3A4, leading to ↑ statin levels and risk of myopathy/rhabdomyolysis.

C. Levothyroxine should be taken on an EMPTY stomach, 30–60 min before breakfast. Food (especially calcium, iron, fiber) decreases absorption.

D. CORRECT. CORRECT — Tyramine-rich foods (aged cheese, cured meats, wine, beer) can cause hypertensive crisis when combined with MAOIs.

E. Dairy (calcium) decreases doxycycline absorption. Take with water; separate from dairy by 2 hours.

NCLEX · Pharmacological & Parenteral Therapies · Adverse Effects/Contraindications

TL;DR · One-glance summary

Pediatrics: organ immaturity affects every phase of ADME. Always weight-based (mg/kg). Older adults: ↓ renal/hepatic function = ↑ drug levels; polypharmacy is a hazard. Pregnancy: avoid teratogens (warfarin, ACE inhibitors, statins, retinoids); use FDA pregnancy risk categories. Lactation: most drugs cross into milk but at low levels.

Pediatric considerations

Doses always per kg of body weight
Immature hepatic enzymes — slower metabolism
Higher % body water — affects distribution
Watch for paradoxical reactions (some get excited from sedatives)

Older adult considerations

Start low, go slow
Watch for polypharmacy and interactions
Beers Criteria flags potentially inappropriate medications
↓ glomerular filtration = renal clearance reduction
↓ albumin = more free (active) drug

Pregnancy & lactation

Teratogens to AVOID: warfarin, ACE inhibitors, ARBs, statins, isotretinoin, valproic acid, lithium (most)
Safer alternatives exist for nearly every category
Lactation: check LactMed before any new med

Lifespan-specific cautions

Pediatric weight-based dosing is universal — always mg/kg
Children's drug response differs: Slower hepatic metabolism (especially neonates), ↑ % body water, immature blood-brain barrier (more CNS effects)
NEVER: Aspirin in children with viral illness (Reye); tetracyclines < 8 yo (teeth); fluoroquinolones < 18 yo (cartilage); codeine < 12 yo (variable metabolism, deaths)
Older adult considerations: ↓ GFR (renal-cleared drugs accumulate), ↓ hepatic metabolism, ↓ serum albumin (more free drug), ↑ body fat (lipid-soluble drugs persist), polypharmacy
Beers Criteria: List of potentially inappropriate medications for adults > 65 yo — examples: long-acting benzodiazepines, anticholinergics, NSAIDs (long-term), 1st-gen antihistamines
STOPP/START criteria: Tool to identify potentially inappropriate prescribing in elderly
Pregnancy: Avoid teratogens — warfarin, ACE/ARB, statins, isotretinoin, methotrexate, valproate, lithium (mostly), tetracyclines, fluoroquinolones
Breastfeeding: Most drugs cross to milk in small amounts; check LactMed; some absolutely contraindicated (chemotherapy, lithium, ergotamine, amiodarone)
Genetics/pharmacogenomics: CYP2D6 variability affects codeine, tamoxifen, antidepressants; HLA-B*5701 → abacavir reaction; HLA-B*1502 → carbamazepine SJS

Pediatric Considerations

Children are not small adults. Pharmacokinetics differs by age, organ maturity, body composition, and metabolism. Dosing is universally weight-based (mg/kg).

Pharmacokinetic differences

Age-related

Infants and young children have unique absorption, distribution, metabolism, and excretion patterns.

Key differences

Absorption: Gastric pH higher in neonates; oral absorption variable
Distribution: Higher % body water; lower body fat; immature blood-brain barrier (more CNS effects)
Metabolism: Immature hepatic enzymes — slower metabolism in neonates and young infants
Excretion: Renal function reaches adult levels by ~1 year

Implications

Higher mg/kg doses needed for some drugs (children metabolize faster than adults after infancy)
Lower mg/kg for neonates due to immature systems
Use specific pediatric dose references — never extrapolate from adult doses

Drugs to AVOID in children

High-risk medications

Several medications have specific age cutoffs based on safety concerns.

Absolute avoidance

Aspirin in viral illness: Reye syndrome (fatal hepatic encephalopathy)
Tetracyclines < 8 yo: Tooth discoloration, bone growth inhibition
Fluoroquinolones < 18 yo: Cartilage damage in animals; tendon issues
Codeine < 12 yo: Variable metabolism, deaths reported
Benzyl alcohol (preservative): Gasping syndrome in neonates

Caution

Promethazine < 2 yo (respiratory depression)
Cold/cough preparations < 6 yo
Pseudoephedrine: variable response in young children

Administration considerations

Technique varies with age and developmental stage.

Pediatric administration tips

Liquid oral medications: use oral syringe (not household teaspoon)
Tablets: consider crushability or use liquid form when available
IM injections: vastus lateralis preferred < 1 year
IV: rates calculated by weight and concentration
Involve caregivers; explain in age-appropriate terms
Praise cooperation; avoid threats or comparisons to other children

Older Adult Considerations

Aging changes affect every phase of pharmacokinetics. Combined with polypharmacy and chronic disease, older adults are at significantly higher risk for adverse drug events.

Pharmacokinetic changes

Aging effects

Multiple physiologic changes alter how medications behave in older adults.

Changes & implications

↓ Renal function (GFR): Accumulation of renally-cleared drugs (digoxin, lithium, aminoglycosides, vancomycin)
↓ Hepatic metabolism: Some drugs accumulate
↓ Serum albumin: More free drug; ↑ effect of highly protein-bound drugs (warfarin, phenytoin)
↑ Body fat / ↓ Body water: Lipid-soluble drugs persist longer (benzodiazepines), water-soluble drugs have higher initial concentrations
↓ Cardiac output: Slower distribution

General principle

"Start low, go slow"
Use the lowest effective dose
Titrate slowly to therapeutic effect
Monitor for accumulation and toxicity

Beers Criteria

Avoid in elderly

A list of potentially inappropriate medications for adults > 65 years, maintained by the American Geriatrics Society.

Examples of medications to avoid

Benzodiazepines (especially long-acting): falls, sedation, cognitive impairment
1st-generation antihistamines (diphenhydramine): anticholinergic effects, confusion
Tricyclic antidepressants: anticholinergic, orthostatic hypotension
NSAIDs (chronic use): GI bleed, renal impairment, HF
Antipsychotics in dementia: increased mortality (BBW)
Muscle relaxants (cyclobenzaprine, carisoprodol): sedation, falls
Sliding-scale insulin alone: risk of hypoglycemia

Application

Use only when no safer alternative exists
Document risk-benefit decision
Monitor closely if used

Polypharmacy

Multiple medications

Older adults often take many medications, increasing risk of interactions, errors, and non-adherence.

Strategies

Medication review at every visit
Deprescribing: Stop medications that are no longer needed
Simplify dosing schedules (once daily preferred)
Use pill organizers and reminder systems
Involve caregivers in administration when needed
STOPP/START criteria: Tool to identify inappropriate prescriptions and missing beneficial ones

Pregnancy & Lactation

Most medications cross the placenta and many enter breast milk. Decisions require weighing maternal benefit against fetal/infant risk.

Pregnancy

The FDA Pregnancy and Lactation Labeling Rule (PLLR, 2015) replaced the A/B/C/D/X categories with narrative labeling, though letter categories still appear on many references.

Generally safe in pregnancy

Acetaminophen (preferred analgesic/antipyretic)
Insulin (preferred for diabetes)
Levothyroxine
Penicillins, cephalosporins (most)
Heparin/LMWH (does not cross placenta — preferred over warfarin)
Methyldopa, labetalol, nifedipine (hypertension in pregnancy)

Avoid in pregnancy

NSAIDs (esp. 3rd trimester — premature ductus closure)
ACE inhibitors, ARBs (renal damage)
Warfarin (teratogen)
Tetracyclines (teeth)
Sulfa drugs (late pregnancy — kernicterus)
Lithium (1st trimester cardiac defects)
Isotretinoin, methotrexate, statins, valproate (teratogens)

Lactation

Most drugs transfer to breast milk in small amounts. Always check LactMed database before prescribing.

Considerations

Check LactMed (NIH database) for specific drugs
Time doses to minimize infant exposure (right after feeding)
Monitor infant for adverse effects
Most antibiotics, acetaminophen, NSAIDs (occasional use) compatible

Avoid during breastfeeding

Chemotherapy
Lithium
Ergotamine, methotrexate
Amiodarone
Iodine 131 (radioactive)
Recreational drugs

Pharmacogenomics

Genetic variation affects how individuals metabolize medications and respond to them. Some medications now require genetic testing before use.

Clinical examples

Several drugs have well-established genetic considerations.

Genetic testing recommendations

Abacavir + HLA-B*5701: Test before use; presence → severe hypersensitivity
Carbamazepine + HLA-B*1502: Test in Asian descent (Stevens-Johnson risk)
Clopidogrel + CYP2C19: Poor metabolizers have reduced antiplatelet effect
Warfarin + CYP2C9/VKORC1: Genotype-guided dosing reduces bleeding
Codeine + CYP2D6: Ultra-rapid metabolizers → toxic morphine levels; poor metabolizers → no analgesic effect
Thiopurines + TPMT: TPMT deficiency → bone marrow suppression

Application

Order testing before initiation when indicated
Adjust dose based on metabolizer status
Document for future reference

Active Learning Scenario

From the book — uses the ATI Active Learning Template: System Disorder. Practice answering before reviewing the key.

Scenario

A nurse is caring for an 82-year-old client who has multiple chronic conditions and takes 9 different medications daily. The client has fallen twice in the past month and reports feeling dizzy when standing. Use the ATI Active Learning Template: System Disorder to analyze concerns.

Show key

Risk Factors Identified

Polypharmacy (≥ 5 medications) — known fall risk factor
Age > 65 — multiple physiologic changes affecting drug response
Symptomatic orthostatic hypotension (dizziness on standing)
Two recent falls — significantly elevated future fall risk

Common Medication Classes Contributing to Falls

Antihypertensives (especially alpha-blockers, ACE inhibitors)
Diuretics (volume depletion)
Benzodiazepines and sleep aids (Beers Criteria — avoid)
Opioids
Tricyclic antidepressants (Beers Criteria — avoid)
Antihistamines (1st-generation — Beers Criteria)
Antiarrhythmics, antipsychotics

Nursing Actions

Conduct a comprehensive medication review with the provider
Identify potentially inappropriate medications (Beers Criteria)
Suggest deprescribing where appropriate
Check orthostatic vital signs
Implement fall precautions
Educate client and family about fall prevention
Consider PT consult for gait/balance

Practice · Application Exercises

5 NCLEX-style questions covering Ch 6 core content. Click each exercise to reveal rationales and NCLEX category.

Q1

A nurse is administering medications to a 75-year-old client. Which of the following changes in pharmacokinetics should the nurse consider in older adults?

A. Increased renal excretion of medications
B. Decreased metabolism of medications
C. Increased serum albumin levels
D. Decreased body fat

Show rationale ▾

A. Renal function DECREASES with age, slowing excretion and increasing accumulation.

B. CORRECT. CORRECT — Hepatic metabolism decreases with age, and renal excretion decreases. Both lead to medication accumulation and require dose adjustments.

C. Serum albumin decreases with age and chronic illness, increasing free drug (and effect) for highly protein-bound medications.

D. Body fat actually INCREASES with age, prolonging the effect of lipid-soluble drugs (e.g., benzodiazepines).

NCLEX · Pharmacological & Parenteral Therapies · Pharmacological Pain Management

Q2

A nurse is reviewing the medications of an 80-year-old client. Which of the following medications should the nurse identify as inappropriate per the Beers Criteria? (Select all that apply.)

A. Diphenhydramine for sleep
B. Acetaminophen for mild pain
C. Long-term diazepam for anxiety
D. Amitriptyline for neuropathy
E. Levothyroxine for hypothyroidism

Show rationale ▾

A. CORRECT. CORRECT — 1st-generation antihistamines have strong anticholinergic effects causing confusion, sedation, and increased fall risk.

B. Acetaminophen is appropriate and is the preferred first-line analgesic in older adults.

C. CORRECT. CORRECT — Long-acting benzodiazepines cause sedation, cognitive impairment, and falls. Avoid in older adults.

D. CORRECT. CORRECT — TCAs have strong anticholinergic effects and orthostatic hypotension. Use SNRIs (duloxetine) or gabapentin instead.

E. Levothyroxine is appropriate; older adults may need lower starting doses but the medication itself is not contraindicated.

NCLEX · Pharmacological & Parenteral Therapies · Adverse Effects/Contraindications

Q3

A pregnant client at 30 weeks gestation reports a headache. Which of the following medications is most appropriate for the nurse to recommend?

A. Ibuprofen 400 mg
B. Acetaminophen 500 mg
C. Aspirin 325 mg
D. Naproxen 220 mg

Show rationale ▾

A. NSAIDs are contraindicated in the 3rd trimester — they can cause premature closure of the fetal ductus arteriosus.

B. CORRECT. CORRECT — Acetaminophen (Category B) is the preferred analgesic/antipyretic throughout pregnancy when used at recommended doses.

C. Aspirin is generally avoided in pregnancy (especially 3rd trimester) due to bleeding risk and possible ductal closure.

D. Like ibuprofen, naproxen is an NSAID and is contraindicated in the 3rd trimester.

NCLEX · Pharmacological & Parenteral Therapies · Pharmacological Pain Management

Q4

A nurse is preparing to administer codeine to a 6-year-old. Which of the following is the most appropriate action?

A. Administer the codeine as prescribed
B. Question the order with the provider
C. Give half the prescribed dose
D. Document the medication was given

Show rationale ▾

A. Codeine is contraindicated in children < 12 years due to variable metabolism (CYP2D6) and reports of fatal respiratory depression in ultra-rapid metabolizers.

B. CORRECT. CORRECT — Codeine carries a black box warning against use in children < 12 years. The nurse should question the order and suggest a safer alternative.

C. Reducing the dose does not address the fundamental safety issue of unpredictable metabolism in children.

D. This would be unsafe practice. Question the order before administration.

NCLEX · Pharmacological & Parenteral Therapies · Adverse Effects/Contraindications

Q5

A provider is considering prescribing carbamazepine to a client of Asian descent for trigeminal neuralgia. Which of the following actions is most appropriate before initiating therapy?

A. Obtain genetic testing for HLA-B*1502
B. Obtain a complete blood count
C. Order a chest X-ray
D. Administer test dose and monitor for 24 hours

Show rationale ▾

A. CORRECT. CORRECT — HLA-B*1502 allele (more common in Asian descent) is strongly associated with Stevens-Johnson Syndrome/TEN with carbamazepine. Testing is recommended before initiation in this population.

B. A CBC may be appropriate as part of overall workup, but the specific concern for this population and medication is the HLA-B*1502 test.

C. A chest X-ray is not specific to carbamazepine initiation.

D. A test dose does not detect the genetic predisposition. The reaction can take days to weeks to manifest.

NCLEX · Pharmacological & Parenteral Therapies · Expected Actions/Outcomes

TL;DR · One-glance summary

Benzodiazepines (alprazolam, lorazepam, diazepam) — fast relief, short-term only due to dependence. Buspirone — non-sedating, takes weeks to work, no dependence. SSRIs (paroxetine, sertraline) — first-line for chronic anxiety. Avoid alcohol with any anxiolytic. Flumazenil reverses benzo overdose.

Benzodiazepines (Alprazolam — prototype)

Action: Enhance GABA inhibition in CNS — rapid anxiolysis
Uses: GAD, panic disorder, PTSD, seizures, alcohol withdrawal, pre-procedure sedation
Adverse: CNS depression, anterograde amnesia, paradoxical excitation (older adults), tolerance/dependence
Overdose: Reverse with flumazenil IV
Avoid: Alcohol, opioids, other CNS depressants (additive respiratory depression)

Atypical anxiolytics & antidepressants

Buspirone: No sedation, no dependence — but takes 3–6 weeks to work
SSRIs (paroxetine, sertraline, escitalopram): First-line for chronic anxiety — slow onset (4 weeks)
SNRIs (venlafaxine, duloxetine): Used for GAD
Beta blockers (propranolol): For performance anxiety (somatic symptoms only)
Hydroxyzine: PRN; antihistamine with anxiolytic effect

Anxiety — additional therapy details

SSRI dosing for anxiety: Often starts lower than depression dosing then titrated up; full effect 4–6 weeks
Serotonin syndrome: Mental status changes, autonomic instability, neuromuscular hyperactivity (tremor, hyperreflexia, clonus); occurs with serotonergic drug combinations
Hydroxyzine (Vistaril, Atarax): H1 antihistamine; rapid relief of anxiety; less sedating than diphenhydramine; useful in pregnancy
Beta blockers (propranolol): Block somatic symptoms (palpitations, tremor) of performance anxiety; ineffective for cognitive symptoms
Alpha-blockers (prazosin): PTSD-related nightmares
Pregabalin, gabapentin: Anxiolytic effects; off-label for GAD
Withdrawal from benzodiazepines: Can be life-threatening — seizures, agitation, autonomic instability; NEVER abruptly discontinue chronic benzo use — taper slowly over weeks

Benzodiazepines

GABA receptor enhancers — provide rapid anxiolysis but carry risks of tolerance, dependence, and withdrawal. Used short-term (2–4 weeks) for acute anxiety, panic, alcohol withdrawal, seizures, and pre-procedure sedation.

Prototype: Alprazolam (Xanax)

Schedule IV

Short-acting benzodiazepine. Other examples: lorazepam (Ativan), diazepam (Valium), midazolam (Versed), chlordiazepoxide (Librium), clonazepam (Klonopin), oxazepam, temazepam, triazolam.

Mechanism & uses

Enhances GABA inhibition in CNS → rapid anxiolysis, sedation, anticonvulsant, muscle relaxant
Uses: GAD, panic disorder, PTSD adjunct, alcohol withdrawal (chlordiazepoxide, diazepam, lorazepam), seizures (lorazepam, diazepam — status epilepticus), pre-procedure sedation, muscle spasm (diazepam)

Adverse effects

CNS depression (sedation, dizziness, confusion)
Anterograde amnesia
Paradoxical excitation (especially elderly)
Tolerance and physical dependence with chronic use
Respiratory depression (especially with other CNS depressants)
Withdrawal can be life-threatening (seizures, autonomic instability)

Nursing actions

Antidote: Flumazenil IV for overdose; reverses sedation, may precipitate seizures in chronic users
AVOID with alcohol, opioids, other CNS depressants
Never abruptly discontinue chronic use — taper over weeks
Beers Criteria: Avoid in older adults (falls, cognitive impairment)
Educate: short-term use only, do not drive until effect known

Buspirone

Anxiolytic with no sedation, no dependence, no withdrawal — but slow onset (3–6 weeks). Useful for chronic generalized anxiety in clients who cannot tolerate or use benzodiazepines.

Buspirone (BuSpar)

Atypical anxiolytic

5-HT1A partial agonist. Not a CNS depressant. Does not cause sedation or impair cognition. No abuse potential (not scheduled).

Uses

Generalized anxiety disorder
Adjunctive treatment of depression
Useful in clients with substance use history (no abuse potential)

Adverse effects

Dizziness, headache, nausea, restlessness
Generally well-tolerated

Nursing actions

Takes 3–6 weeks for full effect — not for acute anxiety relief
AVOID with MAOIs (hypertensive crisis)
AVOID grapefruit juice (↑ levels)
AVOID alcohol
Educate client about delayed onset; do not stop because they don't feel it immediately

Antidepressants for Anxiety

SSRIs and SNRIs are first-line for chronic anxiety disorders. They take 4–6 weeks for full effect but have lower abuse potential and longer-term safety than benzodiazepines.

SSRIs

First-line for chronic anxiety

Examples: paroxetine (Paxil) — prototype for anxiety, sertraline (Zoloft), escitalopram (Lexapro), fluoxetine (Prozac), citalopram, fluvoxamine.

Uses

Generalized anxiety disorder, panic disorder, OCD, PTSD, social anxiety
Also approved for depression

Adverse effects

Initial: GI upset (nausea, diarrhea), headache, jitteriness — often improves in 2 weeks
Sexual dysfunction (often persistent)
Weight gain
Insomnia or sedation (depends on agent)
SIADH/hyponatremia (especially older adults)
Bleeding risk (↑ with NSAIDs)
Serotonin syndrome — autonomic instability, mental status changes, neuromuscular hyperactivity
Sexual dysfunction
Withdrawal syndrome with abrupt discontinuation (paroxetine especially)

Nursing actions

4–6 weeks to full effect — must continue even if not feeling immediate benefit
Lower starting dose for anxiety than for depression; titrate up
BLACK BOX: Suicidal ideation in < 25 yo — monitor closely first 2–3 months
Taper slowly to discontinue (especially paroxetine)
Avoid combining with MAOIs (washout 2 weeks); other serotonergic drugs
Pregnancy: paroxetine = Cat D (cardiac defects); sertraline often preferred

SNRIs

Also first-line

Examples: venlafaxine (Effexor) — prototype, duloxetine (Cymbalta), desvenlafaxine.

Uses & Effects

GAD, panic, social anxiety, depression
Similar AE profile to SSRIs PLUS: hypertension (especially venlafaxine), tachycardia
Duloxetine: also for diabetic neuropathy, fibromyalgia

Cautions

Monitor BP
Withdrawal more severe than SSRIs
Hepatotoxicity (duloxetine — avoid in liver disease)

TCAs (older alternative)

Examples: amitriptyline, nortriptyline, imipramine, clomipramine (most effective for OCD).

AE & Cautions

Anticholinergic (dry mouth, constipation, urinary retention, blurred vision)
Orthostatic hypotension
Sedation, weight gain
Cardiotoxic in overdose — wide QRS, arrhythmias; narrow therapeutic index
Beers Criteria: Avoid in older adults
Lower doses for anxiety/pain than depression

Adjunct Medications

Used for specific symptoms or anxiety subtypes when first-line agents are insufficient or contraindicated.

Beta blockers

Performance anxiety

Propranolol — blocks somatic (physical) symptoms of anxiety.

Uses

Performance anxiety, social anxiety (acute, situational use)
Essential tremor
Migraine prophylaxis

Notes

Blocks palpitations, tremor, sweating, blushing
Does NOT address cognitive symptoms (worry, fear)
Take 30 min before anxiety-provoking event
AVOID in asthma (bronchospasm); use cautiously in diabetes (masks hypoglycemia)

Hydroxyzine

PRN anxiety

H1 antihistamine with anxiolytic effect — useful for occasional anxiety without dependence.

Properties

Sedating but no abuse potential
Useful in pregnancy
PRN dosing (not scheduled)
AE: drowsiness, dry mouth, dizziness
Less sedating than diphenhydramine

Alpha-blockers

PTSD nightmares

Prazosin — for PTSD-related nightmares.

Notes

Bedtime dosing; titrate to effect
AE: orthostatic hypotension, dizziness, headache
Significant nightmare reduction in many PTSD clients

Gabapentin, pregabalin

Off-label

Anticonvulsants with some anxiolytic effect.

Notes

Off-label for GAD; useful adjuncts
Pregabalin is Schedule V
Sedation, dizziness, weight gain

Active Learning Scenario

From the book — uses the ATI Active Learning Template: Medication. Practice answering before reviewing the key.

Scenario

A nurse is teaching a client who has been prescribed paroxetine for generalized anxiety disorder. Use the ATI Active Learning Template: Medication to develop the teaching plan.

Show key

Indications & Expected Pharmacological Action

Selective serotonin reuptake inhibitor (SSRI)
Increases serotonin availability in the synaptic cleft
Used for: generalized anxiety disorder, panic disorder, social anxiety, PTSD, OCD, depression

Adverse Effects to Monitor

Initial: GI upset (nausea, diarrhea), headache, insomnia — usually improves in 2 weeks
Sexual dysfunction (often persistent — sometimes leads to discontinuation)
SIADH/hyponatremia (especially older adults)
Increased bleeding risk (especially with NSAIDs)
Serotonin syndrome (mental status, autonomic, neuromuscular)
BLACK BOX: Suicidal ideation in < 25 yo — monitor closely first 2–3 months

Client Education

Takes 4–6 weeks for full effect — must continue even if not feeling immediate benefit
Take at the same time daily
Do NOT abruptly discontinue — paroxetine has worst withdrawal of SSRIs (flu-like, dizziness, irritability); taper over weeks
AVOID alcohol, MAOIs, St. John's wort, triptans (serotonin syndrome)
Report: worsening depression, suicidal thoughts, unusual bleeding, signs of serotonin syndrome
Sexual side effects: discuss with provider — may switch agent
Avoid in pregnancy (Category D — cardiac defects); use sertraline if needed

Practice · Application Exercises

5 NCLEX-style questions covering Ch 7 core content. Click each exercise to reveal rationales and NCLEX category.

Q1

A nurse is teaching a client newly prescribed buspirone for generalized anxiety disorder. Which of the following statements by the client indicates an understanding of the teaching?

A. "I can take this medication as needed when I feel anxious."
B. "I should expect this medication to take several weeks to work."
C. "I can drink alcohol while taking this medication."
D. "I might become physically dependent on this medication."

Show rationale ▾

A. Buspirone is NOT a PRN medication. It must be taken regularly and takes weeks to reach therapeutic effect.

B. CORRECT. CORRECT — Buspirone has a slow onset of 3–6 weeks. Clients must continue taking it daily even if they do not feel an immediate effect.

C. Alcohol should be avoided with buspirone (CNS depressant interaction).

D. Buspirone does NOT cause dependence — this is one of its advantages over benzodiazepines.

NCLEX · Pharmacological & Parenteral Therapies · Medication Administration

Q2

A nurse is caring for a client who has taken an overdose of lorazepam. Which of the following medications should the nurse anticipate administering?

A. Naloxone
B. Flumazenil
C. Acetylcysteine
D. Protamine sulfate

Show rationale ▾

A. Naloxone reverses opioid overdose, not benzodiazepine overdose.

B. CORRECT. CORRECT — Flumazenil is the antidote for benzodiazepine overdose. It is a competitive GABA receptor antagonist. CAUTION: it may precipitate seizures in chronic benzo users.

C. Acetylcysteine is the antidote for acetaminophen overdose.

D. Protamine reverses heparin, not benzodiazepines.

NCLEX · Pharmacological & Parenteral Therapies · Adverse Effects/Contraindications

Q3

A client taking paroxetine for 6 months reports they wish to stop the medication. Which of the following is the most appropriate response from the nurse?

A. "You can stop the medication today since you no longer need it."
B. "You should taper the medication gradually with provider supervision."
C. "You can stop the medication but continue taking it on alternate days."
D. "There is no need to taper an SSRI."

Show rationale ▾

A. Abrupt discontinuation causes withdrawal symptoms (flu-like, dizziness, irritability), especially with paroxetine.

B. CORRECT. CORRECT — Paroxetine has the worst withdrawal syndrome of SSRIs and must be tapered gradually over weeks under provider supervision.

C. Alternate-day dosing is not an appropriate way to discontinue. Taper according to a structured plan.

D. SSRIs require tapering — paroxetine especially.

NCLEX · Pharmacological & Parenteral Therapies · Medication Administration

Q4

A nurse is monitoring a client who is taking multiple serotonergic medications. Which of the following findings should the nurse identify as signs of serotonin syndrome? (Select all that apply.)

A. Confusion and agitation
B. Hyperreflexia and clonus
C. Bradycardia and hypotension
D. Fever and diaphoresis
E. Pupillary constriction

Show rationale ▾

A. CORRECT. CORRECT — Mental status changes are part of the serotonin syndrome triad.

B. CORRECT. CORRECT — Neuromuscular hyperactivity (hyperreflexia, clonus, tremor, rigidity) is a hallmark.

C. Serotonin syndrome typically causes TACHYcardia and HYPERtension (autonomic instability).

D. CORRECT. CORRECT — Autonomic instability includes hyperthermia and diaphoresis.

E. Pupils typically DILATE (mydriasis) in serotonin syndrome, not constrict.

NCLEX · Pharmacological & Parenteral Therapies · Adverse Effects/Contraindications

Q5

A nurse is preparing to administer alprazolam to a client with anxiety. Which of the following findings would be a reason to hold the medication?

A. Respiratory rate of 10/min
B. Heart rate of 88/min
C. Blood pressure of 130/85 mmHg
D. Temperature of 98.6°F (37°C)

Show rationale ▾

A. CORRECT. CORRECT — Benzodiazepines cause respiratory depression. With an RR of 10/min, hold the medication and notify the provider.

B. A normal heart rate is not a contraindication.

C. A normal-borderline BP is not a contraindication.

D. A normal temperature is not a contraindication.

NCLEX · Pharmacological & Parenteral Therapies · Adverse Effects/Contraindications

TL;DR · One-glance summary

SSRIs (fluoxetine — prototype) = first-line, fewer side effects. Black box warning: suicidal ideation in clients < 25 yo. 4–8 weeks for full effect. Serotonin syndrome if combined with MAOIs, triptans, or St. John's wort. MAOIs require strict tyramine-free diet — risk of hypertensive crisis.

SSRIs & SNRIs

SSRIs (fluoxetine, sertraline, paroxetine, citalopram, escitalopram): First-line for depression
SNRIs (venlafaxine, duloxetine): Also treat neuropathic pain
Common AE: Sexual dysfunction, GI upset, insomnia, weight changes
Serotonin syndrome: Confusion, agitation, hyperthermia, tremor, hyperreflexia, diaphoresis
Discontinuation syndrome: Taper slowly; flu-like symptoms if stopped abruptly

Atypicals, TCAs, MAOIs

Bupropion: No sexual side effects; also for smoking cessation; lowers seizure threshold
Mirtazapine: Sedating, appetite increase — give at bedtime
TCAs (amitriptyline, imipramine): Anticholinergic effects, cardiotoxic in overdose
MAOIs (phenelzine): Avoid tyramine foods (aged cheese, wine, cured meats) — risk of hypertensive crisis
MAOI washout: 2 weeks before/after switching to/from SSRIs

Black box & safety

Suicidal ideation in clients < 25 yo — monitor closely first 4–8 weeks
Pregnancy: Paroxetine = Category D (cardiac defects); others Category C
Onset = 1–3 weeks; full therapeutic effect = 4–8 weeks

Depression — additional details

St. John's wort interactions: CYP3A4 inducer — ↓ OCP, warfarin, digoxin, antiretrovirals; serotonin syndrome with SSRIs/MAOIs
SSRIs in older adults: First-line for depression; ↓ falls vs. TCAs; SIADH/hyponatremia risk
Pregnancy: Untreated depression has its own risks; sertraline often preferred SSRI in pregnancy/lactation; paroxetine = Category D (cardiac defects)
ECT (electroconvulsive therapy): Used for severe/resistant depression, suicidal ideation, severe psychotic depression; safe in pregnancy
Esketamine (Spravato) intranasal: Treatment-resistant depression; REMS program (monitored use due to abuse/dissociation)
Tricyclic overdose triad: Anticholinergic, cardiac (wide QRS), CNS (seizures, coma) — life-threatening; treat with sodium bicarbonate IV

SSRIs — First-Line Antidepressants

Selective Serotonin Reuptake Inhibitors are the first-line treatment for depression. They have a more favorable side effect profile than TCAs and MAOIs but share serotonin syndrome and withdrawal concerns.

SSRIs

Most commonly prescribed antidepressants

Prototype: Fluoxetine (Prozac). Other examples: sertraline (Zoloft), paroxetine (Paxil), citalopram (Celexa), escitalopram (Lexapro), fluvoxamine, vilazodone.

Uses

Major depressive disorder
Anxiety disorders (GAD, panic, OCD, PTSD, social anxiety)
Premenstrual dysphoric disorder
Bulimia (fluoxetine FDA-approved)

Adverse effects

Initial: GI upset, headache, jitteriness — usually improves in 2 weeks
Sexual dysfunction (often persistent — significant quality-of-life issue)
Weight gain (less than TCAs, but possible)
Insomnia or sedation (depends on agent — fluoxetine activating; paroxetine sedating)
Hyponatremia/SIADH (especially older adults — monitor sodium)
Bleeding risk (↑ with NSAIDs, anticoagulants)
Serotonin syndrome
Discontinuation syndrome (paroxetine worst)

Nursing actions

4–6 weeks for full effect — continue even without immediate benefit
BLACK BOX: Suicidal ideation in < 25 yo — monitor closely first 2–3 months
Taper to discontinue
AVOID MAOIs (washout 2 weeks; 5 weeks after fluoxetine due to long half-life)
AVOID St. John's wort, triptans, tramadol (serotonin syndrome)
Pregnancy: paroxetine Cat D; sertraline often preferred
Lactation: most pass into milk in small amounts; sertraline preferred

SNRIs

Serotonin-Norepinephrine Reuptake Inhibitors block reuptake of both serotonin and norepinephrine. Effective for depression, anxiety, and pain syndromes.

SNRIs

Dual action

Examples: venlafaxine (Effexor) — prototype, duloxetine (Cymbalta), desvenlafaxine (Pristiq), levomilnacipran.

Uses

Major depressive disorder, GAD, panic, social anxiety, PTSD
Duloxetine: diabetic neuropathy, fibromyalgia, chronic musculoskeletal pain

Adverse effects

Similar to SSRIs PLUS:
Hypertension (especially venlafaxine — dose-dependent; monitor BP)
Tachycardia
Insomnia, sweating
Hepatotoxicity (duloxetine — avoid in active liver disease)
More severe withdrawal than SSRIs
Serotonin syndrome with other serotonergic agents

Nursing actions

Monitor BP regularly — especially venlafaxine
Lower starting doses; titrate carefully
Taper slowly to discontinue
AVOID with MAOIs

Tricyclic Antidepressants (TCAs)

Older antidepressants with more side effects than SSRIs/SNRIs but useful for specific indications. Effective but cardiotoxic in overdose with a narrow therapeutic index.

TCAs

Second-line — high toxicity in overdose

Prototype: Amitriptyline. Other examples: imipramine, nortriptyline, doxepin, desipramine, clomipramine.

Uses

Depression (resistant or specific symptom patterns)
Neuropathic pain (amitriptyline, nortriptyline — lower doses than depression)
Migraine prevention
Insomnia (amitriptyline, doxepin)
OCD (clomipramine especially effective)
Enuresis in children (imipramine)

Adverse effects

Anticholinergic effects: Dry mouth, constipation, urinary retention, blurred vision, confusion (especially elderly)
Orthostatic hypotension
Sedation, weight gain
Cardiotoxicity: QRS widening, arrhythmias, sudden cardiac death; narrow TI
Lethal in overdose — small amounts can be fatal

Nursing actions

Avoid in older adults (Beers Criteria — anticholinergic effects, falls)
Baseline ECG before initiation
Monitor for suicidal ideation — limit dispensed quantity if suicide risk
AVOID with MAOIs
Slow taper to discontinue
Treat overdose with sodium bicarbonate IV (cardiac toxicity)

MAOIs and Atypical Antidepressants

MAOIs are reserved for treatment-resistant depression because of food and drug interactions. Atypical antidepressants offer alternatives with unique mechanisms.

MAOIs

Last-line — many restrictions

Monoamine oxidase inhibitors — phenelzine (Nardil), tranylcypromine (Parnate), isocarboxazid, selegiline (transdermal patch).

Uses

Treatment-resistant depression
Atypical depression
Selegiline transdermal (Emsam) — Parkinson disease (low dose), depression

Critical warnings

Hypertensive crisis with tyramine foods: Aged cheese, cured/smoked meats, red wine, beer, soy sauce, sauerkraut, fermented foods
Hypertensive crisis with sympathomimetics: Decongestants (pseudoephedrine), amphetamines, cocaine
Serotonin syndrome: SSRIs, SNRIs, TCAs, triptans, meperidine, tramadol, St. John's wort

Nursing actions

Extensive client education about food and drug restrictions
Washout periods: 2 weeks between MAOI and other antidepressants; 5 weeks after fluoxetine
Medical alert bracelet recommended
Treat hypertensive crisis: short-acting antihypertensive (phentolamine, nitroprusside)

Atypical antidepressants

Diverse mechanisms outside SSRI/SNRI/TCA classes.

Bupropion (Wellbutrin)

Norepinephrine and dopamine reuptake inhibitor
Uses: Depression, smoking cessation (as Zyban), seasonal affective disorder
AE: Seizure risk (avoid in seizure history, eating disorders, alcohol withdrawal)
NO sexual dysfunction (advantage)
NO weight gain (advantage)
Activating — good for fatigue, low energy

Mirtazapine (Remeron)

Alpha-2 antagonist; affects serotonin and norepinephrine
Uses: Depression — especially with insomnia, weight loss
AE: Significant sedation (give at bedtime); weight gain; agranulocytosis (rare)
Few sexual side effects

Trazodone

Serotonin modulator
Primarily used for INSOMNIA at low doses (not as primary antidepressant)
AE: Sedation, orthostatic hypotension, priapism (urologic emergency — male clients)

Esketamine (Spravato)

NMDA antagonist intranasal spray
Treatment-resistant depression
REMS program (sedation, dissociation — administered in office under monitoring)

Active Learning Scenario

From the book — uses the ATI Active Learning Template: Medication. Practice answering before reviewing the key.

Scenario

A nurse is providing teaching to a client who has been prescribed phenelzine (an MAOI) for treatment-resistant depression. Use the ATI Active Learning Template: Medication to develop the teaching plan.

Show key

Foods to AVOID (tyramine-containing) — Risk of Hypertensive Crisis

Aged cheeses (cheddar, blue, Swiss, Parmesan, Brie)
Cured and smoked meats (salami, pepperoni, prosciutto, hot dogs)
Smoked or pickled fish
Soy sauce, miso, fermented soybean products
Aged or fermented foods (sauerkraut, kimchi)
Red wine, sherry, vermouth, draft beer
Overripe fruits, fava beans
Yeast extracts (Marmite)

Medications to AVOID

OTC decongestants (pseudoephedrine, phenylephrine)
Stimulants and amphetamines
Other antidepressants (SSRIs, SNRIs, TCAs) — serotonin syndrome
Triptans (migraine medications)
Meperidine, tramadol
St. John's wort

Signs of Hypertensive Crisis (Report Immediately)

Severe occipital (back of head) headache
Stiff neck
Sweating, palpitations
Nausea, vomiting
Photophobia
Markedly elevated blood pressure

Other Education

Effect takes 2–4 weeks to develop
Carry a medical alert card or wear medical alert jewelry
Inform all providers (dentist, surgeons) of MAOI use
Do NOT discontinue suddenly
Washout: 2 weeks before starting another antidepressant; 5 weeks if previous medication was fluoxetine

Practice · Application Exercises

5 NCLEX-style questions covering Ch 8 core content. Click each exercise to reveal rationales and NCLEX category.

Q1

A nurse is teaching a client newly prescribed fluoxetine for depression. Which of the following statements by the client indicates a need for further teaching?

A. "I should expect to feel better within a few weeks."
B. "I will take this medication on an empty stomach in the morning."
C. "I can take St. John's wort as a natural booster."
D. "I will not stop the medication without talking to the provider."

Show rationale ▾

A. This is accurate — SSRIs typically take 2–4 weeks to begin showing effect and 4–6 weeks for full effect.

B. Fluoxetine is activating and best taken in the morning. Empty stomach is acceptable.

C. CORRECT. CORRECT (indicates need for further teaching) — St. John's wort + SSRI can cause serotonin syndrome. Do not combine.

D. This is accurate — SSRIs require tapering to prevent withdrawal syndrome.

NCLEX · Pharmacological & Parenteral Therapies · Adverse Effects/Contraindications

Q2

A nurse is caring for a client who has been taking amitriptyline for chronic neuropathic pain. Which of the following findings should the nurse identify as adverse effects of TCAs? (Select all that apply.)

A. Dry mouth and constipation
B. Orthostatic hypotension
C. Sexual dysfunction
D. Diarrhea
E. Cardiac arrhythmias

Show rationale ▾

A. CORRECT. CORRECT — Anticholinergic effects are very common with TCAs.

B. CORRECT. CORRECT — TCAs commonly cause orthostatic hypotension, increasing fall risk.

C. CORRECT. CORRECT — Common with TCAs as with most antidepressants.

D. TCAs cause CONSTIPATION, not diarrhea (anticholinergic).

E. CORRECT. CORRECT — TCAs cause QRS widening and arrhythmias; cardiotoxic in overdose.

NCLEX · Pharmacological & Parenteral Therapies · Adverse Effects/Contraindications

Q3

A client receiving phenelzine reports a sudden severe headache, palpitations, and neck stiffness after eating dinner at a restaurant. The nurse should identify these findings as a sign of which of the following?

A. Serotonin syndrome
B. Hypertensive crisis from tyramine ingestion
C. Anaphylaxis
D. Migraine headache

Show rationale ▾

A. Serotonin syndrome typically presents with mental status changes, neuromuscular signs (clonus, hyperreflexia), and autonomic instability — different pattern.

B. CORRECT. CORRECT — These are classic signs of MAOI-induced hypertensive crisis. The client likely ate tyramine-containing food (aged cheese, cured meat, fermented foods). Treat with phentolamine or nitroprusside.

C. Anaphylaxis presents with hypotension, wheezing, and urticaria — different pattern.

D. These features (sudden onset, neck stiffness, hypertension) are not typical of migraine.

NCLEX · Pharmacological & Parenteral Therapies · Adverse Effects/Contraindications

Q4

A nurse is preparing to administer bupropion to a client. Which of the following findings would be a contraindication?

A. History of hypertension
B. History of seizure disorder
C. History of insomnia
D. History of obesity

Show rationale ▾

A. Hypertension is not a specific contraindication to bupropion.

B. CORRECT. CORRECT — Bupropion lowers the seizure threshold and is contraindicated in clients with seizure disorders, eating disorders (bulimia, anorexia), or those undergoing alcohol withdrawal.

C. While bupropion can be activating, insomnia is not an absolute contraindication.

D. Bupropion is actually less likely to cause weight gain than other antidepressants.

NCLEX · Pharmacological & Parenteral Therapies · Contraindications/Precautions

Q5

A nurse is monitoring a client who is starting an SSRI for depression. The client is 22 years old. Which of the following should be the priority assessment?

A. Sexual function changes
B. Suicidal ideation
C. Weight changes
D. Sleep quality

Show rationale ▾

A. Sexual dysfunction is a concern but not a priority over suicide assessment.

B. CORRECT. CORRECT — All antidepressants have a BLACK BOX warning for increased suicidal ideation in clients < 25 years, especially during the first 2–3 months of treatment. This is the priority assessment.

C. Weight changes should be monitored but are not priority over suicide risk.

D. Sleep is important but not priority over suicide risk assessment.

NCLEX · Pharmacological & Parenteral Therapies · Expected Actions/Outcomes

TL;DR · One-glance summary

Lithium = prototype mood stabilizer. Therapeutic range: 0.6–1.2 mEq/L (acute: up to 1.5). Toxicity > 1.5 → GI distress, tremor, confusion, ataxia, seizures. Maintain sodium and fluid intake (low sodium = lithium retention = toxicity). Anticonvulsants (valproate, carbamazepine, lamotrigine) also used as mood stabilizers.

Lithium

Therapeutic level: 0.6–1.2 mEq/L (maintenance); up to 1.5 acute
Toxicity: Mild >1.5 (GI, tremor, polyuria); Moderate 2.0–2.5 (confusion, coarse tremor, ataxia); Severe >2.5 (seizures, coma, death)
Common AE: Polyuria, polydipsia, tremor, weight gain, hypothyroidism
Interactions: NSAIDs ↑ lithium levels; thiazide diuretics ↑ levels; ACE inhibitors ↑ levels
Critical teaching: Maintain steady fluid intake (2–3 L/day); steady sodium intake (low Na = lithium retention); avoid NSAIDs
Monitoring: Levels every 1–3 days during initiation, then every 1–3 months; TSH; serum creatinine

Anticonvulsants as mood stabilizers

Valproic acid (Depakote): Hepatotoxic; teratogenic (neural tube defects); ↑ ammonia
Carbamazepine: Stevens-Johnson syndrome (especially HLA-B*1502); CBC monitoring (agranulocytosis)
Lamotrigine: Risk of life-threatening rash (Stevens-Johnson); titrate slowly
Topiramate: Cognitive slowing; kidney stones; weight loss

Other agents

Atypical antipsychotics (olanzapine, risperidone, quetiapine, aripiprazole) for acute mania
Antidepressants used cautiously — can trigger mania

Bipolar — additional

Lithium administration: Take with food (decreases GI distress); maintain 2–3 L fluid/day; consistent sodium intake; AVOID NSAIDs and dehydration
Lithium and pregnancy: Category D — risk of Ebstein cardiac anomaly in first trimester
Lithium pre-treatment workup: Baseline TSH, BUN/Cr, ECG (if > 40 yo or cardiac history), pregnancy test, CBC
Why anticonvulsants work as mood stabilizers: Stabilize neuronal membranes by modulating sodium channels and GABA
Lamotrigine specifics: Best for bipolar DEPRESSION (less so mania); very slow titration to reduce Stevens-Johnson risk
Atypical antipsychotics for bipolar: Olanzapine, quetiapine, risperidone, aripiprazole, lurasidone — used for acute mania and maintenance
Treating bipolar depression: AVOID antidepressant monotherapy (can trigger mania) — use mood stabilizer + antidepressant or atypical antipsychotic

Lithium

The gold standard mood stabilizer for bipolar disorder. Narrow therapeutic index requires careful monitoring, hydration, and consistent sodium intake.

Lithium carbonate (Lithobid, Eskalith)

Mood stabilizer prototype

Mechanism unclear; stabilizes neuronal membranes and alters intracellular signaling. Effective for both acute mania and maintenance.

Uses

Acute mania
Maintenance therapy for bipolar I and II
Prevention of recurrent mood episodes
Augmentation of antidepressants in depression

Therapeutic levels

Acute mania: 0.8–1.4 mEq/L
Maintenance: 0.6–1.2 mEq/L
Toxicity: > 1.5 mEq/L
Severe toxicity: > 2.0 mEq/L (medical emergency)

Side effects (therapeutic range)

GI upset (nausea, diarrhea — usually improves)
Fine hand tremor
Polyuria, polydipsia
Weight gain
Cognitive dulling

Toxicity signs

Early (1.5–2.0): N/V, diarrhea, coarse tremor, slurred speech, lethargy, confusion
Severe (> 2.0): Hyperreflexia, seizures, coma, cardiovascular collapse, death

Long-term concerns

Thyroid: Hypothyroidism (check TSH q6–12 months)
Renal: Nephrogenic diabetes insipidus, CKD with long-term use (check BUN/Cr q6–12 months)
Cardiac: Conduction abnormalities (baseline ECG if > 40 yo)
Pregnancy: Category D — Ebstein cardiac anomaly in 1st trimester

Critical client teaching

Maintain consistent fluid intake (2–3 L/day) — dehydration → toxicity
Maintain consistent sodium intake — low sodium → ↑ lithium retention → toxicity
AVOID NSAIDs and ACE inhibitors — ↑ lithium levels
Take with food (decreases GI upset)
Report: vomiting, diarrhea, fever — risk of dehydration → toxicity
Monitor for thyroid symptoms (cold intolerance, weight gain, fatigue)

Lithium toxicity treatment

Mild toxicity: hold lithium, hydrate, monitor levels
Severe toxicity: hemodialysis (most effective treatment)

Anticonvulsant Mood Stabilizers

Several anticonvulsants are effective mood stabilizers. They work by stabilizing neuronal membranes through sodium channel modulation or GABA enhancement.

Valproic acid / divalproex (Depakote)

First-line for acute mania, especially with rapid cycling or mixed episodes.

Uses

Acute mania, mixed episodes, rapid cycling
Bipolar maintenance
Seizure disorders
Migraine prophylaxis

Adverse effects

Hepatotoxicity — baseline LFTs; monitor
Pancreatitis — severe abdominal pain, elevated amylase/lipase
Thrombocytopenia — check CBC
GI upset, sedation, weight gain
Hair loss
Teratogenicity: Category X — neural tube defects, severe — AVOID in pregnancy

Levels

Therapeutic: 50–125 mcg/mL
Toxic: > 175 mcg/mL

Lamotrigine (Lamictal)

Best for bipolar depression

More effective for bipolar depression than mania.

Uses

Bipolar I maintenance
Bipolar depression
Seizure disorders

Adverse effects

Stevens-Johnson Syndrome — life-threatening rash; very slow titration required
Headache, dizziness, ataxia
Nausea

Nursing actions

Slow titration over 6+ weeks to reduce SJS risk
Hold and report ANY rash
↓ dose with valproate (valproate ↑ lamotrigine levels)

Carbamazepine (Tegretol)

Used when other agents fail. Many drug interactions.

Uses

Bipolar disorder, mania
Seizure disorders
Trigeminal neuralgia

Adverse effects

Agranulocytosis, aplastic anemia — baseline CBC; monitor
Stevens-Johnson Syndrome — HLA-B*1502 testing in Asian descent before initiation
SIADH/hyponatremia
Sedation, ataxia

Interactions

Potent CYP450 inducer — ↓ OCPs (pregnancy risk), warfarin, many other drugs
Auto-induces own metabolism (levels may decrease over time)

Atypical Antipsychotics for Bipolar

Several atypical antipsychotics are FDA-approved for bipolar disorder — acute mania, depression, and maintenance.

Atypical antipsychotics

Multiple indications

Examples used in bipolar: olanzapine (Zyprexa), quetiapine (Seroquel), risperidone, aripiprazole (Abilify), ziprasidone, lurasidone (Latuda), cariprazine.

Uses in bipolar

Acute mania (most atypicals)
Acute bipolar depression (quetiapine, lurasidone, cariprazine, olanzapine + fluoxetine)
Maintenance therapy

Common adverse effects

Metabolic syndrome: Weight gain, hyperglycemia, dyslipidemia (olanzapine and clozapine worst)
Sedation (quetiapine, olanzapine)
Orthostatic hypotension
EPS — less than typical antipsychotics but possible (risperidone has more)
Tardive dyskinesia with long-term use
Increased mortality in elderly with dementia-related psychosis (BBW)

Nursing actions

Baseline weight, fasting glucose, lipids — monitor regularly
AIMS exam for tardive dyskinesia
Educate about long-term metabolic risk
Quetiapine has dose-dependent effects (low dose for sleep/depression, higher for mania)

Active Learning Scenario

From the book — uses the ATI Active Learning Template: System Disorder. Practice answering before reviewing the key.

Scenario

A nurse is caring for a client with bipolar I disorder who has been taking lithium for 6 months. The client reports the past 2 days of vomiting and diarrhea due to gastroenteritis. The client's current lithium level is 1.8 mEq/L. Use the ATI Active Learning Template: System Disorder.

Show key

Recognition of Toxicity

Lithium level of 1.8 mEq/L is in the toxic range (therapeutic: 0.6–1.2 maintenance, 0.8–1.4 acute mania)
Toxicity precipitated by dehydration from vomiting and diarrhea
Decreased fluid → ↑ lithium concentration → toxicity

Toxicity Manifestations to Assess

Coarse tremor, slurred speech
Confusion, lethargy, ataxia
Hyperreflexia, muscle twitching
Severe N/V, diarrhea (worsened by GI illness)
Severe (> 2.0): seizures, coma, cardiovascular collapse

Nursing Actions

HOLD next lithium dose
Notify provider immediately
IV fluid replacement (NS) for hydration
Monitor lithium level every 6–12 hours
Severe toxicity (> 2.0): prepare for hemodialysis (most effective treatment)
Monitor vital signs, neurologic status, intake/output

Client Education for Preventing Recurrence

Maintain 2–3 L fluid intake daily
Maintain consistent sodium intake
When vomiting/diarrhea/fever/heavy sweating: hold lithium and notify provider
AVOID NSAIDs and ACE inhibitors
Carry a medical alert
Schedule routine lithium levels and follow up

Practice · Application Exercises

5 NCLEX-style questions covering Ch 9 core content. Click each exercise to reveal rationales and NCLEX category.

Q1

A nurse is reviewing the medication record of a client taking lithium. Which of the following should the nurse identify as a concerning interaction?

A. Acetaminophen 500 mg PRN for pain
B. Ibuprofen 600 mg three times daily for arthritis
C. Multivitamin once daily
D. Loratadine 10 mg daily for allergies

Show rationale ▾

A. Acetaminophen is safe to use with lithium.

B. CORRECT. CORRECT — NSAIDs (ibuprofen, naproxen) decrease renal clearance of lithium, leading to elevated levels and toxicity. Avoid NSAIDs or use cautiously with monitoring.

C. A standard multivitamin is not contraindicated.

D. Loratadine is safe with lithium.

NCLEX · Pharmacological & Parenteral Therapies · Adverse Effects/Contraindications

Q2

A nurse is teaching a client newly prescribed lithium. Which of the following statements indicate understanding? (Select all that apply.)

A. "I will drink 2–3 liters of fluid each day."
B. "I will take this medication with food."
C. "I will use a low-sodium diet to prevent weight gain."
D. "I will get my blood drawn periodically to check levels."
E. "I will stop taking lithium if I feel better."

Show rationale ▾

A. CORRECT. CORRECT — Adequate hydration is essential to prevent lithium toxicity. Dehydration concentrates lithium and increases risk.

B. CORRECT. CORRECT — Taking lithium with food reduces GI upset.

C. INCORRECT — Sodium restriction increases lithium retention and toxicity risk. Maintain a CONSISTENT sodium intake.

D. CORRECT. CORRECT — Lithium has a narrow therapeutic index and requires routine level monitoring (q3–6 months once stable; more often during titration).

E. INCORRECT — Discontinuing mood stabilizers without medical guidance increases relapse risk and worsens outcomes.

NCLEX · Pharmacological & Parenteral Therapies · Medication Administration

Q3

A client taking valproic acid for bipolar disorder reports severe abdominal pain radiating to the back. Which of the following should the nurse suspect?

A. Constipation
B. Pancreatitis
C. Hepatotoxicity
D. Thrombocytopenia

Show rationale ▾

A. Constipation does not typically cause severe pain radiating to the back.

B. CORRECT. CORRECT — Valproate can cause acute pancreatitis, which presents with severe epigastric pain radiating to the back. This is a serious adverse effect requiring immediate evaluation.

C. Hepatotoxicity typically presents with jaundice, fatigue, and elevated LFTs — not severe back pain.

D. Thrombocytopenia presents with easy bruising and bleeding, not abdominal pain.

NCLEX · Pharmacological & Parenteral Therapies · Adverse Effects/Contraindications

Q4

A nurse is teaching a client newly prescribed lamotrigine for bipolar maintenance. Which of the following teaching points is most important?

A. "Take this medication on an empty stomach."
B. "Report any rash to the provider immediately."
C. "Lamotrigine will work within 24 hours."
D. "You can discontinue this medication when you feel stable."

Show rationale ▾

A. Lamotrigine can be taken with or without food. This is not the priority teaching.

B. CORRECT. CORRECT — Lamotrigine can cause Stevens-Johnson Syndrome, a life-threatening rash. ANY rash warrants immediate evaluation. Slow titration (6+ weeks) is used to reduce this risk.

C. Mood stabilizers take weeks to reach therapeutic effect.

D. Mood stabilizers should be continued long-term to prevent relapse.

NCLEX · Pharmacological & Parenteral Therapies · Adverse Effects/Contraindications

Q5

A client taking carbamazepine for bipolar disorder reports a sore throat and fever. Which of the following should the nurse do first?

A. Administer acetaminophen for the fever
B. Obtain a CBC
C. Increase fluid intake
D. Continue the current dose and recheck in 1 week

Show rationale ▾

A. Symptomatic treatment is important but does not address the priority concern.

B. CORRECT. CORRECT — Carbamazepine can cause agranulocytosis and aplastic anemia. A sore throat and fever can be early signs of infection due to neutropenia. The priority is to check the CBC to assess for blood dyscrasias.

C. Hydration is supportive but not the priority assessment.

D. These symptoms require immediate evaluation, not delayed monitoring.

NCLEX · Pharmacological & Parenteral Therapies · Adverse Effects/Contraindications

TL;DR · One-glance summary

1st-gen (conventional) antipsychotics (haloperidol, chlorpromazine) → high EPS risk. 2nd-gen (atypical) (risperidone, olanzapine, quetiapine, clozapine) → metabolic syndrome risk. EPS: acute dystonia, akathisia, parkinsonism, tardive dyskinesia. NMS (rare, fatal): fever + rigidity + autonomic instability → stop drug + dantrolene. Clozapine: agranulocytosis — weekly CBC.

First-generation (conventional)

Examples: Haloperidol (high-potency), chlorpromazine (low-potency), fluphenazine
Block dopamine D2: Treats positive symptoms (hallucinations, delusions); minimal effect on negative symptoms
EPS effects: Acute dystonia (early), akathisia (early), parkinsonism (weeks), tardive dyskinesia (late, often irreversible)
EPS treatment: Anticholinergics (benztropine, diphenhydramine, trihexyphenidyl)
Other AE: Anticholinergic (dry mouth, constipation, urinary retention), orthostatic hypotension, photosensitivity

Second-generation (atypical)

Examples: Risperidone, olanzapine, quetiapine, ziprasidone, aripiprazole, clozapine
Treat positive AND negative symptoms; less EPS than 1st-gen
Metabolic syndrome: Weight gain, hyperglycemia (new-onset diabetes), dyslipidemia — monitor lipids, glucose, weight
Clozapine: Reserved for treatment-resistant; agranulocytosis (weekly CBC × 6 mo, then biweekly); myocarditis; lowers seizure threshold

Neuroleptic Malignant Syndrome (NMS)

Triad: Hyperthermia + muscle rigidity + autonomic instability (BP/HR fluctuations)
Labs: ↑ CK (rhabdomyolysis), ↑ WBC, AKI
Treatment: STOP antipsychotic, cooling, IV fluids, dantrolene + bromocriptine
Mortality: 10–20% if untreated — true emergency

Typical (First-Generation) Antipsychotics

D2 dopamine receptor blockers — effective for positive symptoms (hallucinations, delusions) but with significant extrapyramidal side effects. Now largely replaced by atypicals for first-line use.

Typical antipsychotics

High EPS

Examples: haloperidol (Haldol) — high potency, chlorpromazine (Thorazine) — low potency, fluphenazine, perphenazine, thioridazine.

Uses

Acute psychosis, schizophrenia (positive symptoms)
Acute agitation (haloperidol IM)
Tourette syndrome
Severe nausea (some)

Extrapyramidal symptoms (EPS)

Acute dystonia (hours-days): Sudden severe muscle spasms, torticollis, oculogyric crisis — emergency; give IM benztropine or diphenhydramine
Akathisia (days): Inner restlessness, inability to sit still — beta blockers or benzodiazepines
Parkinsonism (weeks): Tremor, rigidity, bradykinesia, masked face — benztropine, trihexyphenidyl
Tardive dyskinesia (months-years): Involuntary movements of face, tongue, extremities — often irreversible; AIMS screening; discontinue offending med

Neuroleptic malignant syndrome (NMS)

Life-threatening reaction
Symptoms: hyperthermia (> 103°F), severe muscle rigidity ("lead pipe"), altered mental status, autonomic instability (BP swings, tachycardia, diaphoresis)
Labs: ↑ CK, ↑ WBC
Treatment: DISCONTINUE antipsychotic immediately, cooling, IV fluids, dantrolene, bromocriptine

Other adverse effects

Anticholinergic (dry mouth, constipation, urinary retention)
Sedation
Orthostatic hypotension
Photosensitivity
Sexual dysfunction
Hyperprolactinemia (galactorrhea, amenorrhea, gynecomastia)
QT prolongation (especially thioridazine, haloperidol — torsades de pointes)

Nursing actions

Baseline AIMS exam; repeat every 3–6 months
Monitor for EPS at every encounter
Sun protection education
Increased mortality in elderly with dementia — BLACK BOX

Atypical (Second-Generation) Antipsychotics

D2 and 5HT2A blockers — first-line for psychotic disorders. Better tolerated than typicals (less EPS) but with significant metabolic side effects.

Atypical antipsychotics

First-line

Examples: olanzapine (Zyprexa), risperidone (Risperdal), quetiapine (Seroquel), aripiprazole (Abilify), ziprasidone (Geodon), paliperidone, lurasidone (Latuda), brexpiprazole, cariprazine.

Uses

Schizophrenia, schizoaffective disorder
Bipolar disorder (acute mania and maintenance)
Bipolar depression (quetiapine, lurasidone)
Major depression (adjunctive — aripiprazole, brexpiprazole)
Autism-associated irritability (risperidone, aripiprazole)

Metabolic syndrome

Significant weight gain (worst: olanzapine, clozapine)
Hyperglycemia/new-onset diabetes (BBW)
Dyslipidemia
Monitor baseline and ongoing: weight, BMI, waist, fasting glucose, lipids, BP

Other AE

Less EPS than typicals — but risperidone has highest EPS of atypicals
Tardive dyskinesia (less than typicals but still possible)
NMS (less common than typicals)
Orthostatic hypotension, sedation
Hyperprolactinemia (risperidone, paliperidone especially)
QT prolongation (ziprasidone — take with 500-calorie meal for absorption)

Nursing actions

Baseline metabolic screening; every 3 months × 1 year then yearly
Monitor for early signs of diabetes
Educate on diet, exercise
BLACK BOX: ↑ mortality in elderly with dementia

Clozapine (Clozaril)

Last-line — risks

Most effective antipsychotic — used for treatment-resistant schizophrenia.

Critical risks

Agranulocytosis — life-threatening; weekly CBC for 6 months, then biweekly, then monthly; cannot dispense without ANC check (REMS program)
Myocarditis
Seizures (dose-dependent)
Hypersalivation
Severe weight gain, metabolic syndrome
Constipation (severe — bowel obstruction possible)

Use criteria

Treatment-resistant schizophrenia (failure of 2+ other antipsychotics)
Suicide risk reduction in schizophrenia/schizoaffective

Active Learning Scenario

From the book — uses the ATI Active Learning Template: System Disorder. Practice answering before reviewing the key.

Scenario

A nurse is caring for a client with schizophrenia who has been taking haloperidol for 2 weeks. The client now exhibits severe muscle rigidity, hyperthermia (104°F), altered mental status, and diaphoresis. The blood pressure is fluctuating. Use the ATI Active Learning Template: System Disorder.

Show key

Recognition — Neuroleptic Malignant Syndrome

Tetrad: hyperthermia, severe rigidity, altered mental status, autonomic instability
Life-threatening neurologic emergency
Most often within 2 weeks of starting a typical antipsychotic; can occur with atypicals and abrupt discontinuation of dopamine agonists
Mortality 10–20% if untreated

Differential — Distinguish from Serotonin Syndrome

NMS: "lead pipe" rigidity, hyperthermia, autonomic instability
Serotonin syndrome: clonus, hyperreflexia, neuromuscular hyperactivity, plus autonomic and mental status changes
Both: hyperthermia and altered mental status — clinical context matters

Immediate Nursing Actions

DISCONTINUE the antipsychotic immediately
Notify the provider STAT — transfer to ICU
Cooling measures (cool blankets, IV fluids, ice packs)
IV fluid resuscitation
Continuous monitoring of vital signs, cardiac rhythm, mental status
Anticipate: dantrolene (muscle relaxation), bromocriptine (dopamine agonist)
Monitor CK (rhabdomyolysis); BUN/Cr (renal function); electrolytes

Follow-up After Recovery

Switch to a different (preferably atypical) antipsychotic
Avoid the offending agent for life
Educate client and family about NMS warning signs

Practice · Application Exercises

5 NCLEX-style questions covering Ch 10 core content. Click each exercise to reveal rationales and NCLEX category.

Q1

A nurse is caring for a client receiving haloperidol who develops sudden severe neck spasm and tongue protrusion. The nurse should anticipate administering which of the following medications?

A. Benztropine IM
B. Haloperidol IM
C. Lithium PO
D. Naloxone IM

Show rationale ▾

A. CORRECT. CORRECT — These are acute dystonic reactions, which respond to anticholinergic medications. IM benztropine (or diphenhydramine) is administered for rapid relief.

B. Haloperidol is the cause of the reaction. Giving more would worsen the symptoms.

C. Lithium is a mood stabilizer, not appropriate for acute dystonia.

D. Naloxone reverses opioids, not antipsychotic side effects.

NCLEX · Pharmacological & Parenteral Therapies · Adverse Effects/Contraindications

Q2

A nurse is caring for a client receiving clozapine for treatment-resistant schizophrenia. Which of the following is the priority assessment?

A. Daily weight
B. Fasting glucose
C. WBC and ANC
D. Liver function tests

Show rationale ▾

A. Weight monitoring is important but not the priority for clozapine.

B. Glucose monitoring is important due to metabolic effects but not the priority.

C. CORRECT. CORRECT — Clozapine causes agranulocytosis (life-threatening). Weekly WBC/ANC for 6 months, then biweekly, then monthly is required (REMS program). The medication cannot be dispensed without a current count.

D. LFTs are monitored but not the priority for clozapine.

NCLEX · Pharmacological & Parenteral Therapies · Adverse Effects/Contraindications

Q3

A nurse is monitoring a client on long-term antipsychotic therapy. Which of the following findings indicate tardive dyskinesia? (Select all that apply.)

A. Lip smacking
B. Tongue protrusion
C. Choreoathetoid movements of the extremities
D. Severe muscle rigidity and hyperthermia
E. Acute torticollis

Show rationale ▾

A. CORRECT. CORRECT — Repetitive involuntary movements of the face, especially lip smacking and tongue protrusion, are hallmarks of TD.

B. CORRECT. CORRECT — TD commonly involves the tongue and face.

C. CORRECT. CORRECT — Slow, twisting movements of arms, fingers, and toes are part of TD.

D. These describe NMS, not TD. TD is a movement disorder without autonomic instability.

E. Acute torticollis is acute dystonia, not TD. TD develops over months/years.

NCLEX · Pharmacological & Parenteral Therapies · Adverse Effects/Contraindications

Q4

A nurse is teaching a client newly prescribed risperidone. Which of the following statements indicates the need for further teaching?

A. "I will have my weight and blood sugar monitored regularly."
B. "I can stop taking this medication when I no longer hear voices."
C. "I will avoid alcohol while taking this medication."
D. "I will report any uncontrolled muscle movements."

Show rationale ▾

A. Correct understanding — atypicals require metabolic monitoring.

B. CORRECT. CORRECT (indicates further teaching needed) — Antipsychotics must be continued long-term to prevent relapse. Abrupt discontinuation often leads to symptom return.

C. Correct understanding — alcohol increases sedation and risk.

D. Correct understanding — risperidone has the highest EPS risk among atypicals.

NCLEX · Pharmacological & Parenteral Therapies · Expected Actions/Outcomes

Q5

A nurse is assessing a client newly prescribed an atypical antipsychotic. Which of the following baseline assessments are appropriate? (Select all that apply.)

A. Weight, BMI, waist circumference
B. Fasting glucose
C. Fasting lipid panel
D. AIMS exam
E. Pulmonary function tests

Show rationale ▾

A. CORRECT. CORRECT — Baseline anthropometrics are essential for monitoring metabolic side effects.

B. CORRECT. CORRECT — Baseline glucose is needed; atypicals can cause new-onset diabetes (BBW).

C. CORRECT. CORRECT — Dyslipidemia is a known effect of atypical antipsychotics.

D. CORRECT. CORRECT — Abnormal Involuntary Movement Scale screens for tardive dyskinesia; reassess every 3–6 months.

E. Not routinely indicated for antipsychotic monitoring.

NCLEX · Pharmacological & Parenteral Therapies · Expected Actions/Outcomes

TL;DR · One-glance summary

ADHD stimulants (methylphenidate, amphetamines) — Schedule II, monitor weight/height/sleep, take in AM. Atomoxetine — non-stimulant alternative, no abuse potential. SSRIs in pediatrics: fluoxetine and escitalopram FDA-approved; black box for suicidal ideation. Atypicals for severe behavioral issues.

ADHD stimulants

Methylphenidate (Ritalin, Concerta, Daytrana patch): Schedule II
Amphetamines (Adderall, Vyvanse, dextroamphetamine): Schedule II
AE: Appetite suppression (weight loss/growth delay), insomnia, tachycardia, hypertension, irritability
Teaching: Give in AM (avoid evening dose); take with food; monitor weight/height; "drug holidays" sometimes used
Contraindicated: Cardiac structural abnormalities; severe anxiety

Non-stimulants & antidepressants

Atomoxetine (Strattera): SNRI; non-controlled; 1–3 weeks for onset; black box for suicidal ideation
Clonidine, guanfacine: Alpha-2 agonists; help with ADHD + tics; sedating
SSRIs for pediatric depression/anxiety: Fluoxetine (8+ yo), escitalopram (12+ yo) — FDA approved
Black box warning: Heightened suicide risk in children — close monitoring required

Other pediatric psychotropics

Atypical antipsychotics (risperidone, aripiprazole) for autism-related irritability, Tourette
Lithium and anticonvulsants used cautiously
Always consider non-pharm interventions first (behavioral therapy)

Pediatric MH — additional

Desipramine, nortriptyline (TCAs): Sometimes used cautiously for ADHD or depression in adolescents; baseline ECG (cardiac monitoring); narrow TI in overdose
Lithium use in children: Approved > 7 yo for bipolar; close monitoring of levels
Vyvanse (lisdexamfetamine): Prodrug — must be metabolized to be active; less abuse potential than other amphetamines
Strattera (atomoxetine): Non-stimulant; 1–3 weeks to onset; black box for suicidal ideation; hepatotoxicity risk
Guanfacine (Intuniv), clonidine (Kapvay): Alpha-2 agonists; help with ADHD impulsivity, sleep, Tourette's; sedating; rebound HTN if stopped
Eating disorders: Fluoxetine FDA-approved for bulimia; do not initiate antidepressants if active anorexia (risk of seizures with electrolyte imbalances)

Active Learning Scenario

From the book — uses the ATI Active Learning Template: Medication. Practice answering before reviewing the key.

Scenario

A nurse working in a pediatric mental health clinic is caring for a client who has a new prescription for risperidone for the treatment of conduct disorder. Use the ATI Active Learning Template: medication to complete this item.

COMPLICATIONS: Identify at least four adverse effects of this medication.
NURSING INTERVENTIONS: Identify at least four nursing interventions to prevent or minimize the adverse effects of this medication.

Show key

Complications

New onset of diabetes mellitus or loss of glucose control in clients who have diabetes
Weight gain
Hypercholesterolemia
Orthostatic hypotension
Anticholinergic effects (urinary hesitancy or retention, dry mouth)
Agitation
Dizziness
Sedation
Sleep disruption
Tremors
Agranulocytosis, neutropenia
Hyperprolactinemia

Nursing Interventions

Obtain the client's fasting blood glucose prior to and periodically throughout treatment.
Instruct the client to report indications of diabetes mellitus including increased thirst, urination, and appetite.
Advise clients to follow a healthy, low-caloric diet.
Recommend regular exercise.
Monitor weight throughout treatment.
Monitor cholesterol and triglycerides, especially if weight gain is more than 30 lb.
Monitor blood pressure with first dose and instruct client to change positions slowly.
Encourage the client to sip fluids throughout the day.
Monitor and report manifestations of an infection (a sore throat).
Monitor and report gyneocomastia and amenorrhea.

TL;DR · One-glance summary

Alcohol: Disulfiram (deterrent — avoid all alcohol/mouthwash), naltrexone, acamprosate. Opioids: Methadone (long-acting agonist replacement), buprenorphine (partial agonist), naltrexone (antagonist), naloxone (overdose reversal). Tobacco: Nicotine replacement, varenicline, bupropion. Acute withdrawal: benzos for alcohol; clonidine for opioids.

Alcohol use disorder

Disulfiram (Antabuse): Aversion therapy — inhibits acetaldehyde dehydrogenase → severe reaction (flushing, vomiting, hypotension) if alcohol consumed
AVOID: All alcohol-containing products (cough syrup, mouthwash, vanilla extract, aftershave) for 2 weeks after stopping
Naltrexone: Opioid antagonist — reduces alcohol craving and pleasure response
Acamprosate: Reduces craving; OK with active drinking
Withdrawal: Benzodiazepines (lorazepam, chlordiazepoxide) prevent seizures and DTs

Opioid use disorder

Methadone: Full agonist, long half-life — replacement therapy; only at certified clinics
Buprenorphine (Subutex, Suboxone): Partial agonist; ceiling effect on respiratory depression; office-based
Naltrexone: Antagonist — must be opioid-free 7–10 days before starting
Naloxone (Narcan): EMERGENCY OVERDOSE REVERSAL — IM, IV, intranasal; short duration (may need repeat dosing)
Withdrawal: Clonidine (alpha-2 agonist) reduces autonomic symptoms

Tobacco & other

Nicotine replacement (gum, patch, lozenge, inhaler, spray)
Varenicline (Chantix): Partial nicotinic agonist — black box for neuropsychiatric symptoms
Bupropion (Zyban): Atypical antidepressant for smoking cessation

Active Learning Scenario

From the book — uses the ATI Active Learning Template: Medication. Practice answering before reviewing the key.

Scenario

A nurse is teaching a client who has tobacco use disorder about a new prescription for varenicline to promote smoking cessation. Use the ATI Active Learning Template: medication to complete this item.

EXPECTED PHARMACOLOGICAL ACTION THERAPEUTIC USES COMPLICATIONS: Identify at least three adverse effects.
CLIENT EDUCATION: Identify at least two teaching points.
EVALUATION OF MEDICATION EFFECTIVENESS: Identify a client outcome to indicate medication effectiveness.

Show key

Expected Pharmacological Action

Varenicline is a nicotinic receptor agonist that promotes the release of dopamine to simulate the pleasurable effects of nicotine.

Therapeutic Uses

Varenicline is indicated to reduce nicotine cravings and block the desired effects of nicotine in clients who have tobacco use disorder.

Complications

New-onset hypertension
Loss of glycemic control in clients who have diabetes mellitus
Nausea
Vomiting
Insomnia
New-onset depression
Suicidal thoughts

Client Education

Clients who are commercial truck or bus drivers, airplane pilots, or air traffic controllers should not take varenicline.
Take medication after a meal.
Titrate as prescribed to minimize adverse effects.
Notify the provider if adverse effects occur.

Evaluation Of Medication Effectiveness

The client will maintain smoking cessation.
The client will report reduced cravings for nicotine.

TL;DR · One-glance summary

Parkinson: Levodopa/carbidopa (prototype) — wearing-off, on-off; avoid high-protein meals. Alzheimer: Donepezil (cholinesterase inhibitor) for mild-moderate; memantine for moderate-severe. Seizures: Phenytoin therapeutic 10–20 mcg/mL; gingival hyperplasia. Myasthenia gravis: Neostigmine. Migraine: Sumatriptan (acute), propranolol (prevention).

Parkinson disease

Levodopa/carbidopa (Sinemet): Prototype; carbidopa prevents peripheral conversion
Wearing-off effect (end-of-dose return of symptoms); on-off phenomenon (sudden loss of function)
Avoid high-protein meals with levodopa (amino acids compete for absorption)
Other: Dopamine agonists (pramipexole, ropinirole), COMT inhibitors (entacapone), MAO-B inhibitors (selegiline)
AVOID conventional antipsychotics — worsen symptoms

Alzheimer disease & dementia

Cholinesterase inhibitors: Donepezil, rivastigmine, galantamine — mild-moderate
Memantine (Namenda): NMDA antagonist — moderate-severe
Cholinergic AE: Bradycardia, GI distress, dizziness
These medications slow progression — they do not cure

Seizures, MS, ALS, MG

Phenytoin: Therapeutic 10–20 mcg/mL; gingival hyperplasia, hirsutism, ataxia, narrow TI
Valproate, carbamazepine, lamotrigine, gabapentin, levetiracetam: Various seizure types
Multiple sclerosis: Interferon beta, glatiramer (immunomodulators)
ALS: Riluzole (slows progression)
Myasthenia gravis: Neostigmine, pyridostigmine (cholinesterase inhibitors) — atropine reverses cholinergic crisis

Migraine

Acute: Triptans (sumatriptan) — contraindicated in CAD, uncontrolled HTN, recent MI; ergot alkaloids (ergotamine)
Prevention: Propranolol, topiramate, valproate, amitriptyline; new CGRP inhibitors
NEVER combine triptans + MAOIs or 2 triptans within 24 hr (serotonin syndrome)

Active Learning Scenario

From the book — uses the ATI Active Learning Template: Medication. Practice answering before reviewing the key.

Scenario

A nurse is planning care for a client who has tonic-clonic seizures and a new prescription for phenytoin. Considering the adverse effects and nursing interventions, what should the nurse include in the plan of care? Use the ATI Active Learning Template: medication to complete this item to include the following:

THERAPEUTIC USES: Describe.
COMPLICATIONS: Describe two adverse effects and two medication interactions.
NURSING INTERVENTIONS: Include two interventions that relate to the two adverse effects, and two interventions that relate to the two medication interactions.

Show key

Therapeutic Uses

Phenytoin is a hydantoin medication that suppresses partial seizure and primary generalized seizure activity in the affected neurons.

Complications

CNS effects
Gingival hyperplasia
Teratogenic birth defects
Decreases effectiveness of oral contraceptives, warfarin, and glucocorticoids
Causes stimulation of hepatic medication-metabolizing enzymes
Alcohol (acute use), diazepam, cimetidine, and valproic acid increase phenytoin levels.
Carbamazepine, phenobarbital, and chronic alcohol use decrease phenytoin levels.
Additive CNS depressant effects can occur with concurrent use of CNS depressants.

Nursing Interventions

Instruct the client to refrain from alcohol and other medications that cause CNS depression, such as barbiturates.
Encourage the client to use dental floss and massage gums daily.
Instruct the client to avoid pregnancy and use an alternate form of contraception.
Monitor INR if on warfarin and blood glucose levels if taking a glucocorticoid.
Monitor therapeutic effects of warfarin and glucocorticoids.
Never abruptly discontinue antiepileptic medications.
Advise clients to avoid use of alcohol and other CNS depressants
Monitor blood phenytoin levels

TL;DR · One-glance summary

Glaucoma medications lower IOP. Prostaglandin analogs (latanoprost) = first-line, once-daily. Beta blockers (timolol) = systemic AE possible (bradycardia, bronchospasm). Cholinergics (pilocarpine) = miosis, blurred vision. Eye drop technique: press inner canthus 1 min to prevent systemic absorption. Ear drops: warm to body temp, pull pinna up/back (adult) or down/back (child).

Glaucoma medications

Prostaglandin analogs (latanoprost, bimatoprost, travoprost): First-line; iris color change, lash growth
Beta-adrenergic blockers (timolol, betaxolol): Avoid in asthma/COPD/heart block — can cause systemic effects
Alpha-adrenergic agonists (brimonidine): Drowsiness, dry mouth
Cholinergics (pilocarpine): Miosis, blurred vision, headache
Carbonic anhydrase inhibitors (acetazolamide PO, dorzolamide drops): Sulfa allergy caution

Eye drop administration

Wash hands; tilt head back; pull lower lid down to form cul-de-sac
Instill drop without touching eye
Apply pressure to nasolacrimal duct (inner canthus) for 1 minute — prevents systemic absorption
Wait 5–10 minutes between different drops
Suspensions: shake well; ointments: applied last

Ear & other ophthalmic

Otic drops: Warm to body temp (prevent dizziness); adult: pinna up & back; child < 3: down & back
Have client lie on opposite side for 5 min after instilling
Otitis media: Oral antibiotics (amoxicillin first-line)
Otitis externa: Topical antibiotic + corticosteroid drops
Allergic conjunctivitis: Antihistamine drops, mast cell stabilizers

Glaucoma — additional medications

Carbonic anhydrase inhibitors — Acetazolamide (PO), dorzolamide (drops): Reduce aqueous humor production
Acetazolamide also treats: Acute glaucoma, altitude sickness, seizures
Sulfonamide-derived — caution with sulfa allergy
Mannitol (IV): Osmotic agent — acute angle-closure glaucoma emergency
Brimonidine (alpha-2 agonist): First-line; can cross BBB; monitor BP
Allergic conjunctivitis: Olopatadine, cromolyn (mast cell stabilizer); avoid in active eye infection
Cerumenolytics (carbamide peroxide): Soften ear wax; never if perforated eardrum

Active Learning Scenario

From the book — uses the ATI Active Learning Template: Medication. Practice answering before reviewing the key.

Scenario

A nurse in a provider's office is teaching a client who has a prescription for ciprofloxacin/hydrocortisone about the medication and how to prevent otitis externa. Use the ATI Active Learning Template: medication to complete this item.

THERAPEUTIC USES: Identify two therapeutic effects of the medication.
COMPLICATIONS: Identify two potential adverse effects.
CLIENT EDUCATION: Identify two actions to prevent otitis externa.

Show key

Therapeutic Uses

The bactericidal effects of ciprofloxacin and the anti-inflammatory effect of hydrocortisone decreases pain, edema, and erythema in the ear.

Complications

Rash
Dizziness, lightheadedness, tremors, restlessness, and convulsions

Client Education

Keep foreign bodies out of ear canal.
Avoid manual measures to remove cerumen.
Dry ear canal after bathing or swimming using a towel.
Avoid use of ear plugs except for swimming.

TL;DR · One-glance summary

Centrally-acting muscle relaxants (cyclobenzaprine, methocarbamol, baclofen, tizanidine) — all cause CNS depression and drowsiness. Cyclobenzaprine: most prescribed; anticholinergic; not with MAOIs. Dantrolene (direct-acting): treats malignant hyperthermia and NMS. Baclofen: spasticity from MS/spinal cord injury; do not abruptly stop (withdrawal seizures).

Centrally-acting muscle relaxants

Cyclobenzaprine (Flexeril): Most common; anticholinergic effects; max 2–3 weeks; contraindicated with MAOIs
Methocarbamol, carisoprodol, metaxalone, chlorzoxazone: Short-term muscle spasm
Baclofen (Lioresal): Spasticity (MS, spinal cord injury); abrupt discontinuation = seizures, hallucinations
Tizanidine: Hypotension, hepatotoxicity
All cause: Drowsiness, dizziness — avoid alcohol, hazardous activities

Direct-acting & key uses

Dantrolene (Dantrium): Direct skeletal muscle relaxant
Critical uses: Malignant hyperthermia (anesthesia complication) and neuroleptic malignant syndrome (NMS)
Hepatotoxic — monitor LFTs with chronic use

General anesthesia adjuncts & cholinergics

Bethanechol: Cholinergic (muscarinic agonist) — treats urinary retention, post-op ileus
Bethanechol AE: Bradycardia, hypotension, bronchospasm, sweating, abdominal cramps
Contraindicated in asthma, peptic ulcer, hyperthyroidism, urinary tract obstruction
Antidote for bethanechol toxicity: Atropine
Centrally-acting muscle relaxants (also covered in Ch 16 sedatives) for spasticity

Active Learning Scenario

From the book — uses the ATI Active Learning Template: Medication. Practice answering before reviewing the key.

Scenario

A nurse manager in a surgical center is reviewing nursing responsibilities regarding administration of succinylcholine. Use the ATI Active Learning Template: medication to complete this item.

THERAPEUTIC USES: Identify two common indications for use.
MEDICATION ADMINISTRATION: Identify two nursing responsibilities regarding the use of succinylcholine.

Show key

Therapeutic Uses

Endotracheal intubation
Electroconvulsive therapy
Endoscopy
Adjunct to mechanical ventilation
Muscle relaxation during surgery

Medication Administration

Clients must receive continuous cardiac and respiratory monitoring during therapy.
Monitor clients following administration of a neuromuscular blocker for respiratory depression and have life support equipment available.
Continue to carefully monitor for return of respiratory function.
Succinylcholine is contraindicated for clients at risk for hyperkalemia (trauma, severe burns).

TL;DR · One-glance summary

Benzodiazepines (diazepam prototype, lorazepam, temazepam, midazolam) — risk dependence, anterograde amnesia, paradoxical reactions in older adults; reverse with flumazenil. Z-drugs (zolpidem, eszopiclone, zaleplon) — less dependence; complex sleep behaviors (sleep-driving). Ramelteon — melatonin agonist, no dependence. All: avoid alcohol, evening dosing only.

Benzodiazepines

Diazepam (Valium): Long-acting prototype; metabolites prolong effect
Lorazepam, oxazepam, temazepam: No active metabolites — safer in elderly and liver disease
Midazolam: Short-acting; pre-procedural sedation
AE: CNS depression, ataxia, anterograde amnesia, tolerance, dependence
Paradoxical reactions (excitation) in children and older adults
Overdose: Reverse with flumazenil (may precipitate seizures in dependent clients)
Pregnancy: Category D — avoid; teratogenic (cleft palate)

Z-drugs (non-benzodiazepine hypnotics)

Zolpidem (Ambien): Most prescribed; rapid onset
Eszopiclone (Lunesta), zaleplon (Sonata): Similar mechanism
Complex sleep behaviors: Sleep-driving, sleep-eating, sleep-walking — discontinue if occurs
Take only when 7–8 hours of sleep available
Less dependence risk than benzos but still controlled (Schedule IV)

Newer agents & general teaching

Ramelteon (Rozerem): Melatonin receptor agonist; no dependence; no Schedule classification
Suvorexant (Belsomra): Orexin antagonist
Doxepin (low-dose): Antihistamine action for sleep
Diphenhydramine: OTC; anticholinergic — avoid in older adults (Beers Criteria)
NEVER combine with alcohol or opioids

General anesthesia adjuncts

Propofol (Diprivan): IV induction & maintenance of anesthesia; rapid onset/offset; propofol infusion syndrome (PRIS) with prolonged use (acidosis, rhabdomyolysis); supports bacterial growth — change tubing q12h; egg/soy allergy caution
Ketamine (Schedule III): Dissociative anesthetic; bronchodilator (good in asthma); causes emergence reactions (hallucinations, vivid dreams) — pretreat with benzodiazepine; ↑ BP/HR (avoid in CAD); also low-dose for treatment-resistant depression
Fentanyl (anesthesia adjunct): Potent opioid; balanced anesthesia; respiratory depression
Etomidate: IV induction; minimal CV depression; adrenal suppression (avoid in sepsis)
Barbiturates — Pentobarbital: Older sedative; Schedule II–IV; respiratory depression; no antidote (unlike benzos); rarely used due to safety profile

Active Learning Scenario

From the book — uses the ATI Active Learning Template: Medication. Practice answering before reviewing the key.

Scenario

A nurse manager is preparing an educational session to review client use of benzodiazepines for the nurses on their unit. Use the ATI Active Learning Template: medication to complete this item.

THERAPEUTIC USES: Identify five therapeutic uses for benzodiazepines.
CONTRAINDICATIONS/PRECAUTIONS: Identify four contraindications for taking benzodiazepines.

Show key

Therapeutic Uses

Anxiety disorders
Seizure disorders
Insomnia
Muscle spasms
Alcohol withdrawal
Panic disorder
Induction of anesthesia

Contraindications / Precautions

Pregnancy: Benzodiazepines are Pregnancy Risk Category D (a high risk to the fetus)
Sleep apnea
Respiratory depression
Organic brain disease
Lactation
Cautious use in clients who have a history of substance use disorders, liver dysfunction, and kidney failure

TL;DR · One-glance summary

Quick-relief: SABA (albuterol — prototype) for acute attacks. Long-term controllers: ICS (fluticasone), LABA (salmeterol — never solo, always with ICS), leukotriene modifiers (montelukast), anticholinergics (ipratropium short, tiotropium long). Status asthmaticus: IV magnesium, IV corticosteroids. Teach: rinse mouth after ICS (prevents thrush).

Bronchodilators

SABA — Albuterol (prototype): Quick relief for acute bronchospasm; onset 5–15 min; AE: tachycardia, tremor, nervousness
LABA — Salmeterol, formoterol: Long-term control; BLACK BOX warning — never use alone in asthma (↑ death risk); always combine with ICS
Anticholinergics — Ipratropium (short), tiotropium (long): COPD first-line; dry mouth, urinary retention
Methylxanthines — Theophylline: Narrow TI (10–20 mcg/mL); monitor levels; avoid caffeine; toxicity = N/V, tremor, seizures

Anti-inflammatory & biologics

Inhaled glucocorticoids — Fluticasone, budesonide: First-line controller for asthma
Rinse mouth after each use — prevents oral candidiasis (thrush) and hoarseness
Leukotriene modifiers — Montelukast: PO; daily; AE: mood/behavior changes (black box for neuropsych)
Mast cell stabilizers — Cromolyn: Preventive only — NOT for acute attacks
Biologics — Omalizumab (anti-IgE): Severe persistent asthma; SC injection; risk anaphylaxis

Critical teaching

Order with combo: SABA first, wait 5 min, then ICS — opens airway before steroid
Always carry rescue inhaler; track frequency of SABA use (>2 days/week = poor control)
Use spacer to improve delivery and reduce thrush
Peak flow monitoring: green (>80%), yellow (50–79%), red (<50% = ER)

Inhaler technique & asthma severity

MDI technique: Shake well, exhale, seal lips around mouthpiece (or use spacer), press canister while inhaling slowly over 3–5 sec, hold breath 10 sec; wait 1 min between puffs
Spacer benefits: Better drug delivery to lungs, reduces oropharyngeal deposition (less thrush with ICS), critical for children/older adults
DPI (dry powder inhaler): Don't exhale into the device (moisture clumps powder); inhale fast and deep; no spacer
Asthma severity classification guides therapy: Intermittent → Mild persistent → Moderate persistent → Severe persistent
Asthma action plan (color zones): Green = good control, Yellow = caution (use SABA, contact provider), Red = medical alert (severe, ER)
Status asthmaticus: Life-threatening; IV magnesium sulfate, IV corticosteroids, IV epinephrine, intubation if respiratory failure
COPD GOLD stages: Stage 1 mild (FEV1 ≥ 80%), 2 moderate (50–79%), 3 severe (30–49%), 4 very severe (< 30%)
COPD treatment progression: SABA PRN → add LABA + LAMA → add ICS if frequent exacerbations
Roflumilast: PDE-4 inhibitor for severe COPD with chronic bronchitis; reduces exacerbations

Active Learning Scenario

From the book — uses the ATI Active Learning Template: Medication. Practice answering before reviewing the key.

Scenario

A nurse is instructing a client who has a new prescription for albuterol PO. What should the nurse include in the teaching? Use the ATI Active Learning Template: medication to complete this item.

THERAPEUTIC USES COMPLICATIONS: List two adverse effects.

Show key

Therapeutic Uses

Beta2-adrenergic agonists act by selectively activating the beta2-receptors in the bronchial smooth muscle, resulting in bronchodilation. They also suppress histamine release and promote ciliary motility.

Complications

Oral agents can cause tachycardia and angina due to activation of alpha1 receptors in the heart.
Activation of beta2 receptors in skeletal muscle causes tremors.

TL;DR · One-glance summary

Antitussives: Codeine (opioid — controlled), dextromethorphan (OTC). Expectorant: guaifenesin (thins secretions). Mucolytic: acetylcysteine (also acetaminophen overdose antidote). Decongestants (phenylephrine, pseudoephedrine) — caution in HTN. Antihistamines: 1st-gen (diphenhydramine) = sedating, anticholinergic; 2nd-gen (loratadine, cetirizine) = non-sedating.

Cough & secretion management

Codeine: Opioid antitussive; Schedule II/III; AE: respiratory depression, constipation, dependence
Dextromethorphan: Non-opioid; common in OTC products; abuse potential at high doses
Guaifenesin: Expectorant — thins respiratory secretions; encourage fluids
Acetylcysteine: Mucolytic (inhaled, smells like rotten eggs); also antidote for acetaminophen overdose (PO/IV)

Nasal congestion & allergies

Phenylephrine, pseudoephedrine (PO): Sympathomimetic decongestants; AE: HTN, tachycardia, insomnia, restlessness
Avoid in HTN, CAD, glaucoma, hyperthyroidism, BPH
Oxymetazoline (intranasal): Limit to 3–5 days — rebound congestion if longer
Intranasal glucocorticoids (fluticasone, mometasone): First-line for allergic rhinitis

Antihistamines (H1 blockers)

First-generation — Diphenhydramine, chlorpheniramine, hydroxyzine: Sedating; strong anticholinergic effects
Beers Criteria: AVOID 1st-gen antihistamines in older adults (confusion, falls)
Second-generation — Loratadine, cetirizine, fexofenadine, desloratadine: Non-sedating; less anticholinergic
Diphenhydramine also used for anaphylaxis (after epinephrine), motion sickness, EPS reactions

Decision-making & age-specific cautions

Productive cough: Use expectorant (guaifenesin) + ↑ fluids; avoid suppressants — they keep mucus in lungs
Non-productive (dry) cough: Antitussive (dextromethorphan, codeine) appropriate; sleep-disrupting cough
Children < 4 yo: AVOID OTC cough/cold medications (FDA warning) — risk outweighs benefit
Children < 12 yo: AVOID codeine and tramadol (variable metabolism, deaths reported)
Methamphetamine precursor: Pseudoephedrine sale tracked (BTC — behind-the-counter); ID required; limited monthly
Nasal saline irrigation/neti pot: Use distilled or sterile water only (tap water → fatal amebic meningoencephalitis from Naegleria fowleri)
Intranasal glucocorticoids (fluticasone, mometasone, triamcinolone, budesonide): First-line for allergic rhinitis; takes days to work; AE: epistaxis, nasal dryness; teach proper technique (point away from septum)
Combination products (Theraflu, NyQuil, etc.) — multiple ingredients risk duplicate/overdose; check for hidden acetaminophen and pseudoephedrine
Cetirizine vs loratadine vs fexofenadine: All 2nd-gen, similar efficacy; cetirizine slightly more sedating than the others

Active Learning Scenario

From the book — uses the ATI Active Learning Template: Medication. Practice answering before reviewing the key.

Scenario

A nurse in a provider's office is providing teaching for a client who has a new prescription for guaifenesin. Use the ATI Active Learning Template: medication to complete this item.

COMPLICATIONS: Identify two adverse effects of this medication.
EVALUATION OF MEDICATION EFFECTIVENESS: Identify two findings that indicate that the medication is effective.

Show key

Complications

GI upset
Drowsiness
Dizziness
Rash

Evaluation Of Medication Effectiveness

Cough is more productive, mucous is easier to expectorate.
Chest congestion is decreased.

TL;DR · One-glance summary

Loop (furosemide — prototype): Most powerful; HF, edema, HTN; ↓K, ↓Mg, ↓Ca; ototoxic (slow IV push). Thiazide (HCTZ): First-line HTN; ↓K; ↑Ca, ↑uric acid, ↑glucose. K-sparing (spironolactone): ↑K (hyperkalemia risk); gynecomastia. Osmotic (mannitol): IV only; ↑ICP, glaucoma; crystals — use filter needle.

Loop diuretics

Furosemide (prototype), bumetanide, torsemide, ethacrynic acid
Mechanism: Block Na/K/2Cl reabsorption in ascending loop of Henle
Uses: Heart failure, pulmonary edema, severe HTN, edema
Major AE: ↓K (hypokalemia), ↓Mg, ↓Ca, ↓Na; dehydration; hypotension
Ototoxicity: Especially with rapid IV push or concurrent aminoglycoside — administer IV slowly
Encourage K-rich foods (bananas, oranges, potatoes); monitor BUN/Cr

Thiazide & K-sparing

Thiazide — Hydrochlorothiazide (HCTZ), chlorthalidone, metolazone
HCTZ first-line for HTN; works on distal tubule
HCTZ AE: ↓K, ↓Na; ↑Ca, ↑glucose, ↑uric acid (gout), ↑lipids; sulfa allergy caution
K-sparing — Spironolactone (aldosterone antagonist), eplerenone, triamterene, amiloride
Spironolactone AE: Hyperkalemia (avoid salt substitutes, K supplements, ACE/ARB combo without monitoring); gynecomastia, menstrual irregularity

Osmotic & critical teaching

Mannitol: IV only — reduces ICP (TBI), intraocular pressure; treats acute renal failure
Filter needle required — solution may have crystals
NEVER add electrolytes to mannitol — precipitation
All diuretics: Monitor I&O, daily weights (2 lb/day = fluid retention/loss), BP, electrolytes

Active Learning Scenario

From the book — uses the ATI Active Learning Template: Medication. Practice answering before reviewing the key.

Scenario

A charge nurse is reviewing the use of loop diuretics with a group of nurses. Use the ATI Active Learning Template: medication to complete this item.

THERAPEUTIC USES: Identify two.
COMPLICATIONS: Describe three adverse effects.
NURSING INTERVENTIONS: Describe two interventions for each of the three adverse effects.

Show key

Therapeutic Uses

Used when there is an emergent need for rapid mobilization of fluid
Pulmonary edema caused by heart failure
Liver, cardiac, or kidney disease
Hypertension
Unlabeled use: hypercalcemia

Complications

Dehydration
Hypotension
Ototoxicity
Hypokalemia

Nursing Interventions

Dehydration: Assess for dry mouth, increased thirst, low urine output, weight loss.
Hypotension: monitor orthostatic blood pressure and pulse; monitor for manifestations of postural hypotension.
Ototoxicity: Assess for tinnitus; avoid administering ototoxic medications.
Hypokalemia: monitor laboratory values; offer potassium-rich foods; assess for general weakness, nausea, and vomiting.

TL;DR · One-glance summary

ACE inhibitors (captopril, lisinopril, enalapril) — "-pril"; dry cough, angioedema, hyperkalemia; Category D — teratogenic. ARBs (losartan, valsartan) — "-sartan"; switch from ACEi for cough; same risks otherwise. Clonidine — central α2; rebound HTN if abruptly stopped. Hydralazine, nitroprusside — direct vasodilators (IV for emergency).

ACE inhibitors & ARBs

ACE inhibitors — Captopril, lisinopril, enalapril, ramipril ("-pril")
Mechanism: Block conversion of angiotensin I → II; ↓ aldosterone; vasodilation
Uses: HTN, HF, post-MI, diabetic nephropathy (renoprotective)
Key AE: Persistent dry cough (10–20%), angioedema (life-threatening), hyperkalemia, hypotension (especially first dose)
ARBs — Losartan, valsartan, irbesartan ("-sartan") — no cough, less angioedema
BOTH contraindicated in pregnancy (Category D — fetal renal damage)
Monitor BUN/Cr (renal function) and K+
AVOID combining ACE + ARB (no benefit, more harm)

Aldosterone antagonists & DRI

Eplerenone, spironolactone: Block aldosterone; hyperkalemia risk
Aliskiren (direct renin inhibitor): Less commonly used; same Category D pregnancy restriction

Alpha blockers, central agonists, vasodilators

Alpha-1 blockers — Prazosin, doxazosin, terazosin: First-dose orthostatic hypotension — take at bedtime; rise slowly
Central alpha-2 — Clonidine, methyldopa: NEVER abruptly stop — rebound HTN crisis; sedation, dry mouth
Methyldopa = safe in pregnancy
Hydralazine (PO/IV): Direct vasodilator; reflex tachycardia; lupus-like syndrome at high dose
Nitroprusside (IV only): Hypertensive emergency; cyanide toxicity (max 72 hr); protect from light

Active Learning Scenario

From the book — uses the ATI Active Learning Template: Medication. Practice answering before reviewing the key.

Scenario

A nurse in an outpatient facility is teaching a client who has a new prescription for aliskiren to treat hypertension. What should the nurse teach the client about this medication? Use the ATI Active Learning Template: medication to complete this item.

THERAPEUTIC USES: Identify the therapeutic use for aliskiren.
COMPLICATIONS: List two adverse effects of this medication.
NURSING INTERVENTIONS: Describe one test to monitor.
CLIENT EDUCATION: Identify two teaching points.

Show key

Therapeutic Uses

Aliskiren binds with renin to inhibit production of angiotensin I, thus decreasing production of both angiotensin II and aldosterone. Aliskiren is used solely for treating hypertension alone or in combination with other antihypertensives.

Complications

Diarrhea: dose-related, occurs most frequently in females and older adult clients
Risk for angioedema and rash caused by allergy to the medication
Hyperkalemia
Hypotension

Nursing Interventions

Monitor blood electrolytes, paying close attention to potassium levels, because the client is at risk for hyperkalemia. This is especially important when the client takes ACE inhibitors concurrently, because these medications also raise potassium levels.

Client Education

Do not take aliskiren with foods high in fat, which decreases absorption of the medication.
Do not take potassium supplements or salt substitutes containing potassium.
Clients should not take aliskiren during pregnancy.
If a rash or angioedema occurs, discontinue aliskiren and notify the provider.
Call 911 if severe manifestations of allergy are present.

TL;DR · One-glance summary

Digoxin: positive inotrope (↑ contractility), negative chronotrope (↓ HR). Therapeutic 0.5–2.0 ng/mL. Apical pulse 1 min before dose — hold if <60 (adult) or <90–110 (infants/kids). Toxicity: N/V, anorexia, visual halos (yellow-green), dysrhythmias. Hypokalemia ↑ toxicity. Antidote: digoxin immune Fab (Digibind).

Digoxin

Mechanism: Inhibits Na/K ATPase → ↑ intracellular Ca → ↑ contractility (positive inotrope); slows AV conduction (negative chronotrope/dromotrope)
Uses: HF with reduced EF, atrial fibrillation (rate control)
Therapeutic level: 0.5–2.0 ng/mL
Before each dose: Check apical pulse for 1 full minute
HOLD and call provider: Adult HR <60; child <90; infant <110

Digoxin toxicity

Early signs: Anorexia, nausea, vomiting
Cardiac: Bradycardia, AV blocks, ventricular dysrhythmias
Visual: Yellow-green halos around lights, blurred vision
Neurological: Fatigue, weakness, confusion
Risk factors: Hypokalemia (most common), hypomagnesemia, hypercalcemia, renal impairment, advanced age
Antidote: Digoxin immune Fab (Digibind) for life-threatening toxicity

Other inotropic & HF agents

Catecholamines — Dopamine, dobutamine: IV infusion; short-term inotropic support (cardiogenic shock)
Sacubitril/valsartan (Entresto): ARNI for HF; replaces ACE/ARB (don't combine — angioedema)
Nesiritide: Recombinant BNP for acute decompensated HF
Ivabradine: Slows HR; for HF with elevated HR despite beta blockade

Active Learning Scenario

From the book — uses the ATI Active Learning Template: Medication. Practice answering before reviewing the key.

Scenario

A nurse is caring for a client who has heart failure and a new prescription for digoxin 0.125 mg PO daily. What should the nurse teach the client about this medication? Use the ATI Active Learning Template: medication to complete this item.

THERAPEUTIC USES COMPLICATIONS: Identify two adverse effects.
NURSING INTERVENTIONS: Describe two diagnostic tests to monitor.
CLIENT EDUCATION: Include three teaching points.

Show key

Therapeutic Uses

Digoxin improves the heart's pumping effectiveness and increases cardiac output and stroke volume. It decreases heart rate by slowing depolarization through the SA node, thus allowing more time for the ventricles to fill with blood. Due to these effects, digoxin is used to treat heart failure, atrial fibrillation, and some other tachydysrhythmias.

Complications

The client should monitor for manifestations of digoxin toxicity, which include GI effects (nausea, vomiting, diarrhea), CNS effects (fatigue, weakness), visual effects (yellow-tinged vision, halos around lights, diplopia), heart rate less than 60/ min in adults, or skipped beats when checking the pulse.

Nursing Interventions

Monitor digoxin blood levels periodically during treatment. The expected reference range is 0.5 to 0.8 ng/mL.
Monitor blood potassium levels because hypokalemia can cause cardiac dysrhythmias, especially in older adult clients. monitoring ECG is also important to check for dysrhythmias.

Client Education

Take oral digoxin at the same time each day. Do not skip a dose or take more than the prescribed dose each day.
Monitor for manifestations of toxicity.
Report any new prescriptions and to contact provider before taking OTC medications, because digoxin interacts with many other substances.

TL;DR · One-glance summary

Nitroglycerin (prototype): SL tab/spray for acute attack — take 1 dose, wait 5 min, repeat; if no relief after 3 doses or 15 min → 911. Patch: 10–12 hr on, 12–14 hr off to prevent tolerance. Side effects: headache (common), orthostatic hypotension. AVOID with PDE-5 inhibitors (sildenafil, tadalafil) — severe hypotension. Beta blockers + CCBs for chronic angina.

Nitrates

Nitroglycerin (NTG): Vasodilation → ↓ preload (mainly) and afterload → ↓ myocardial O2 demand
Sublingual: Acute angina — take 1 tab, wait 5 min, take another; max 3 doses; call 911 if no relief
SL storage: Original dark glass bottle; replace q6mo (loses potency); should cause slight burning/tingling
Patch: Apply hairless skin; remove 12–14 hr/day to prevent tolerance
Ointment: Apply paper applicator; do not rub in; wear gloves
IV NTG: Glass bottle and tubing (absorbs into PVC); for unstable angina/HF
AE: Headache (common — pretreat with acetaminophen), orthostatic hypotension, reflex tachycardia

Drug interactions

NEVER combine with PDE-5 inhibitors (sildenafil/Viagra, tadalafil/Cialis, vardenafil) — severe, prolonged hypotension
Caution with alcohol, other antihypertensives

Other anti-anginal agents

Beta blockers (metoprolol, atenolol): Reduce HR, contractility — long-term prevention; do not abruptly stop (rebound angina, MI)
Calcium channel blockers (verapamil, diltiazem, amlodipine): For variant (Prinzmetal) angina; vasodilate coronary arteries
Ranolazine: For chronic angina unresponsive to standard tx; doesn't affect HR/BP; can prolong QT

Angina types & post-MI medications

Stable angina: Predictable pain with exertion, relieved by rest or NTG; chronic CAD
Unstable angina: New, worsening, or at rest pain → potential STEMI/NSTEMI; ER, ECG, troponin, aspirin, nitroglycerin, possible heparin, urgent cath
Variant (Prinzmetal/vasospastic) angina: Caused by coronary artery spasm (not occlusion); often at rest, sometimes triggered by cold/stress; CCBs are first-line (not beta blockers)
NTG sublingual sequence: Sit/lie down (orthostatic hypotension), take 1 SL → wait 5 min → if no relief, call 911 → take 2nd → wait 5 → take 3rd; do not delay 911
Post-MI medications (MONA-BASH then home regimen):
• Acute: Morphine, Oxygen if hypoxic, Nitroglycerin, Aspirin, Beta blocker, ACE inhibitor, Statin, Heparin/thrombolytic
• Discharge regimen: Aspirin (often + P2Y12 inhibitor for 12 months), beta blocker, ACE/ARB, statin, NTG SL PRN
Dual antiplatelet therapy (DAPT): Aspirin + clopidogrel/ticagrelor/prasugrel after PCI/stent — typically 12 months
Ranolazine specifics: Late sodium channel modulator; doesn't change HR or BP (useful when patient can't tolerate beta blocker or CCB); CYP3A4 substrate; QT prolongation
Cardiac rehab: Recommended for all MI/CABG patients — exercise prescription, diet, smoking cessation, stress management

Active Learning Scenario

From the book — uses the ATI Active Learning Template: Medication. Practice answering before reviewing the key.

Scenario

A nurse is caring for a client who has angina pectoris and a new prescription for oral nitroglycerin capsules. What should the nurse teach the client about this medication? Use the ATI Active Learning Template: medication to complete this item.

THERAPEUTIC USES: Identify similarities and differences for the forms of nitroglycerin: oral, sublingual, and transdermal.
COMPLICATIONS: Identify two adverse effects of the medication.
NURSING INTERVENTIONS: Describe three nursing actions for clients taking nitroglycerin oral capsules.

Show key

Therapeutic Uses

Sublingual tablets or spray are used to treat an angina attack after it begins, while the oral tablets, transdermal patch, and transdermal ointment are used for prevention of angina. The capsules and transdermal forms have a slower onset and longer duration of action than the sublingual forms. Sublingual nitroglycerin begins working within 2 min, but the duration of action is only 30 min. Oral forms are taken several times daily, but duration of action is several hours.

Complications

Major adverse effects include headache, dizziness caused by hypotension, and rebound tachycardia.

Nursing Interventions

Teach the client that the oral sustained-release form of nitroglycerin should not be used to abort an angina attack. In addition, it should be taken on an empty stomach with at least 8 oz of water and must be swallowed whole.
Teach the client not to perform activities that require alertness if dizziness is experienced while taking oral nitroglycerin.
The client should inform the provider if headaches are persistent because the dose of nitroglycerin might need to be decreased.
The client should inform the provider if tachycardia occurs, because a beta-adrenergic blocker or other medication can be prescribed to slow the pulse rate.

TL;DR · One-glance summary

Vaughan Williams classes: I (Na+ block — procainamide, lidocaine), II (β-block — propranolol), III (K+ block — amiodarone), IV (Ca++ block — verapamil). Amiodarone: pulmonary fibrosis, hepatotoxicity, thyroid (hypo/hyper), corneal deposits, blue-gray skin, photosensitivity, very long half-life (40–60 days). Adenosine: rapid IV push (1–2 sec); brief asystole.

Classes I & II

Class I — Sodium channel blockers (slow conduction)
Class IA — Procainamide, quinidine, disopyramide: Risk of torsades de pointes; lupus-like syndrome (procainamide)
Class IB — Lidocaine (IV only): Ventricular arrhythmias; CNS toxicity (confusion, seizures); narrow TI
Class IC — Propafenone, flecainide: Proarrhythmic; avoid in structural heart disease
Class II — Beta blockers (propranolol, esmolol, metoprolol): Slow AV conduction; treat SVT, afib rate control; bronchospasm, bradycardia, hypoglycemia masking

Class III & IV

Amiodarone (Class III): Most effective antiarrhythmic; treats VT, VF, afib
Amiodarone toxicities (MANY): Pulmonary fibrosis (most serious — baseline CXR, PFTs), hepatotoxicity, thyroid dysfunction, corneal microdeposits, photosensitivity, blue-gray skin (slate), bradycardia/heart block
Amiodarone half-life: 40–60 days — effects persist long after stopping
Sotalol, dofetilide (Class III): QT prolongation; torsades risk
Class IV — Verapamil, diltiazem (CCB): SVT, afib rate control; constipation (verapamil), bradycardia, heart block

Other key agents

Adenosine: Terminates SVT; very short half-life (10 sec); rapid IV push (1–2 sec) followed by 20 mL saline flush; expect brief asystole; flushing, chest pain
Digoxin: Rate control in afib
Magnesium sulfate: Torsades de pointes — IV
Atropine: Symptomatic bradycardia

Active Learning Scenario

From the book — uses the ATI Active Learning Template: Medication. Practice answering before reviewing the key.

Scenario

A nurse is preparing to provide teaching to a client who has a new prescription for verapamil for recurrent supraventricular tachycardia. What should the nurse teach the client about this medication? Use the ATI Active Learning Template: medication to complete this item.

THERAPEUTIC USES COMPLICATIONS: Identify three adverse effects.
NURSING INTERVENTIONS: Describe three, including diagnostic tests the nurse should monitor.

Show key

Therapeutic Uses

Verapamil is a calcium channel blocker and a class IV antidysrhythmic medication that decreases heart rate, slows conduction through both the SA and AV nodes, and decreases force of contraction of the heart. It is used to treat supraventricular tachycardia (SVT).

Complications

Bradycardia
Hypotension
Heart failure
Constipation

Nursing Interventions

Monitor both kidney and liver function because the medication dosage might need to be lowered if either kidney or liver impairment are present.
Monitor blood pressure and pulse.
Monitor periodic ECG testing for dysrhythmias and for improvement of SVT.
Assess for manifestations of heart failure, such as dyspnea and crackles in the lungs.
Question the client about dizziness, which can occur due to hypotension.
Teach the client to move slowly from lying to sitting or standing and to avoid driving or operating heavy machinery until effects of verapamil are known.

TL;DR · One-glance summary

Statins (atorvastatin — prototype): First-line; ↓LDL most; AE: myopathy/rhabdomyolysis (muscle pain + ↑CK — STOP drug), hepatotoxicity (↑LFTs), Category X — teratogenic. Take in evening (cholesterol synthesis peaks at night). Avoid grapefruit juice. Ezetimibe: blocks intestinal absorption. Bile acid sequestrants (colesevelam): constipation; separate from other meds 4 hr. PCSK9 inhibitors (alirocumab): SC injection.

Statins (HMG-CoA reductase inhibitors)

Atorvastatin (Lipitor — prototype), simvastatin, rosuvastatin, pravastatin, lovastatin
Mechanism: Inhibit HMG-CoA reductase → ↓ hepatic cholesterol synthesis → ↑ LDL receptors → ↓ LDL
Take in the evening (cholesterol synthesis higher at night) — except atorvastatin and rosuvastatin (long half-life, anytime)
Major AE: Myopathy → rhabdomyolysis — myalgia + ↑ CK (CPK) + dark urine; STOP and call provider
Hepatotoxicity: Baseline LFTs, then if symptoms; jaundice, malaise
Category X — teratogenic; discontinue before pregnancy
AVOID grapefruit juice (CYP3A4 inhibitor — ↑ levels → toxicity)
Statin myopathy risk ↑ with fibrates (gemfibrozil), azoles, macrolides

Other lipid-lowering agents

Ezetimibe (Zetia): Blocks cholesterol absorption in small intestine; often combined with statin (Vytorin)
Bile acid sequestrants — Colesevelam, cholestyramine, colestipol: Bind bile acids; constipation, bloating
Separate from other meds by 4 hours — bind/decrease absorption of many drugs
Fibrates — Gemfibrozil, fenofibrate: ↓ triglycerides most; gallstones; ↑ myopathy with statins
Niacin (nicotinic acid): Flushing (pretreat with aspirin); hepatotoxicity at high doses
PCSK9 inhibitors — Alirocumab, evolocumab: SC injection q2wk; very effective LDL ↓; expensive

Active Learning Scenario

From the book — uses the ATI Active Learning Template: Medication. Practice answering before reviewing the key.

Scenario

A nurse is providing care for a client who has elevated total cholesterol, LDL, and triglycerides, and has a new prescription for atorvastatin once daily. The client has type 2 diabetes mellitus and hypertension. What should the nurse teach the client about atorvastatin? Use the ATI Active Learning Template: medication to complete this item.

THERAPEUTIC USES: Identify for atorvastatin.
COMPLICATIONS: Identify two adverse effects.
NURSING INTERVENTIONS: Describe three two tests to monitor.
CLIENT EDUCATION: Include two teaching points.

Show key

Therapeutic Uses

Atorvastatin decreases LDL and triglycerides, and elevates hDL. It reduces the risk for cardiovascular events (myocardial infarction) and also provides secondary prevention in clients who have had a cardiovascular event. In clients who have diabetes mellitus and hypertension, atorvastatin can reduce mortality by controlling cholesterol levels.

Complications

Muscle pain/tenderness (myopathy)
Liver toxicity with findings (jaundice, upper abdominal pain, anorexia, and nausea)

Nursing Interventions

Monitor baseline and periodic cholesterol levels (including LDL, hDL, and triglycerides), creatine kinase levels for myopathy, and liver function tests for liver toxicity.

Client Education

Perform additional ways to help decrease cholesterol and improve health (exercise, low-fat diet, weight control, and smoking cessation).
Take atorvastatin in the evening without regard to meals. (Antilipemic agents are given in the evening because cholesterol is mostly synthesized during the night.)

TL;DR · One-glance summary

Heparin (parenteral): aPTT 1.5–2× normal (60–80 sec); antidote protamine sulfate; HIT — switch to argatroban. Warfarin (PO): INR 2–3 (or 2.5–3.5 mech valve); antidote vitamin K; many interactions; consistent green leafy vegetable intake. DOACs (dabigatran, rivaroxaban, apixaban): no routine labs. Antiplatelets: aspirin, clopidogrel. Thrombolytics: alteplase — short window post-stroke/MI.

Heparin & LMWH

Heparin (unfractionated): IV continuous or SC; immediate onset
Monitor aPTT (therapeutic 1.5–2× control = 60–80 sec); platelet count for HIT
Antidote: protamine sulfate
HIT (heparin-induced thrombocytopenia): Stop heparin, use argatroban or bivalirudin
LMWH — Enoxaparin (Lovenox): SC; no routine labs; abdomen "love handle"; don't expel air bubble; do not rub site
Fondaparinux: Synthetic factor Xa inhibitor; no HIT risk

Warfarin & DOACs

Warfarin (Coumadin): PO; 3–5 days for full effect; vitamin K antagonist
Monitor INR: target 2–3 (DVT/PE/afib); 2.5–3.5 (mechanical heart valve)
Antidote: Vitamin K (phytonadione); severe bleed = FFP
Consistent intake of vitamin K foods (green leafy vegetables) — not avoid, just consistent
Many interactions: Many antibiotics, NSAIDs, herbals (ginkgo, garlic) ↑ INR; rifampin, OCPs, foods ↓ INR
Category X — teratogenic
DOACs — Dabigatran (direct thrombin), rivaroxaban/apixaban (factor Xa): No labs; idarucizumab reverses dabigatran; andexanet alfa for Xa

Antiplatelets & thrombolytics

Aspirin: Irreversible COX inhibition; ASA 81 mg daily for cardiovascular prevention; bleeding, GI ulcer, Reye syndrome (children)
Clopidogrel (Plavix), prasugrel, ticagrelor: P2Y12 inhibitors; post-stent placement
Abciximab, eptifibatide, tirofiban: GP IIb/IIIa inhibitors; IV for ACS
Thrombolytics — Alteplase (tPA), tenecteplase: Acute MI within 12 hr; ischemic stroke within 3 hr (up to 4.5); PE
Thrombolytic contraindications: Active bleeding, recent surgery, recent hemorrhagic stroke, severe HTN

Other antiplatelets & specifics

Dipyridamole (Persantine): Antiplatelet + vasodilator; combined with aspirin (Aggrenox) for stroke prevention; caution in angina (steal phenomenon)
Cilostazol, pentoxifylline: Intermittent claudication (PAD)
Heparin reversal step-by-step: Calculate based on time since heparin dose; protamine sulfate 1 mg per 100 units heparin remaining (max 50 mg/dose)
Warfarin reversal: Low INR no bleed = hold + reduce dose; high INR no bleed = oral vit K; bleeding = IV vit K + FFP or PCC; major bleed = 4-factor PCC (faster than FFP)

Active Learning Scenario

From the book — uses the ATI Active Learning Template: Medication. Practice answering before reviewing the key.

Scenario

A nurse is teaching a client who has a new prescription for clopidogrel following a myocardial infarction. Use the ATI Active Learning Template: medication to complete this item.

THERAPEUTIC USES: Identify the intended effect.
COMPLICATIONS: Identify two adverse effects for this medication.
NURSING INTERVENTIONS: Describe three, including one test the nurse should monitor periodically.

Show key

Therapeutic Uses

Clopidogrel inhibits platelet aggregation and prolongs bleeding time. It is used to prevent myocardial infarction (mI) or stroke in clients who have already had an mI or stroke.

Complications

Like other platelet inhibitors, clopidogrel can cause bleeding due to thrombocytopenia. It can also cause GI effects (abdominal pain, nausea, diarrhea).

Nursing Interventions

The nurse should plan to monitor the platelet count periodically while the client takes clopidogrel.
Teach the client to monitor for bleeding. The client should watch for black stools, coffee-ground emesis, blood in the urine, nose bleeds, unusual bruising, or petechiae. The client should inform the provider if these occur and about GI effects.
The nurse should be aware of all medications the client is taking, because risk for bleeding increases if the medication is taken with anticoagulants or antiplatelet medications. Clopidogrel is sometimes administered concurrently with aspirin, and that increases the risk for bleeding. The medication should be discontinued 7 days before any elective surgery.

TL;DR · One-glance summary

Epoetin alfa (Epogen, Procrit): SC/IV for anemia (CKD, chemo, HIV); target Hgb < 11–12 (higher = stroke/MI/death). Filgrastim (Neupogen): SC for chemo-induced neutropenia; bone pain common. Sargramostim (Leukine): bone marrow transplant recovery. Oprelvekin, romiplostim: thrombopoietic agents for thrombocytopenia.

Erythropoietin & RBC growth factors

Epoetin alfa, darbepoetin: Stimulate RBC production; treat anemia in CKD, chemo, HIV
Target Hgb: 10–11 g/dL — higher levels associated with cardiovascular events
Black box warning: ↑ risk of stroke, MI, tumor progression at higher Hgb
AE: HTN, headache; ensure adequate iron stores (ferritin) before initiation
Subcutaneous typically; do NOT shake vials

WBC growth factors

Filgrastim (G-CSF): Stimulates neutrophil production; chemo-induced neutropenia
Pegfilgrastim: Long-acting (single dose per chemo cycle)
Sargramostim (GM-CSF): Broader effect on multiple WBC lines; post-bone marrow transplant
AE: Bone pain (very common — pretreat with acetaminophen), leukocytosis, splenic rupture (rare)
Monitor CBC with differential

Platelet growth factors

Oprelvekin (IL-11): Stimulates megakaryocytes; for chemo-induced thrombocytopenia
Romiplostim, eltrombopag: Thrombopoietin receptor agonists for ITP
AE: Fluid retention, edema, thromboembolism risk

Active Learning Scenario

From the book — uses the ATI Active Learning Template: Medication. Practice answering before reviewing the key.

Scenario

A nurse is teaching a client who has chronic kidney disease and a new prescription for subcutaneous epoetin alfa three times weekly. What should the nurse teach the client about this medication? Use the ATI Active Learning Template: medication to complete this item.

THERAPEUTIC USES: Identify why epoetin alfa would benefit this client.
COMPLICATIONS: Identify two adverse effects the client should watch for.
NURSING INTERVENTIONS: Describe four, including two tests the nurse should monitor periodically.

Show key

Therapeutic Uses

Erythropoietin, a substance that stimulates bone marrow to produce red blood cells, is produced by the kidney. In clients who have chronic kidney disease, erythropoietin is no longer present and anemia results. Epoetin alfa stimulates production of red blood cells in these clients.

Complications

Headaches and myalgia (body aches)
Thrombotic events, such as myocardial infarction and stroke
Hypertension (common, sometimes serious)
A too-rapid increase (hgb greater than 1 g/dL over 2 weeks, or hgb greater than 10 g/dL) can worsen hypertension, increase risk of thrombosis, and cause seizures.

Nursing Interventions

Monitor baseline iron levels, CBC with differential, and platelet count.
Monitor hgb and hct twice weekly until blood counts stabilize.
Calculate dosages carefully. Both subcutaneous and IV epoetin alfa have dosages based on the client's weight. Do not shake the epoetin alfa vial, and discard vial after one dose is removed.
Monitor blood pressure carefully, and report increases to the provider. Question the client about frequency and severity of headaches, which could be an indication of increasing blood pressure or a simple adverse effect.

TL;DR · One-glance summary

Verify identity with 2 people, 2 identifiers, blood band match. Y-site only with 0.9% NS — never D5W or LR (hemolysis). Stay with client first 15 min; vital signs: baseline, 15 min, then per protocol. Complete within 4 hr. Acute hemolytic reaction (ABO mismatch — fever, chills, back pain, dark urine, shock) → STOP, NS, call provider. FFP, cryoprecipitate, platelets for specific deficiencies.

Pre-transfusion safety

Verify with two licensed staff: Client identity (two identifiers), blood band, unit number, ABO/Rh, expiration, crossmatch
Obtain informed consent; assess history of prior reactions
Establish IV access with large-bore (18-20 gauge); use blood tubing with filter
Compatible with 0.9% NS ONLY — D5W and LR cause hemolysis
Baseline vital signs and temperature; complete within 4 hours of leaving blood bank

Monitoring & reactions

Start slowly (~2 mL/min); stay with client first 15 min — most reactions occur early
Vital signs: baseline, 15 min, then per facility (often hourly), at completion
Acute hemolytic reaction (ABO mismatch): Fever, chills, low back/flank pain, hematuria, hypotension, shock → STOP immediately, infuse NS through new line, save bag/tubing
Febrile non-hemolytic: Fever, chills, headache; STOP, treat symptomatically
Mild allergic: Hives, itching → slow rate, give diphenhydramine, may resume
Anaphylaxis: Severe — STOP, epinephrine, support
TRALI (transfusion-related acute lung injury): Dyspnea, hypoxia within 6 hr — STOP, respiratory support
Circulatory overload (TACO): Slow rate, sit up, diuretic

Component therapy

Packed RBCs: Anemia, blood loss; raises Hgb 1 g/dL per unit
Platelets: Thrombocytopenia, active bleeding; rapid infusion (under 30 min); ABO ideally matched but not required
FFP: Clotting factor replacement (warfarin reversal urgent, DIC, liver failure); must be ABO-compatible
Cryoprecipitate: Fibrinogen, factor VIII, vWF — DIC, hemophilia A
Albumin: Volume expander; hypovolemia, hypoalbuminemia

Active Learning Scenario

From the book — uses the ATI Active Learning Template: Therapeutic Procedure. Practice answering before reviewing the key.

Scenario

A nurse is preparing to transfuse a unit of packed red blood cells (PRBCs) to a client who has who has a GI bleed and hgb 6.0 g/dL. Use the ATI Active Learning Template: Therapeutic Procedure to complete this item.

INDICATIONS: What assessment data would indicate to the nurse that transfusion of PRBCs is indicated in this client?

Show key

Indications

A client who lost blood from a GI bleed can need a unit of PRBCs for a hgb level below 10 g/dL especially if demonstrating manifestations of hypovolemia (increase in pulse and respiration rate; decrease in blood pressure; low oxygen saturation; cool and pale or cyanotic; increased capillary refill time; increased urinary output). If hypoxic, the client will exhibit decreased level of consciousness and confusion. PRBCs restore red blood cells and improve oxygenation. If the client has lost a large amount of fluid volume, whole blood, rather than PRBCs, can be indicated.

TL;DR · One-glance summary

H2 blockers (cimetidine, famotidine, ranitidine) — "-tidine": ↓ acid secretion; cimetidine has many drug interactions. PPIs (omeprazole, pantoprazole, esomeprazole) — "-prazole": most effective; long-term: ↓ B12, ↑ fracture risk, C. difficile, pneumonia, hypomagnesemia. Sucralfate: coats ulcer; 1 hr before meals, empty stomach. Misoprostol: NSAID-induced ulcer prevention; Category X — abortifacient.

Acid-suppressive therapy

H2 antagonists — Cimetidine, ranitidine, famotidine, nizatidine ("-tidine")
Cimetidine: Many interactions (CYP450 inhibitor); gynecomastia, impotence; avoid in older adults
Famotidine = preferred H2 blocker (fewer interactions)
PPIs — Omeprazole, esomeprazole, lansoprazole, pantoprazole, rabeprazole ("-prazole")
Most effective — block H+/K+ ATPase pump
Take before meals; do not crush enteric-coated; can sprinkle granules on applesauce
Long-term AE: ↓ B12 absorption, ↑ hip/spine fracture, hypomagnesemia, ↑ C. diff infection, pneumonia, rebound hypersecretion when stopped

Mucosal protectants & antacids

Sucralfate (Carafate): Forms protective barrier over ulcer
Take 1 hour before meals and at bedtime on empty stomach; separate from other meds by 2 hr (decreases absorption)
Antacids — Aluminum hydroxide, magnesium hydroxide, calcium carbonate: Neutralize acid
Aluminum: Constipation; Magnesium: Diarrhea (often combined); Calcium: Rebound acid, hypercalcemia
Separate antacids from other meds by 1–2 hr
Misoprostol (Cytotec): PG E1 analog; prevents NSAID-induced ulcers; CATEGORY X — abortifacient — pregnancy test before; effective contraception

H. pylori eradication

Triple therapy: PPI + clarithromycin + amoxicillin (or metronidazole) × 10–14 days
Quadruple therapy: PPI + bismuth subsalicylate + tetracycline + metronidazole × 10–14 days
Confirm eradication with urea breath test or stool antigen 4+ weeks after

Active Learning Scenario

From the book — uses the ATI Active Learning Template: Medication. Practice answering before reviewing the key.

Scenario

A nurse is caring for a client who has a prescription for calcium carbonate. Use the ATI Active Learning Template: medication to complete this item.

THERAPEUTIC USES: Identify the therapeutic use of calcium carbonate.
CLIENT EDUCATION: Identify three instructions the nurse should include regarding taking this medication. on Exercises

Show key

Therapeutic Uses

Calcium carbonate is an antacid that raises the ph of gastric contents, which reduces irritation of stomach mucosa, resulting in relief of pain.

Client Education

Shake liquid suspensions prior to taking each dose in order to disperse the medication.
Take other medications at least 1 hr before or after taking aluminum hydroxide.
Calcium carbonate can cause constipation. Notify the provider if it persists. You might need to alternate this antacid with one that is a magnesium compound and has diarrhea as an adverse effect.
Report manifestations of hypercalcemia (constipation, anorexia, nausea, vomiting, confusion) to the provider.

TL;DR · One-glance summary

Antiemetics: ondansetron (5-HT3 — QT prolongation), metoclopramide (EPS, tardive dyskinesia), prochlorperazine (EPS, sedation), scopolamine (motion sickness). Antidiarrheals: loperamide, diphenoxylate. Laxatives: bulk (psyllium), surfactant (docusate), stimulant (bisacodyl), osmotic (lactulose, PEG), saline (Mg hydroxide). IBS: alosetron (women, severe IBS-D — black box for ischemic colitis); lubiprostone. IBD: sulfasalazine, biologics.

Antiemetics

5-HT3 antagonists — Ondansetron (Zofran), granisetron, palonosetron: Chemo-induced N/V, post-op
Ondansetron AE: Headache, constipation, QT prolongation — caution with other QT-prolonging drugs
Metoclopramide (Reglan): Prokinetic; for diabetic gastroparesis, post-op; EPS reactions, tardive dyskinesia (black box); limit to 12 weeks
Phenothiazines — Prochlorperazine, promethazine: Sedation, EPS, anticholinergic; IV promethazine = tissue damage if extravasates
Scopolamine: Anticholinergic patch behind ear for motion sickness; dry mouth, drowsiness
Cannabinoids — Dronabinol: Chemo-induced N/V, AIDS-related anorexia

Diarrhea, constipation, IBS

Antidiarrheals — Loperamide (Imodium), diphenoxylate/atropine (Lomotil): Slow GI motility
Bulk-forming laxatives — Psyllium, methylcellulose: Take with plenty of water (obstruction risk)
Surfactant — Docusate: Stool softener
Stimulant — Bisacodyl, senna: Short-term; risk of dependence with chronic use
Osmotic — Lactulose, polyethylene glycol (PEG/MiraLAX), magnesium hydroxide: Draw water into bowel; lactulose also reduces ammonia in hepatic encephalopathy
Alosetron (Lotronex): Severe IBS-D in women only; BLACK BOX — ischemic colitis; restricted prescribing
Lubiprostone (Amitiza): Chronic idiopathic constipation, IBS-C

IBD & emetic agents

Sulfasalazine (Azulfidine): Mild-moderate UC, RA; sulfa allergy contraindicated; folic acid deficiency; orange-yellow body fluids
Mesalamine: 5-ASA derivative; UC
Glucocorticoids — Prednisone, budesonide: Acute exacerbations
Biologics — Infliximab, adalimumab: Refractory IBD; infection risk
Emetics — Syrup of ipecac: No longer recommended for most ingestions

Active Learning Scenario

From the book — uses the ATI Active Learning Template: Medication. Practice answering before reviewing the key.

Scenario

A nurse is caring for a client who has a prescription for sulfasalazine. Use the ATI Active Learning Template: medication to complete this item to include the following sections.

THERAPEUTIC USES: Identify two therapeutic uses for sulfasalazine.
COMPLICATIONS: Identify two blood disorders that occur as a complication with the use of sulfasalazine.
MEDICATION ADMINISTRATION: Identify how frequently the client should take the medication.

Show key

Therapeutic Uses

Crohn's disease and ulcerative colitis

Complications

Complications that occur with the use of sulfasalazine include agranulocytosis, and hemolytic and macrocytic anemia.

Medication Administration

The client should take sulfasalazine four times per day in divided doses.

TL;DR · One-glance summary

Iron (ferrous sulfate): empty stomach with vitamin C; dark/tarry stools normal; liquid stains teeth (use straw); IM by Z-track only. B12 (cyanocobalamin): pernicious anemia → lifelong IM/intranasal. Folic acid: pregnancy 600–800 mcg/day to prevent neural tube defects; megaloblastic anemia. K+ (KCl): NEVER IV push; max 10 mEq/hr peripheral, 20 mEq/hr central; PO with food to avoid GI upset.

Iron

Ferrous sulfate, ferrous gluconate, ferrous fumarate (PO): Iron-deficiency anemia
Take on empty stomach for max absorption (or with food if GI upset)
Vitamin C (orange juice) ↑ absorption; antacids, dairy, tea, coffee ↓ absorption
Dark/tarry stools are NORMAL (not melena)
Liquid forms stain teeth — dilute, use straw, rinse mouth
IM iron dextran: Z-track injection to prevent staining; risk of anaphylaxis (test dose first)
Monitor reticulocyte count (responds in 1 week)

B12 & folic acid

Vitamin B12 (cyanocobalamin): Pernicious anemia (lack of intrinsic factor)
Pernicious anemia = LIFELONG IM (or intranasal); PO ineffective for malabsorption
Monitor reticulocytes; treat hypokalemia that may occur with reticulocyte response
Folic acid (folate): Megaloblastic anemia, malabsorption, pregnancy
Pregnancy: 600–800 mcg/day — prevents neural tube defects (start before conception)
NEVER give folic acid alone for B12 deficiency — masks anemia but neurologic damage progresses

Electrolytes — Potassium chloride

NEVER push IV potassium — fatal cardiac arrhythmia
Peripheral IV: max 10 mEq/hr
Central line: max 20 mEq/hr (or per facility)
Always use infusion pump
Burning at IV site = slow rate, change site, evaluate concentration
PO KCl: Take with full glass of water, with food; do not crush sustained-release
Monitor for hyperkalemia: peaked T waves, arrhythmias

Active Learning Scenario

From the book — uses the ATI Active Learning Template: Medication. Practice answering before reviewing the key.

Scenario

A nurse is educating a client about a new prescription for cyanocobalamin. What should the nurse include in the teaching? Use the ATI Active Learning Template: medication to complete this item.

EXPECTED PHARMACOLOGICAL ACTION CLIENT EDUCATION: Describe four teaching points for the client.
EVALUATION OF MEDICATION EFFECTIVENESS: Describe two nursing interventions.

Show key

Expected Pharmacological Action

Cyanocobalamin converts folic acid from an inactive form to an active form. It corrects megaloblastic anemia related to a deficiency of vitamin B12.

Client Education

Review manifestations of hypokalemia.
Discuss the use of potassium supplements, if prescribed.
Discuss dietary sources of potassium.
Consume foods high in vitamin B12.
Administer intranasal cyanocobalamin 1 hr before or after eating hot foods when nasal secretions are decreased.
Periodic laboratory testing of hgb, hct, RBC, reticulocyte count, and folate levels is advised.

Evaluation Of Medication Effectiveness

Review laboratory values for increased reticulocyte count and macrocytes and hgb and hct levels within the expected reference range.
Assess for improvement of neurologic manifestations (numbness, tingling of hands and feet).

TL;DR · One-glance summary

Combined OCPs (estrogen + progestin): ACHES warning (Abdominal pain, Chest pain, Headache, Eye changes, Severe leg pain); avoid in smokers > 35 yo, history of VTE/MI/stroke. Progestin-only: safer in lactation. HRT: shortest duration possible; ↑ DVT/stroke/breast cancer. Testosterone: controlled substance; gel — risk of transfer to others. BPH: finasteride (5α-reductase), tamsulosin (α1 blocker). ED: sildenafil — NEVER with nitrates.

Oral contraceptives & HRT

Combined OCPs (estrogen + progestin): Most effective with consistent use
ACHES warning signs: Abdominal pain (liver/gallbladder), Chest pain (PE/MI), Headache (stroke), Eye changes (stroke/clot), Severe leg pain (DVT)
Contraindicated: Smokers > 35 yo, history of VTE/MI/stroke, breast cancer, severe HTN, migraine with aura, pregnancy
Progestin-only ("mini-pill"): Less effective; safer during lactation; must take same time every day
HRT (post-menopause): Shortest effective dose, shortest duration; ↑ DVT, stroke, breast cancer (combined), endometrial cancer (estrogen alone — protect with progestin if uterus intact)
Long-acting: Depo-Provera (medroxyprogesterone IM q3mo), Nexplanon implant, IUDs (hormonal Mirena, copper)

Androgens

Testosterone: Hypogonadism, gender-affirming care; Schedule III
Gel: Apply to dry skin (chest/shoulders); wash hands; cover with clothing to prevent transfer to others (especially children, women)
AE: ↑ lipids, polycythemia (monitor H&H), acne, prostatic enlargement, gynecomastia
Patch: Rotate sites; do not apply to scrotum (most products)

BPH & erectile dysfunction

5-alpha-reductase inhibitors — Finasteride, dutasteride: Shrink prostate over months
Pregnant women should not handle crushed/broken tablets — Category X teratogen
Alpha-1 blockers — Tamsulosin (Flomax), doxazosin, terazosin: Relax bladder neck; orthostatic hypotension; cataract surgery interaction (intraoperative floppy iris)
PDE-5 inhibitors — Sildenafil (Viagra), tadalafil (Cialis), vardenafil: Vasodilation in penis
NEVER combine with nitrates or alpha-blockers (severe hypotension)
Priapism > 4 hr = emergency
Vision changes (NAION) — discontinue

Active Learning Scenario

From the book — uses the ATI Active Learning Template: Medication. Practice answering before reviewing the key.

Scenario

A nurse in a provider's office is instructing a client who has a new prescription for finasteride to treat benign prostatic hyperplasia. Use the ATI Active Learning Template: medication to complete this item.

EXPECTED PHARMACOLOGICAL ACTION COMPLICATIONS: Identify two adverse effects.

Show key

Expected Pharmacological Action

Finasteride slows the production of testosterone, which reduces the size of the prostate and subsequently promotes urinary elimination.

Complications

Decreased libido
Decreased ejaculate volume
Gynecomastia
Orthostatic hypotension

TL;DR · One-glance summary

Oxytocin (Pitocin): Induction/augmentation of labor, postpartum hemorrhage; tachysystole (>5 contractions/10 min) — stop; uterine rupture; water intoxication. Tocolytics: magnesium sulfate (preterm labor, eclampsia prophylaxis — antidote calcium gluconate); terbutaline (β2 agonist — tachycardia, hyperglycemia); nifedipine; indomethacin. Cervical ripening: misoprostol, dinoprostone (no concurrent oxytocin within hours).

Oxytocin

Uses: Induce/augment labor, treat postpartum hemorrhage (PPH), milk ejection
Administration: IV piggyback diluted; titrate to effective contraction pattern
Tachysystole (more than 5 contractions in 10 min averaged over 30 min): Stop infusion, reposition, IV fluid bolus, O2; tocolytic if needed
Non-reassuring FHR: Stop oxytocin immediately
Uterine rupture: Sudden severe pain, loss of contractions, fetal distress, hypotension — emergency C-section
Water intoxication (with prolonged high doses): Headache, confusion, hyponatremia — limit IV fluids
Postpartum oxytocin: 20 units in 1 L LR/NS at brisk rate after delivery to control bleeding

Tocolytics

Magnesium sulfate (IV): Tocolysis (preterm labor up to 32 wk), seizure prophylaxis in preeclampsia, fetal neuroprotection
Magnesium therapeutic 4–7 mEq/L; toxicity = ↓ reflexes, ↓ RR <12, ↓ urine output, mental status changes
Antidote: Calcium gluconate IV
Terbutaline (β2 agonist): SC for preterm labor; AE: maternal tachycardia, palpitations, hyperglycemia, pulmonary edema; FDA black box — not for prolonged use (>48–72 hr)
Nifedipine (CCB): Preterm labor; maternal hypotension
Indomethacin (NSAID): Preterm labor <32 wk; risk premature ductus arteriosus closure

Cervical ripening & analgesia

Misoprostol (Cytotec): PG E1; cervical ripening, induction, PPH; cheap and effective
Dinoprostone (Cervidil insert, Prepidil gel): PG E2; cervical ripening
Prostaglandins: Watch for tachysystole, fetal distress; wait 4–6 hr after prostaglandin before oxytocin
Methylergonovine (Methergine): IM for PPH; contraindicated in HTN, preeclampsia
Carboprost (Hemabate): IM for PPH; contraindicated in asthma
Labor analgesia: Epidural fentanyl/bupivacaine; IV opioids (limit late in labor — neonatal respiratory depression)

Active Learning Scenario

From the book — uses the ATI Active Learning Template: Medication. Practice answering before reviewing the key.

Scenario

A nurse is reviewing a new prescription for methylergonovine for a client who is postpartum. What information should the nurse include in this review? Use the ATI Active Learning Template: medication to complete this item.

THERAPEUTIC USES COMPLICATIONS: Describe one adverse effect.
CONTRAINDICATIONS/PRECAUTIONS: Describe one contraindication.
NURSING INTERVENTIONS: Describe at least three.

Show key

Therapeutic Uses

Prevent postpartum hemorrhage

Complications

Hypertensive crisis

Contraindications / Precautions

Hypertension, preeclampsia, cardiac disease: Use with caution with maternal history of severe renal or hepatic disease, and sepsis.

Nursing Interventions

Monitor vital signs for increase in blood pressure.
Monitor for manifestations of hypertensive crisis (headache, nausea, vomiting, and increased blood pressure).
Monitor for uterine tone and vaginal bleeding.
Provide emergency interventions.

TL;DR · One-glance summary

NSAIDs (covered in Ch 35) = first-line for symptoms. DMARDs: Methotrexate (folic acid daily; hepatotoxic; teratogenic Category X), hydroxychloroquine (retinal toxicity — annual eye exam), sulfasalazine, leflunomide. Biologic DMARDs (etanercept, infliximab, adalimumab) — "-mab" or "-cept"; TB screening before, infection risk. Gout: colchicine (acute), allopurinol (long-term — never start during acute attack), probenecid.

DMARDs (Disease-Modifying Antirheumatic Drugs)

Methotrexate (Rheumatrex): First-line for RA, also used for psoriasis, cancer chemotherapy
WEEKLY dose for RA (not daily); supplement with folic acid daily
AE: Hepatotoxicity (monitor LFTs), bone marrow suppression, mucositis, pulmonary fibrosis, photosensitivity
Category X — teratogenic, abortifacient
Hydroxychloroquine (Plaquenil): RA, SLE; retinal toxicity — annual eye exams
Sulfasalazine, leflunomide: Alternative DMARDs

Biologic DMARDs

TNF-alpha inhibitors — Etanercept, infliximab, adalimumab, certolizumab, golimumab
SCREEN FOR TB (PPD or quantiferon) before initiating — reactivates latent TB
Avoid live vaccines while on therapy
Infection risk: Hold if active infection, scheduled surgery
Other biologics: Rituximab (anti-CD20), abatacept (T-cell modulator), tocilizumab (IL-6)
JAK inhibitors — Tofacitinib (Xeljanz): Oral; similar infection precautions

Gout therapy

Acute gout — Colchicine: Most effective if started within 24 hr; AE: severe GI (diarrhea, N/V), bone marrow suppression
Acute gout — NSAIDs (indomethacin classic; ibuprofen, naproxen) or glucocorticoids
Long-term — Allopurinol: Xanthine oxidase inhibitor; ↓ uric acid production
DO NOT start allopurinol during acute attack — can precipitate flare; take with food, plenty of water
Allopurinol AE: Stevens-Johnson syndrome, hepatotoxicity
Probenecid: Uricosuric — ↑ renal excretion; encourage fluids 3 L/day
Febuxostat (Uloric): Alternative xanthine oxidase inhibitor

Active Learning Scenario

From the book — uses the ATI Active Learning Template: Medication. Practice answering before reviewing the key.

Scenario

A nurse is teaching a client who has rheumatoid arthritis (RA) about a new prescription for etanercept. What should the nurse teach the client about this medication? Use the ATI Active Learning Template: medication to complete this item.

THERAPEUTIC USES: Describe the therapeutic use for etanercept in this client.
COMPLICATIONS: Describe at least three adverse effects the client should monitor for.
NURSING INTERVENTIONS: Describe one for each of the adverse effects above.
MEDICATION ADMINISTRATION: Describe at least three important factors.

Show key

Therapeutic Uses

Etanercept is a biologic DMARD classified as a tumor necrosis factor antagonist. It suppresses manifestations of moderate to severe RA and slows the progression of the disorder.

Complications

Severe infections, including tuberculosis or reactivation of hepatitis B
Heart failure
Severe skin reactions, such as Stevens-Johnson syndrome
Hematologic disorders

Nursing Interventions

Instruct clients to monitor for infection, and to report sore throat and other manifestations.
Discuss reasons for TB testing and possible hepatitis B testing.
Clients should notify the provider for edema, shortness of breath, and other manifestations of heart failure.
Report skin rash to provider.
Report easy bruising, bleeding, or unusual fatigue to provider.

Medication Administration

Teach clients to administer by subcutaneous injection twice weekly.
Discard solutions that are discolored or that contain particulate matter.
Monitor for injection-site reactions, and report them to provider.
Rotate injection sites.
Avoid skin areas that are bruised or reddened when injecting.

TL;DR · One-glance summary

Calcium + vitamin D: foundation of bone health; calcium 1000–1200 mg/day; vit D 600–800 IU. Bisphosphonates (alendronate, risedronate, ibandronate, zoledronate) — strict admin: take with 8 oz plain water, empty stomach AM, stay upright 30+ min, wait 30 min before any food/drink/meds; esophagitis, atypical fractures, jaw osteonecrosis (dental work). Raloxifene (SERM): ↑ DVT risk; hot flashes. Calcitonin-salmon: intranasal alternate nostrils. Denosumab: SC q6mo; monitor calcium.

Calcium & Vitamin D

Calcium 1000–1200 mg/day total intake (diet + supplement)
Vitamin D 600–800 IU/day (more if deficient)
Calcium carbonate (Tums): Take with food; cheapest; constipation
Calcium citrate: Take with or without food; preferred if PPI/H2 blocker user or low stomach acid
Divided doses (max 500–600 mg per dose) — absorption limited
Separate from levothyroxine, iron, tetracyclines, fluoroquinolones

Bisphosphonates

Alendronate (Fosamax), risedronate, ibandronate (PO); zoledronic acid (IV q1y)
Strict administration:
• Take with FULL glass of plain water (no other fluid)
• First thing in the morning, empty stomach
• Stay upright (sit, stand, walk) for at least 30 minutes (60 for ibandronate)
• Wait 30 min before any food, drink, or other medication
AE: Esophagitis, GI distress, musculoskeletal pain, atypical femur fractures, osteonecrosis of the jaw (especially after dental procedures)
Dental clearance before starting; avoid invasive dental work during therapy

Other osteoporosis agents

Raloxifene (Evista) — SERM: Estrogen agonist on bone, antagonist on breast; ↑ DVT/PE risk; hot flashes; lowers breast cancer risk
Calcitonin-salmon (Miacalcin): Intranasal — alternate nostrils daily; rhinitis; less effective than bisphosphonates
Denosumab (Prolia) — RANKL inhibitor: SC q6mo; monitor for hypocalcemia; risk of infection, jaw osteonecrosis
Teriparatide (Forteo) — PTH analog: Daily SC × 2 yr max; rebuilds bone (anabolic); ↑ osteosarcoma risk in animals; not for pediatric/Paget
Romosozumab: Newer anabolic; monthly SC × 12 doses

Active Learning Scenario

From the book — uses the ATI Active Learning Template: Medication. Practice answering before reviewing the key.

Scenario

A nurse in a provider's office is teaching a client who is postmenopausal and at high risk for osteoporosis about a new prescription for alendronate. What should the nurse teach the client about this medication? Use the ATI Active Learning Template: medication to complete this item.

THERAPEUTIC USES: Identify the therapeutic use for alendronate.
COMPLICATIONS: List two adverse effects of this medication. NURSING INTERVENTIONS ● Describe two diagnostic tests to monitor. ● Describe two nursing actions.

Show key

Therapeutic Uses

In this client who is at high risk for osteoporosis, the purpose of alendronate is to prevent osteoporosis from occurring by decreasing resorption of bone. The medication also is used to treat existing osteoporosis and Paget's disease.

Complications

Alendronate can cause esophagitis and esophageal ulceration; other GI effects (nausea, diarrhea, and constipation); muscle pain; and visual disturbances. Rarely, it can cause atraumatic femoral fracture.

Nursing Interventions

Diagnostic tests: Blood calcium, bone density scans Nursing interventions

Assess the client's ability to follow administration directions (must be able to sit upright or stand for at least 30 min after taking alendronate).
Teach the client to take this medication first thing in the morning with at least 240 mL (8 oz) water and wait 30 min before eating or drinking anything else or taking any other medications or supplements.
Teach the client other ways to help prevent osteoporosis, such as performing weight-bearing exercises daily and obtaining adequate amounts of calcium and vitamin D.

TL;DR · One-glance summary

Acetaminophen: analgesic + antipyretic, NO anti-inflammatory; max 4 g/day adult (3 g if liver disease); hepatotoxic in overdose — antidote acetylcysteine. Aspirin: antiplatelet; Reye syndrome in kids; tinnitus = salicylism. Ibuprofen/naproxen: GI ulcer/bleed, renal, CV events. Celecoxib: COX-2 selective; less GI bleed but ↑ CV risk.

Acetaminophen

Mechanism: Inhibits CNS prostaglandins only (no peripheral anti-inflammatory)
Max dose: 4 g/day adult (3 g if older, alcohol use, liver disease)
Hepatotoxic in overdose — antidote N-acetylcysteine (within 8–10 hr most effective)
Check for hidden acetaminophen in combo products (Percocet, NyQuil)
Safe in pregnancy and children

NSAIDs

Aspirin: Irreversible COX inhibition; antiplatelet; Reye syndrome in children with viral illness
Salicylism toxicity: Tinnitus, hyperventilation, sweating, dizziness
Ibuprofen, naproxen, ketorolac, indomethacin: Non-selective
Major AE: GI ulceration/bleeding, renal impairment, MI/stroke, HTN, decreased platelets
Take with food; avoid in late pregnancy (premature ductus closure)
Ketorolac: Limit to 5 days (bleed risk)
Celecoxib (COX-2): Less GI bleed; sulfa structure caution

Key interactions & warnings

NSAIDs ↑ lithium and warfarin effects
NSAIDs ↓ ACE inhibitor/diuretic efficacy
NEVER combine multiple NSAIDs
BLACK BOX CV risk for all NSAIDs (varies by drug)

Active Learning Scenario

From the book — uses the ATI Active Learning Template: Medication. Practice answering before reviewing the key.

Scenario

A nurse at a provider's office is providing teaching to a client who has osteoarthritis and is starting long-term therapy with NSAIDs. What should the nurse include in the teaching? Use the ATI Active Learning Template: medication to complete this item.

THERAPEUTIC USES COMPLICATIONS: Describe two adverse effects.
NURSING INTERVENTIONS: Describe three nursing actions, including two laboratory values the nurse should monitor.

Show key

Therapeutic Uses

NSAIDs will treat mild to moderate joint pain and stiffness, and decrease inflammation in the client who has osteoarthritis.

Complications

Gastrointestinal effects can occur, including anorexia, abdominal pain, nausea, vomiting, and heartburn.
GI bleeding can occur because NSAIDs affect platelet function.
Nephrotoxicity can occur.
NSAIDs can cause CNS effects (dizziness, headache, blurred vision, and tinnitus).
Allergy can occur, including cross allergy with other NSAIDs (aspirin).

Nursing Interventions

Monitor hgb/hct and kidney function tests.
Assess the client for previous allergy to NSAIDs.
Assess the GI system, and ask about any history of GI bleed or peptic ulcer disease.
Advise the client to take the medication with food, milk, or an 8 oz glass of water to prevent GI distress.
Advise the client to tell provider about any over-the-counter medications, vitamins, or herbal supplements before taking them.

TL;DR · One-glance summary

Morphine (prototype): severe pain; respiratory depression (sedation precedes it); universal constipation (prophylactic bowel regimen); urinary retention; pruritus (histamine). Naloxone: antidote — short half-life, may need repeats. Fentanyl patch: opioid-tolerant only; NEVER heat. Tramadol: seizure risk; serotonin syndrome with SSRIs. Schedule II for most strong opioids.

Pure opioid agonists

Morphine (IV, PO, IM, SC, epidural) — prototype
Others: Oxycodone, hydromorphone (Dilaudid), fentanyl, hydrocodone, codeine, methadone, meperidine (avoid in renal failure)
Sedation precedes respiratory depression — assess sedation level
Hold if RR < 12; have naloxone available
Constipation universal — start senna + docusate prophylactically
Other AE: Urinary retention, pruritus, N/V, miosis (pinpoint pupils), hypotension

Special opioids

Fentanyl patch: Opioid-tolerant chronic pain only; 12+ hr to peak; remove old before new
NEVER apply heat to fentanyl patch — fatal overdose
Tramadol: Weak agonist + serotonin/NE reuptake; seizure risk; serotonin syndrome with SSRIs
Methadone: Long half-life; for OUD treatment, chronic pain
Buprenorphine: Partial agonist; OUD, chronic pain; ceiling effect on respiratory depression
Agonist-antagonists (butorphanol, nalbuphine): Ceiling effect on analgesia

Naloxone & overdose

Naloxone (Narcan): Pure opioid antagonist — IV/IM/intranasal
Half-life shorter than most opioids — may need repeat dosing
Precipitates withdrawal in opioid-dependent: agitation, tachycardia, N/V, abdominal pain
Naltrexone: Long-acting; OUD/AUD maintenance — must be opioid-free 7–10 days
Reassess respiratory status frequently after naloxone

Opioid administration & monitoring details

Patient-controlled analgesia (PCA): Client self-administers via pump; lockout interval prevents overdose
PCA safety: ONLY the client presses button (not family — "PCA by proxy" causes deaths); document pain score and sedation regularly
Equianalgesic dosing: Conversion between opioids and routes (e.g., morphine 10 mg IV = 30 mg PO); reduce dose 25–50% when switching due to incomplete cross-tolerance
Breakthrough pain: Acute exacerbation of pain in someone on stable scheduled opioid — give immediate-release opioid 10–15% of 24-hour scheduled dose
Around-the-clock dosing for chronic pain (not "as needed") prevents pain valleys
Opioid-induced respiratory depression: Pasero opioid-induced sedation scale (POSS); RR < 12, ↓ O2 sat, lower sedation score; treat: O2, stimulate, naloxone if necessary
Tolerance vs dependence vs addiction:
• Tolerance: Need ↑ dose for same effect (physiologic, normal)
• Physical dependence: Withdrawal symptoms if stopped abruptly (physiologic, normal)
• Addiction: Compulsive use despite harm (psychologic, disease)
Opioid withdrawal: Restlessness, anxiety, sweating, rhinorrhea, lacrimation, abdominal cramping, diarrhea — distressing but rarely fatal (unlike alcohol/benzo withdrawal)

Active Learning Scenario

From the book — uses the ATI Active Learning Template: Medication. Practice answering before reviewing the key.

Scenario

A nurse is providing discharge teaching for a client who is postoperative and has a new prescription for an opioid medication for incisional pain. What should the nurse include in the teaching? Use the ATI Active Learning Template: medication to complete this item.

THERAPEUTIC USES: Describe for oxycodone.
COMPLICATIONS: List three adverse effects for oxycodone.
NURSING INTERVENTIONS: List three.

Show key

Therapeutic Uses

Opioid medication is indicated for relief of moderate to severe pain.

Complications

Sedation
Nausea/vomiting
Constipation
Orthostatic hypotension
Urinary retention

Nursing Interventions

Instruct the client not to drive or perform other hazardous activities while using this medication.
Notify the provider for severe nausea or vomiting.
Prevent constipation by increasing intake of liquids and foods with fiber. Consider use of a stool softener or laxatives if necessary.
Move the client slowly from lying or sitting to standing to minimize effects of orthostatic hypotension.
Instruct the client to void every 4 hr. Contact the provider for manifestations of dysuria.

TL;DR · One-glance summary

Neuropathic pain (diabetic neuropathy, post-herpetic, fibromyalgia): gabapentin, pregabalin (sedation, weight gain, edema; renal dosing); duloxetine (SNRI); amitriptyline (TCA — anticholinergic). Topical: lidocaine patch (12 on/12 off), capsaicin (gloves; transient burning). Trigeminal neuralgia: carbamazepine first-line.

Anticonvulsants for pain

Gabapentin, pregabalin (Lyrica — Schedule V): Neuropathic pain prototype
AE: Sedation, dizziness, peripheral edema, weight gain
Renal dosing required; titrate slowly
Carbamazepine: Trigeminal neuralgia drug of choice; CBC; Stevens-Johnson risk; HLA-B*1502 testing in Asian descent

Antidepressants for pain

Duloxetine (Cymbalta) — SNRI: Diabetic neuropathy, fibromyalgia, chronic musculoskeletal pain
TCAs — Amitriptyline, nortriptyline: Neuropathic pain, migraine prevention
TCA AE: Anticholinergic, sedation, orthostatic hypotension, cardiotoxic in overdose
Beers Criteria: Avoid TCAs in older adults
Lower doses for pain than for depression

Topical agents

Lidocaine 5% patch: Post-herpetic neuralgia; 12 hr on, 12 hr off
Capsaicin cream: Wear gloves; transient burning; avoid eyes/mucous membranes
Glucocorticoids: Reduce inflammation in nerve compression

Active Learning Scenario

From the book — uses the ATI Active Learning Template: Medication. Practice answering before reviewing the key.

Scenario

A nurse in an acute care facility is teaching a client who has metastatic cancer and is receiving morphine and carbamazepine for pain. What information should the nurse provide about the use of these medications? Use the ATI Active Learning Template: medication to complete this item.

THERAPEUTIC USES: Describe the therapeutic use for carbamazepine in this client.
COMPLICATIONS: Describe two adverse effects the client should monitor for.
INTERACTIONS: Describe two interactions with carbamazepine.
NURSING INTERVENTIONS: Describe two. on Exercises

Show key

Therapeutic Uses

Carbamazepine relieves neuropathic (nerve) pain, which can be described as sharp, burning, or aching.

Complications

Adverse effects of carbamazepine include GI manifestations (abdominal pain, nausea, and vomiting). It also can cause bone marrow suppression, affecting all blood cell types.

Interactions

The medication can cause hypertensive crisis if taken within 14 days of an mAOI antidepressant.
Toxicity can result if the client drinks grapefruit juice while taking carbamazepine.

Nursing Interventions

Monitor CBC, including platelet counts.
Assess for abnormal bleeding, bruising, or infection.
Monitor for GI manifestations, and advise the client to take the medication with food.

TL;DR · One-glance summary

Migraine acute: triptans (sumatriptan SC/PO/intranasal); contraindicated in CAD, uncontrolled HTN; not with MAOIs or 2 triptans/24 hr. Migraine prevention: propranolol, topiramate, valproate, amitriptyline, CGRP inhibitors (-mab; monthly SC). Cluster headache: 100% O2, sumatriptan SC.

Acute migraine therapy

Triptans — Sumatriptan, rizatriptan, zolmitriptan: 5-HT1B/1D agonists
Contraindicated: CAD, uncontrolled HTN, peripheral vascular disease, ischemic stroke, hemiplegic/basilar migraine, pregnancy
Interactions: No MAOIs (within 2 weeks); SSRIs/SNRIs (serotonin syndrome); no ergot within 24 hr; no 2nd triptan within 24 hr
AE: Chest pressure (usually benign), tingling, flushing
Ergot alkaloids — Ergotamine, DHE: Category X; ergotism (peripheral ischemia)
Antiemetics (metoclopramide, prochlorperazine) for migraine nausea

Migraine prevention

Indicated if > 4 attacks/month or significant disability
Beta blockers (propranolol, metoprolol, timolol)
Anticonvulsants (topiramate, valproate)
TCAs (amitriptyline)
CGRP antagonists ("-mab"): Erenumab, fremanezumab, galcanezumab — monthly SC; eptinezumab IV q3mo
Oral CGRP ("-gepants"): Ubrogepant, rimegepant (acute); atogepant (prevention)
Lasmiditan: 5-HT1F selective; no vasoconstriction (safer in CAD); 8 hr driving restriction
OnabotulinumtoxinA (Botox): Chronic migraine (>15 days/month)

Active Learning Scenario

From the book — uses the ATI Active Learning Template: Medication. Practice answering before reviewing the key.

Scenario

A nurse is teaching a client who has frequent migraine headaches about a new prescription for sumatriptan. What should the nurse teach the client about this medication? Use the ATI Active Learning Template: medication to complete this item.

THERAPEUTIC USES: Describe the therapeutic use for sumatriptan in this client.
COMPLICATIONS: Describe two adverse effects the client should monitor for.
INTERACTIONS: Describe two interactions the nurse should teach the client about.
NURSING INTERVENTIONS: Describe two for this client.

Show key

Therapeutic Uses

Sumatriptan is used to abort a migraine headache and associated manifestations (nausea and vomiting) after it begins by causing cranial artery vasoconstriction.

Complications

The nurse should monitor for chest and arm heaviness/pressure, angina caused by coronary vasospasm, dizziness, and vertigo.

Interactions

Toxicity can result if sumatriptan is given concurrently or within 2 weeks of an mAOI antidepressant. Sumatriptan should not be given concurrently with other triptan medications or within 24 hr of ergotamine or dihydroergotamine.

Nursing Interventions

Teach clients to take sumatriptan at the first finding of migraine manifestations.
Teach client how to administer sumatriptan if it is prescribed intranasally or by subcutaneous injection.
Monitor cardiovascular risk factors and vital signs while taking this medication.
Advise clients to notify the provider immediately for onset of angina pain. Teach clients to distinguish transient chest or arm heaviness caused by sumatriptan from angina pain.

TL;DR · One-glance summary

T1DM: insulin required. T2DM: metformin first-line. Insulins: rapid (lispro/aspart — 15 min); short (regular — 30–60 min, only IV insulin); intermediate (NPH — 1–2 hr); long (glargine/detemir — peakless). Mix "clear before cloudy." Hypoglycemia <70: rule of 15. Sick days: never skip insulin. Metformin: lactic acidosis (rare); hold for IV contrast.

Insulin types

Rapid (lispro, aspart, glulisine): Onset 15 min, peak 30–90 min, duration 3–5 hr; give immediately before/with meals
Short (Regular): Onset 30–60 min, peak 2–4 hr, duration 5–8 hr; ONLY insulin given IV
Intermediate (NPH): Onset 1–2 hr, peak 6–12 hr, duration 14–24 hr; cloudy — gently roll
Long (glargine, detemir, degludec): Peakless basal; do not mix
Mixing: "clear before cloudy" — draw up Regular before NPH
Rotate sites within same anatomic region; abdomen absorbs fastest/most consistent
Storage: Unopened in fridge; opened — room temp 28–30 days
Sick days: Never skip insulin — illness raises blood sugar

Oral & injectable T2DM agents

Metformin (biguanide) — FIRST-LINE T2DM: ↓ hepatic glucose; AE: GI distress, B12 deficiency, lactic acidosis (rare); hold 24–48 hr before/after IV contrast
Sulfonylureas (glipizide, glyburide, glimepiride): Hypoglycemia, weight gain, sulfa allergy
Glinides (repaglinide): With meals; skip if skipping meal
Thiazolidinediones (pioglitazone): ↑ insulin sensitivity; fluid retention/HF; fractures
Alpha-glucosidase inhibitors (acarbose): Flatulence; treat hypoglycemia with glucose, NOT sucrose
DPP-4 ("-gliptin"): Sitagliptin; weight-neutral; pancreatitis
GLP-1 agonists (exenatide, liraglutide, semaglutide): SC (semaglutide also PO); weight loss; pancreatitis; thyroid C-cell tumors
SGLT2 inhibitors ("-flozin"): Empagliflozin; renal glucose excretion; GU infections, DKA possible with normal glucose

Hypoglycemia & DKA

Hypoglycemia < 70: Sweating, tremor, tachycardia, hunger, confusion
Rule of 15: 15 g rapid carbs (4 oz juice, 3–4 glucose tabs) → wait 15 min → recheck → repeat if still low → then complex carb + protein
Unconscious: Glucagon IM/SC at home; D50W IV in hospital
Somogyi effect: Nocturnal hypoglycemia → AM rebound — give bedtime snack, ↓ evening insulin
Dawn phenomenon: Early AM glucose rise — ↑ evening NPH
DKA: IV insulin (regular), aggressive fluids, K+ replacement

Newer agents & complete diabetes drug list

Canagliflozin (SGLT2) AE: Cystitis, candidiasis (males AND females), polyuria, dehydration, hypotension; ↑ amputation risk historically reported
Pramlintide (Symlin) — amylin analog: Adjunct to insulin in T1DM and insulin-using T2DM; SC before meals; severe hypoglycemia risk when added to insulin (reduce mealtime insulin by 50%); do not mix with insulin (separate syringe)
Pregnancy Risk categories: Metformin = B (often preferred PO if needed); Insulin = B (preferred overall); avoid most other PO agents during pregnancy
Bariatric surgery can resolve T2DM in many cases — insulin doses often substantially reduced post-op
DKA vs HHS: DKA — T1DM, ↑ ketones, ↓ pH, glucose 250–800; HHS — T2DM, no/minimal ketones, glucose > 600, severe dehydration, ↑ osmolality

Active Learning Scenario

From the book — uses the ATI Active Learning Template: Medication. Practice answering before reviewing the key.

Scenario

A nurse is teaching a client who has type 2 diabetes mellitus and is taking exenatide along with an oral antidiabetic agent. What should the nurse teach the client about this medication? Use the ATI active learning template: Medication to complete this item.

THERAPEUTIC USES: Identify the therapeutic use for exenatide in this client.
COMPLICATIONS: Identify two adverse effects the client should watch for.
NURSING INTERVENTIONS: Describe two laboratory tests the nurse should monitor.
CLIENT EDUCATION: Describe teaching points to give a client taking exenatide.

Show key

Therapeutic Uses

Exenatide is prescribed along with an oral antidiabetic medication (metformin or a sulfonylurea medication) for clients who have type 2 diabetes mellitus to improve diabetes control. exenatide improves insulin secretion by the pancreas, decreases secretion of glucagon, and slows gastric emptying.

Complications

Gi effects (nausea and vomiting)
Pancreatitis manifested by acute abdominal pain and possibly severe vomiting
Hypoglycemia, especially when taken concurrently with a sulfonylurea medication (glipizide)

Nursing Interventions

Monitor daily blood glucose testing by the client, periodic Hba1c tests, and periodic kidney function testing. exenatide should be used cautiously in clients who have any renal impairment.

Client Education

Inject exenatide subcutaneously.
Take exenatide within 60 min before the morning and evening meal but not following the meal.
Withhold exenatide and notify the provider for severe abdominal pain.
Recognize and treat hypoglycemia.
Exenatide should not be given within 1 hr of oral medications, particularly antibiotics, acetaminophen, or contraceptives due to its ability to slow gastric emptying.

TL;DR · One-glance summary

Hypothyroid — levothyroxine: empty stomach AM (1 hr before food); lifelong; never abruptly stop; monitor TSH. Hyperthyroid: methimazole (preferred); PTU (1st trimester pregnancy, thyroid storm); radioactive iodine (avoid pregnancy/breastfeeding). Lugol's: pre-thyroidectomy; straw to avoid teeth staining. Vasopressin/DDAVP: DI; watch for hyponatremia. Glucocorticoids: taper; Cushingoid with long-term.

Hypothyroidism — Levothyroxine

Levothyroxine (Synthroid) — T4: Drug of choice
Administration: AM, empty stomach, 30–60 min before food/other meds; same time daily
Lifelong therapy; never stop abruptly
Monitor TSH q6–8 weeks during titration, then annually
Overdose signs: Tachycardia, palpitations, weight loss, insomnia, heat intolerance, tremor
↓ Absorption: Antacids, calcium, iron, fiber, coffee — separate by 4 hr
Liothyronine (T3): For myxedema coma

Hyperthyroidism

Methimazole (Tapazole): Preferred for most adults; inhibits T4 synthesis
Propylthiouracil (PTU): Preferred in 1st trimester pregnancy and thyroid storm; hepatotoxicity
Both: Agranulocytosis (sore throat, fever) — discontinue; weeks to effect
Radioactive iodine (131I): Destroys thyroid; contraindicated pregnancy/breastfeeding; radiation precautions × few days
Strong iodine (Lugol's, SSKI): Pre-thyroidectomy, thyroid storm; use straw (stains teeth); dilute in juice
Beta blockers (propranolol): Symptomatic relief of tachycardia, tremor

Pituitary & adrenal

Somatropin (GH): GH deficiency; SC injection
Vasopressin/desmopressin (DDAVP): Central diabetes insipidus; also bedwetting, hemophilia A
Monitor for hyponatremia/water intoxication — restrict fluids
Glucocorticoids — Prednisone, hydrocortisone, dexamethasone: Multiple uses
Cushingoid: Weight gain, moon face, buffalo hump, thin skin, easy bruising, muscle wasting, osteoporosis, hyperglycemia, HTN, mood changes
NEVER stop abruptly — taper to prevent adrenal crisis
Take with food, AM dosing mimics circadian; calcium + vit D for bone protection
Fludrocortisone (mineralocorticoid): Addison disease

Pituitary & growth hormone disorders

Octreotide (Sandostatin) — somatostatin analog: Treats acromegaly, gigantism, severe diarrhea (carcinoid, VIPoma), variceal bleeding
Octreotide AE: Gallbladder disease (cholelithiasis), hyperglycemia/hypoglycemia, GI distress, bradycardia
Lanreotide, pegvisomant: Other agents for acromegaly
Somatropin (GH): For pediatric GH deficiency; SC injection; monitor growth; avoid in active malignancy
SIADH treatment: Fluid restriction, demeclocycline, tolvaptan, conivaptan (vaptans) — caution rapid sodium correction (central pontine myelinolysis)
Adrenal crisis treatment: IV hydrocortisone (Solu-Cortef), IV fluids, glucose; emergency situation

A client has been on prednisone 40 mg/day for 6 weeks for autoimmune disease. Why must it never be stopped abruptly, and what teaching addresses Cushingoid effects?

Chronic glucocorticoids suppress the HPA axis; abrupt discontinuation causes adrenal crisis (hypotension, weakness, hypoglycemia, shock — can be fatal). Taper slowly per provider plan, often weeks to months. Stress doses (ER, surgery, severe illness) may be needed for up to a year after stopping. Cushingoid effects: moon face, buffalo hump, central obesity, thin skin, easy bruising, muscle wasting, hyperglycemia, HTN, osteoporosis, mood changes. Teach: take in AM with food (mimics circadian), calcium + vitamin D for bone protection, monitor glucose and BP, medical alert ID, never stop without provider.

Active Learning Scenario

From the book — uses the ATI Active Learning Template: Medication. Practice answering before reviewing the key.

Scenario

A nurse in a provider's office is providing instructions to a client who has a new prescription for levothyroxine to treat hypothyroidism. Use the ATI Active Learning Template: medication to complete this item.

THERAPEUTIC USES: Describe the therapeutic use of levothyroxine in this client.
COMPLICATIONS: Identify two adverse effects of this medication.
NURSING INTERVENTIONS: Describe two laboratory tests the nurse should monitor.
CLIENT EDUCATION: Describe teaching points for a client taking levothyroxine.

Show key

Therapeutic Uses

Levothyroxine replaces T4 and is used as thyroid hormone replacement therapy. Replacement of T4 also raises T3 levels, because some T4 is converted into T3.

Complications

Adverse effects are essentially the same as manifestations of hyperthyroidism: cardiac manifestations (hypertension and angina pectoris); insomnia; anxiety; weight loss; heat intolerance; increased body temperature; tremors; and menstrual irregularities.

Nursing Interventions

Monitor thyroid function tests: T3, T4, and TSh.

Client Education

Take levothyroxine on an empty stomach, usually 1 hr before breakfast.
Thyroid replacement therapy is usually required for life
Monitor for adverse effects that indicate that the dosage needs to be adjusted.

TL;DR · One-glance summary

Live attenuated (MMR, varicella, rotavirus, BCG, intranasal flu): contraindicated in pregnancy and immunocompromise. Inactivated/subunit: safe in immunocompromised. Two live vaccines: same day OR ≥ 4 weeks apart. Egg allergy: caution with influenza/yellow fever. Common AE: injection site, low-grade fever. Severe AE: anaphylaxis (rare) — don't repeat vaccine.

Vaccine types

Live attenuated: MMR, varicella, rotavirus (oral), BCG, intranasal flu (FluMist), yellow fever, oral typhoid
Inactivated: Influenza (injection), polio (IPV), Hep A, rabies
Subunit/recombinant: HPV, Hep B, Tdap, Hib, Shingrix (zoster)
Toxoid: Tetanus, diphtheria
Adult schedule: Flu annual; Tdap q10y; Shingrix > 50 (2 doses); pneumococcal > 65 or risk factors
HPV: Routine ages 11–12; catch-up to 26; eligible to 45

Contraindications & precautions

Live vaccines contraindicated: Pregnancy, severe immunocompromise (chemo, high-dose steroids, HIV/CD4 < 200, transplant), SCID infants
Egg allergy: Most flu vaccines OK; cell-based/recombinant alternatives; yellow fever produced in eggs
Defer: Moderate-severe acute illness (mild illness OK)
Anaphylaxis to previous dose = absolute contraindication
Pediatric aspirin: Avoid varicella + live flu (Reye risk)

Administration & reactions

Routes: Most IM (deltoid adult; vastus lateralis infant); some SC (MMR, varicella); intranasal/PO for specific vaccines
Common AE: Injection site soreness, low-grade fever, fussiness
Severe AE to report: Anaphylaxis, encephalopathy, seizures, persistent crying > 3 hr
Document: Vaccine name, lot #, manufacturer, date, site, route, VIS
Immunoglobulin/blood products: Delay live vaccine 3+ months

Active Learning Scenario

From the book — uses the ATI Active Learning Template: Medication. Practice answering before reviewing the key.

Scenario

A nurse at a community health clinic is planning to administer the human papilloma virus (9vHPV) vaccine to an 11-year-old client. Use the ATI Active Learning Template: medication to complete this item.

COMPLICATIONS: Identify two adverse effects the client should monitor for.
CONTRAINDICATIONS/PRECAUTIONS: Identify contraindications to receiving the HPV vaccine.
CLIENT EDUCATION: Describe two teaching points for a client who receives a first dose of the HPV vaccine.

Show key

Complications

The 9vHPV vaccine can cause redness, tenderness, and swelling at the injection site.
It has caused fainting in some clients shortly after the vaccine is administered.
Headache and mild to moderate fever are also possible adverse effects the client should monitor for.

Contraindications / Precautions

Contraindications to receiving the 9vHPV vaccine include pregnancy and a severe allergy to yeast.

Client Education

Monitor for adverse effects; the common adverse effects are mild and temporary.
The adolescent will require a second dose in 6 to 12 months since this one occurred before age 16. Initial administration after 16 years of age requires a three dose series.

TL;DR · One-glance summary

All chemo: bone marrow suppression (neutropenia, anemia, thrombocytopenia), N/V, alopecia, mucositis, fatigue, ↑ infection risk. Doxorubicin: cardiotoxicity (cumulative); red urine (harmless); vesicant. Cyclophosphamide: hemorrhagic cystitis — ↑ fluids, mesna. Methotrexate: leucovorin rescue. Vincristine: peripheral neuropathy; FATAL if intrathecal. PPE required; hazardous waste disposal.

Major drug categories

Alkylating agents — Cyclophosphamide, cisplatin, carboplatin:
• Cyclophosphamide: Hemorrhagic cystitis — ↑ fluids, mesna; secondary leukemia
• Cisplatin: Nephrotoxicity, ototoxicity, severe N/V
Antimetabolites — Methotrexate, 5-FU, cytarabine, mercaptopurine:
• Methotrexate: Leucovorin (folinic acid) rescue; hepatotoxic; teratogenic
Antitumor antibiotics — Doxorubicin, daunorubicin, bleomycin:
• Doxorubicin: Cardiotoxicity (dose-limited; baseline echo); red/orange urine (harmless); vesicant — extravasation = necrosis
• Bleomycin: Pulmonary fibrosis (dose-limited)
Mitotic inhibitors — Vincristine, vinblastine, paclitaxel:
• Vincristine: Peripheral neuropathy; NEVER intrathecal — fatal
Hormonal — Tamoxifen, raloxifene, anastrozole, leuprolide
Targeted/biologics — Imatinib, trastuzumab, bevacizumab, rituximab

Universal toxicities

Myelosuppression: Nadir at 7–14 days; monitor CBC
Neutropenia: ANC < 1500; precautions if < 500 (neutropenic precautions)
Fever in neutropenic: EMERGENCY — pan-culture, broad-spectrum antibiotics
N/V: Pre-medicate with ondansetron, dexamethasone, aprepitant
Alopecia: Begins 2–3 weeks; grows back when therapy ends
Mucositis: Soft toothbrush; saline rinses; avoid alcohol-based mouthwash; acidic foods
Tumor lysis syndrome: Hyperuricemia, hyperphosphatemia, hyperkalemia, hypocalcemia, AKI; allopurinol or rasburicase prophylaxis

Safety in handling chemo

PPE required: Double gloves, gown, eye protection, mask
Closed system transfer devices for preparation
Spill kits readily available; specialized cleanup
Hazardous waste disposal per facility protocol
Pregnant or trying to conceive nurses: Avoid handling
Body fluids contaminated 48–72 hr after admin; flush toilet twice

Additional chemo subcategories

Nitrosoureas — Carmustine, lomustine: Cross BBB (brain tumors); cumulative bone marrow toxicity; topical Gliadel wafer for brain tumor resection
Topoisomerase inhibitors — Topotecan, irinotecan, etoposide: Topotecan (ovarian, small-cell lung); irinotecan: cholinergic diarrhea (give atropine)
Asparaginase, hydroxyurea: Specific leukemias
Hormonal/anti-androgens — Flutamide, bicalutamide, enzalutamide: Prostate cancer; GnRH agonists (leuprolide, goserelin)
Aromatase inhibitors — Anastrozole, letrozole, exemestane: Postmenopausal breast cancer
Immunomodulators — Interferon alfa, interleukin-2: Hairy cell leukemia, melanoma, renal cell carcinoma; flu-like symptoms
Monoclonal antibodies — Trastuzumab (HER2+ breast), bevacizumab (anti-VEGF), rituximab (CD20), cetuximab (EGFR): Infusion reactions; cetuximab — acneiform rash
Tyrosine kinase inhibitors — Imatinib, erlotinib, sorafenib: "-tinib"/"-fenib"; oral; targeted therapy for specific mutations

A client starts doxorubicin chemotherapy. What baseline cardiac test is required, what dose-limiting toxicity does this monitor, and what harmless side effect is expected?

Baseline echocardiogram or MUGA scan to assess left ventricular ejection fraction (LVEF) — doxorubicin causes cumulative, dose-related cardiomyopathy that can progress to irreversible heart failure. Lifetime cumulative dose limit: ~450–500 mg/m². Repeat cardiac imaging during therapy. Dexrazoxane may be used as cardioprotective in some regimens. Harmless expected effect: red/orange urine, tears, and sweat for 1–2 days after each dose. Doxorubicin is also a vesicant — extravasation causes severe tissue necrosis; administer through central line when possible, have antidote (dexrazoxane IV) ready.

A client on chemotherapy presents with fever 38.5°C (101.3°F) and an ANC of 400. What is this called, and what is the immediate action sequence?

Neutropenic fever (febrile neutropenia) — a medical EMERGENCY in cancer care. ANC < 500 with fever ≥38.3°C (or 38.0°C sustained 1 hr). Risk of sepsis is extremely high; mortality climbs with delay. Action: (1) Pan-culture (blood × 2 sets, urine, sputum, line tip if applicable, wound), (2) Broad-spectrum IV antibiotics WITHIN 1 HOUR — do NOT delay for culture results (typical: cefepime, piperacillin-tazobactam, or meropenem ± vancomycin). (3) Neutropenic precautions: private room, no fresh flowers, no raw fruits/vegetables, meticulous hand hygiene. Avoid rectal temps, suppositories, or IM injections.

Active Learning Scenario

From the book — uses the ATI Active Learning Template: Medication. Practice answering before reviewing the key.

Scenario

A nurse is teaching a client who has prostate cancer and a new prescription for monthly injections of leuprolide Im. What should the nurse teach this client about leuprolide? Use the atI Active Learning Template: medication to complete this item.

THERAPEUTIC USES: Identify for leuprolide.
COMPLICATIONS: Identify two adverse effects.
NURSING INTERVENTIONS: Describe two diagnostic tests to monitor.
CLIENT EDUCATION: Include two teaching points. on Exercises

Show key

Therapeutic Uses

Leuprolide is a gonadotropin-releasing hormone agonist of luteinizing and follicle-stimulating hormones. It is used instead of surgical ca

Complications

Hot flashes (or flashes), decreased libido, gynecomastia
Cardiac manifestations (dysrhythmias) and increased edema, which can lead
Decreased bone density, which can lead to fractures
Disease flare, which means manifestations of the client's prostate cancer can

Nursing Interventions

Monitor prostate-specific antigen and testosterone levels, which should both
Bone density testing can be needed for some clients, as well as ECG if cardia

Client Education

Increase calcium and vitamin D in diet.
Increase weight-bearing exercise to minimize bone loss.
Report a flare in prostate manifestations to the provider.
Report adverse effects (palpitations, edema, and hot flashes) to the provider.

TL;DR · One-glance summary

Before antibiotics: obtain cultures (blood, sputum, urine, wound) BEFORE first dose. Empiric therapy until cultures return; narrow once organism identified. Complete entire course even if feeling better. Resistance prevention: appropriate selection, adequate dosing, full course. Hypersensitivity: ask about prior reactions; cross-reactivity (PCN-cephalosporin minimal). Superinfection: C. difficile, yeast.

Selection principles

Culture & sensitivity BEFORE first dose (when possible)
Empiric therapy: Best guess based on likely organism, site, local resistance
Targeted therapy: Switch to narrow-spectrum once culture returns
Bactericidal vs bacteriostatic — choose bactericidal if immunocompromised or serious infection
Host factors: Age, pregnancy, renal/hepatic function, allergies
Site factors: Penetration (CNS, prostate, biofilm)

Resistance prevention

Use antibiotics only when truly bacterial (not viral)
Use narrowest spectrum effective
Adequate dosing (avoid subtherapeutic)
Complete full course as prescribed
Do not save antibiotics for later use
MRSA, VRE, ESBL, CRE: Healthcare-associated; contact precautions

Adverse effects & monitoring

Hypersensitivity: Most common AE; PCN most common allergen
Penicillin-cephalosporin cross-reactivity: < 1% with modern cephalosporins (was overestimated)
Superinfection: Eradication of normal flora → opportunistic — C. difficile (severe diarrhea), oral/vaginal yeast
C. difficile: Stop offending antibiotic; treat with oral vancomycin or fidaxomicin (NOT metronidazole first-line anymore)
Renal/hepatic adjustments often required

A client with suspected sepsis has a fever and orders for blood cultures plus IV ceftriaxone. What is the correct order of these tasks, and why?

Obtain blood cultures BEFORE the first antibiotic dose (cultures of urine, sputum, wound, CSF — whatever applies). Even one dose of antibiotic can sterilize cultures and prevent organism identification, which then prevents narrowing therapy. BUT — in suspected sepsis, do not delay antibiotics waiting for cultures: if cultures can be obtained within 45 minutes, do them first; otherwise, give antibiotics within 1 hour of recognition (each hour of delay increases mortality). Two peripheral blood culture sets from different sites are standard. After cultures return: narrow spectrum to the targeted organism.

A client on clindamycin develops profuse watery diarrhea with cramping. What is the likely diagnosis, and what is the current first-line treatment (not metronidazole)?

Clostridioides difficile colitis (C. diff) — antibiotic-associated colitis from disruption of normal gut flora. Clindamycin and fluoroquinolones carry the highest risk. Action: (1) stop the offending antibiotic if possible. (2) First-line treatment (updated IDSA): oral vancomycin OR oral fidaxomicin — NOT IV vancomycin (doesn't reach gut lumen). Metronidazole is NO LONGER first-line (used only in non-severe cases when others unavailable). Strict contact precautions, soap-and-water hand hygiene (alcohol-based does NOT kill spores), single-patient room. Recurrent or fulminant C. diff: fecal microbiota transplant or bezlotoxumab.

A client with documented penicillin allergy needs cefazolin for surgical prophylaxis. What is the actual cross-reactivity rate, and what factors guide the decision?

The "10% cross-reactivity" figure is outdated and overestimated. True cross-reactivity is < 1% with modern cephalosporins, especially 3rd–5th generation. Decision-making: get a detailed allergy history — was it a true IgE reaction (urticaria, anaphylaxis, angioedema) or just GI upset (not an allergy)? If non-severe PCN allergy: cephalosporins generally safe (especially later generations); modern guidelines allow administration with monitoring. If true anaphylaxis to PCN: consider alternative (e.g., clindamycin or vancomycin for surgical prophylaxis) or do allergy consultation/desensitization. Document the actual reaction in the chart.

Active Learning Scenario

From the book — uses the ATI Active Learning Template: Basic Concept. Practice answering before reviewing the key.

Scenario

A staff educator is providing information to a group of nurses about ways to prevent the spread of micro-organisms. What information should the educator include? Use the ATI Active Learning Template: Basic Concept to complete this item.

RELATED CONTENT: Determine one related concept.
UNDERLYING PRINCIPLES: Describe one related to the concept.
NURSING INTERVENTIONS: Identify five related to the concept.

Show key

Underlying Principles

Controlling the spread of infection to staff and clients in a health care setting

Nursing Interventions

Perform hand hygiene before and after each client contact to prevent the spread of infection.
Recognize invasive procedures that increase the risk of infection (indwelling urinary catheter, IV catheter, cardiac catheterization).
Encourage prevention by having clients maintain an up-to-date immunization status.
Instruct clients to take the full course of antimicrobials the provider prescribes to prevent medication resistance and recurrence of infection.
Use infection-control procedures to prevent transmission of resistant micro-organisms.
Evaluate the effectiveness of treatment.

TL;DR · One-glance summary

Penicillins (PCN G, amoxicillin, piperacillin): bactericidal; cross-reactivity with cephalosporins rare with modern; rash to anaphylaxis. Cephalosporins (cephalexin oral; cefazolin, ceftriaxone IV; cefepime broader): 5 generations of increasing gram-neg coverage. Carbapenems (imipenem, meropenem): broad-spectrum, last-line. Vancomycin: MRSA, C. diff (PO); red man syndrome with rapid IV; nephro/ototoxic; trough monitoring.

Penicillins

Penicillin G: Narrow-spectrum gram-positive (Strep)
Amoxicillin, ampicillin: Broader spectrum; PO
Piperacillin, ticarcillin: Extended spectrum (Pseudomonas)
Beta-lactamase inhibitor combos: Amoxicillin-clavulanate (Augmentin), piperacillin-tazobactam (Zosyn), ampicillin-sulbactam
AE: Allergic reaction (rash → anaphylaxis), GI upset, diarrhea (C. difficile risk)
Document allergies clearly; ask about specific reaction
PCN + aminoglycoside synergy for serious gram-positive (endocarditis)

Cephalosporins

1st gen — Cephalexin (PO), cefazolin (IV): Gram-positive; cefazolin = surgical prophylaxis
2nd gen — Cefuroxime, cefoxitin: More gram-negative
3rd gen — Ceftriaxone (IM/IV), cefotaxime, ceftazidime: Broad; CNS penetration (meningitis); ceftriaxone — incompatible with calcium IV; bilirubin displacement (avoid in neonates)
4th gen — Cefepime: Broad gram-pos AND gram-neg + Pseudomonas
5th gen — Ceftaroline: MRSA coverage
Cross-reactivity with PCN: Rare (< 1% with modern cephalosporins)
AE: Same as PCN; some cause disulfiram-like reaction with alcohol

Carbapenems, monobactams, vancomycin

Carbapenems — Imipenem-cilastatin, meropenem, ertapenem, doripenem: Very broad-spectrum; last-line for resistant gram-negative
Imipenem: Lower seizure threshold
Monobactams — Aztreonam: Gram-negative only; safe in PCN allergy
Vancomycin (IV): MRSA, severe gram-positive
Vancomycin (PO): C. difficile colitis — not absorbed, stays in gut
Red man syndrome: Flushing, hypotension with rapid IV — infuse over ≥ 60 min
Nephrotoxicity, ototoxicity: Monitor trough levels (10–20 mcg/mL; higher for serious infection)
Monitor BUN/Cr, urine output, hearing

A neonate needs ceftriaxone for sepsis. What is the absolute contraindication regarding concurrent IV solutions, and why is this drug avoided in the very young?

NEVER co-administer ceftriaxone with IV calcium-containing solutions (LR, calcium gluconate, calcium chloride, TPN with calcium) — forms a fatal calcium-ceftriaxone precipitate in the lungs and kidneys. Even Y-site at separate ports is problematic in neonates. Avoid ceftriaxone in neonates < 28 days, especially hyperbilirubinemic — ceftriaxone displaces bilirubin from albumin → kernicterus (bilirubin encephalopathy). Cefotaxime is the preferred 3rd-gen cephalosporin alternative in neonates. Some cephalosporins (cefotetan, cefoperazone) also cause a disulfiram-like reaction with alcohol.

Active Learning Scenario

From the book — uses the ATI Active Learning Template: Medication. Practice answering before reviewing the key.

Scenario

A nurse is administering vancomycin IV to a client who has a serious wound infection. What should the nurse teach the client about this medication? Use the ATI Active Learning Template: medication to complete this item.

THERAPEUTIC USES: Identify for vancomycin for this client.
COMPLICATIONS: Identify two adverse effects the client should watch for.
NURSING INTERVENTIONS: Describe two nursing actions for clients receiving vancomycin.

Show key

Therapeutic Uses

Vancomycin is an antibiotic that kills bacteria by disrupting their cell wall. The IV form treats serious infections due to methicillin-resistant Staphylococcus aureus, Staphylococcus epidermidis, and streptococci.

Complications

Infusion reactions (red man syndrome: rashes, flushing, tachycardia, and hypotension)
Ototoxicity (rare and reversible)
Renal toxicity
Thrombophlebitis at the IV site
Im and IV injection-site pain

Nursing Interventions

Infuse vancomycin over at least 60 min/dose to prevent an infusion reaction.
Monitor the IV site for redness, pain, or other manifestations of thrombophlebitis.
Monitor I&O, and notify the provider for oliguria or other findings of acute renal injury.
Monitor for hearing loss.
Ask the client about allergy to antibiotics before administering the medication. Watch for allergic manifestations during and after the infusion.

TL;DR · One-glance summary

Tetracyclines (doxycycline, minocycline): not in children < 8 yo or pregnancy (tooth staining, bone growth); photosensitivity; ↓ absorption with calcium/iron/dairy. Macrolides (azithromycin, erythromycin, clarithromycin): GI distress; QT prolongation; CYP450 interactions. Aminoglycosides (gentamicin, tobramycin, amikacin): narrow TI; nephrotoxic, ototoxic; peaks and troughs. Clindamycin: high C. difficile risk. Linezolid: MRSA/VRE; thrombocytopenia.

Tetracyclines

Doxycycline (most used), tetracycline, minocycline
Uses: Acne, Lyme disease, rickettsial, atypical pneumonia, malaria prophylaxis
AVOID in children < 8 yo, pregnancy, breastfeeding — permanent tooth discoloration, bone growth inhibition
Photosensitivity — sunscreen, protective clothing
↓ Absorption: Calcium (dairy), iron, antacids, magnesium — separate by 2 hr
Esophagitis: Take with full glass of water; sit upright 30 min

Macrolides

Azithromycin, erythromycin, clarithromycin
Uses: Respiratory infections, atypical pneumonia, STIs (chlamydia), pertussis
Alternative for PCN-allergic
AE: GI distress (erythromycin most), QT prolongation (especially erythromycin, clarithromycin), hepatotoxicity, hearing loss
CYP450 interactions (erythromycin, clarithromycin): ↑ warfarin, statins, theophylline, digoxin
Azithromycin: Z-Pak; longer half-life; better tolerated

Aminoglycosides

Gentamicin, tobramycin, amikacin, streptomycin, neomycin
Uses: Serious gram-negative infections (gram-positive synergy with PCN/vanc)
NARROW THERAPEUTIC INDEX — monitor peak & trough
Nephrotoxicity: ATN; monitor BUN/Cr, urine output
Ototoxicity: Vestibular AND auditory — hearing loss may be permanent; baseline audiogram
Neuromuscular blockade (with anesthetics) — respiratory arrest possible
IV only: Not absorbed PO; neomycin = oral pre-bowel surgery (gut sterilization)

Other protein synthesis inhibitors

Clindamycin: Anaerobes, gram-positive; highest C. difficile risk
Linezolid (Zyvox): MRSA, VRE; thrombocytopenia (CBC monitoring); serotonin syndrome with SSRIs; MAOI activity
Daptomycin: MRSA, VRE; myopathy (CK monitoring)
Quinupristin-dalfopristin: VRE
Tigecycline: Multi-drug resistant infections

Doxycycline is prescribed for a 7-year-old child with Lyme disease. What are the major concerns, and what reduces absorption?

Caution in children < 8 yo — historically avoided due to permanent tooth discoloration and enamel hypoplasia plus bone growth inhibition. However, for serious indications like Rocky Mountain spotted fever or anaphylaxis-risk Lyme disease, doxycycline can be given even in young children (short courses appear lower-risk per modern data). Also avoid in pregnancy and breastfeeding. ↓ Absorption substances (separate by 2 hr): dairy products, calcium supplements, iron, antacids, magnesium, sucralfate. Photosensitivity — use sunscreen and protective clothing. Esophagitis — take with full glass of water, sit upright 30 min after.

A client on IV gentamicin needs peak and trough levels. When are each drawn, what are the major toxicities to monitor, and what baseline test is recommended?

Trough: 30 min BEFORE the next dose (target < 2 mcg/mL for most aminoglycosides). Peak: 30 min AFTER the END of the infusion (target 5–10 mcg/mL for gentamicin/tobramycin; higher for amikacin). Many centers now use extended-interval (once-daily) dosing with random levels and Hartford nomogram. Major toxicities — both can be permanent: (1) Nephrotoxicity (acute tubular necrosis) — monitor BUN/Cr, urine output. (2) Ototoxicity — both vestibular AND auditory; baseline audiogram recommended for long courses. (3) Neuromuscular blockade with concurrent anesthetics — respiratory arrest possible.

Active Learning Scenario

From the book — uses the ATI Active Learning Template: Medication. Practice answering before reviewing the key.

Scenario

A nurse is teaching a client who has a new prescription for oral erythromycin every 6 hr to treat pneumonia. What should the nurse teach the client about this medication? Use the ATI Active Learning Template: medication to complete this item.

THERAPEUTIC USES: Describe the therapeutic use for erythromycin in this client.
COMPLICATIONS: Identify two adverse effects the client should monitor for.
NURSING INTERVENTIONS: Describe two diagnostic tests to monitor for clients taking erythromycin.
CLIENT EDUCATION: Include two teaching points for clients taking erythromycin.

Show key

Therapeutic Uses

Erythromycin inhibits protein synthesis in the cells of susceptible micro-organisms, usually gram-positive bacteria. Erythromycin can be either bacteriostatic or bactericidal, depending on the organism and on the medication's dosage. It also treats infections for clients who are allergic to penicillin.

Complications

The most common adverse effects of erythromycin are GI manifestations, including abdominal pain, nausea, vomiting, and diarrhea.
Hepatotoxicity with abdominal pain, anorexia, fatigue, and possibly jaundice can occur after 1 to 2 weeks of erythromycin therapy.
Erythromycin can cause a prolonged QT interval on ECG, which can lead to potentially fatal tachydysrhythmias.
Ototoxicity can occur with high doses, especially after prolonged periods.

Nursing Interventions

Monitor liver function tests for clients who take erythromycin over a period of several weeks.
If the client is concurrently taking warfarin or digoxin with erythromycin, carefully monitor PT and INR or digoxin levels.
Monitor WBC counts for effectiveness of erythromycin treatment.

Client Education

Take erythromycin on an empty stomach, 1 hr before or 2 hr after meals with 8 oz of water.
Observe for adverse effects, and call the provider for severe GI distress, manifestations of liver toxicity, and ototoxicity.
Take the entire course of the medication and not to stop when feeling better.

TL;DR · One-glance summary

Uncomplicated cystitis: TMP/SMX (Bactrim) — sulfa allergy contraindicated; or nitrofurantoin (Macrobid) — turns urine brown, take with food, do not crush. Complicated UTI/pyelo: ciprofloxacin (FQ) — tendon rupture (black box), C. diff, photosensitivity; not in < 18 yo or pregnancy. Phenazopyridine (Pyridium): urinary analgesic — orange-red urine; stains clothes/contacts; max 2 days; treats symptoms not infection.

First-line UTI antibiotics

TMP/SMX (Bactrim, Septra) — sulfa drug:
• Uncomplicated cystitis first-line (3 days)
• AE: Stevens-Johnson, hyperkalemia, photosensitivity, crystalluria (↑ fluids)
• Sulfa allergy = contraindicated
• Avoid in late pregnancy (kernicterus risk) and G6PD deficiency (hemolysis)
Nitrofurantoin (Macrobid, Macrodantin):
• Concentrates in urine — UTI only (not systemic infections)
• Turns urine brown/dark yellow (harmless)
• Take with food; do not crush
• Avoid if CrCl < 60 mL/min
• Avoid in late pregnancy (term/labor) and infants < 1 mo
• Pulmonary toxicity with long-term use (suppressive therapy)

Fluoroquinolones

Ciprofloxacin, levofloxacin, moxifloxacin, ofloxacin
Uses: Complicated UTI, pyelonephritis, prostatitis; respiratory; anthrax; some STIs
BLACK BOX warnings:
• Tendinitis and tendon rupture (Achilles); ↑ risk: older adults, corticosteroids, post-transplant
• Peripheral neuropathy (possibly permanent)
• CNS effects (psychosis, depression, suicidal thoughts)
• QT prolongation
• C. difficile (high risk)
• Aortic aneurysm/dissection risk
Avoid in: Children < 18 yo (cartilage damage in animals), pregnancy
Photosensitivity
↓ Absorption: Calcium, iron, antacids, dairy, sucralfate — separate 2 hr
↑ warfarin, theophylline levels

Urinary tract analgesia & teaching

Phenazopyridine (Pyridium): Local anesthetic; orange-red urine; stains clothing, soft contact lenses
Maximum 2 days with antibiotic; doesn't treat infection
Take after meals
UTI teaching: ↑ fluids; cranberry products may help; void after intercourse; wipe front to back; avoid bubble baths/feminine sprays; complete full antibiotic course

A client is prescribed nitrofurantoin (Macrobid) for uncomplicated cystitis. What are the four key teaching points, and what is the renal function cutoff?

(1) Take with food — improves absorption and reduces GI upset. (2) Brown/dark-yellow urine is NORMAL — not blood, not concerning. (3) Do NOT crush sustained-release capsules (Macrobid). (4) Limited to lower UTI only — nitrofurantoin concentrates in urine but does NOT achieve systemic levels — useless for pyelonephritis or systemic infection. Avoid if CrCl < 60 mL/min (per IDSA; some guidelines say < 30) — won't reach therapeutic urinary levels and risk of peripheral neuropathy. Also avoid at term/labor (neonatal hemolysis) and infants <1 mo. Long-term suppressive therapy → rare pulmonary fibrosis (cough, dyspnea).

List the black-box warnings for fluoroquinolones (ciprofloxacin, levofloxacin) and the populations at highest risk for tendon rupture.

FQ black-box warnings: (1) Tendinitis and tendon rupture (especially Achilles — can occur during therapy or weeks after). (2) Peripheral neuropathy (may be permanent). (3) CNS effects (psychosis, depression, suicidality, seizures). (4) QT prolongation, (5) C. difficile, (6) Aortic aneurysm/dissection risk, (7) Avoid in myasthenia gravis (worsens weakness). Tendon rupture risk highest in: age >60, concurrent corticosteroids, post-transplant, kidney/heart transplant recipients. Stop FQ at first sign of tendon pain/swelling. Avoid in: children <18 (cartilage damage in animal models), pregnancy. ↓ Absorption: calcium, iron, antacids, dairy, sucralfate — separate by 2 hr.

Active Learning Scenario

From the book — uses the ATI Active Learning Template: Medication. Practice answering before reviewing the key.

Scenario

A client who has a UTI has a prescription for phenazopyridine. What information should the nurse review? Use the ATI Active Learning Template: medication to complete this item.

EXPECTED PHARMACOLOGICAL ACTION THERAPEUTIC USES: Describe four.
CLIENT EDUCATION: Include three teaching points.

Show key

Expected Pharmacological Action

Phenazopyridine is an azo dye, which acts as a local anesthetic on the mucosa of the urinary tract. It is not an antibiotic.

Therapeutic Uses

Relieves urinary burning, urgency, pain, and frequency

Client Education

Acute kidney injury and chronic kidney disease are contraindications.
It changes urine to an orange-red color.
Tell clients that the urine can stain clothes.
Instruct clients to take it with or after meals to minimize GI discomfort.

TL;DR · One-glance summary

TB — RIPE × 2 mo intensive, then RI × 4–7 mo continuation. Isoniazid: peripheral neuropathy (give B6), hepatotoxic. Rifampin: red-orange body fluids; CYP inducer; OCPs ineffective. Ethambutol: optic neuritis. Pyrazinamide: hepatotoxic, hyperuricemia. Antifungals: amphotericin B (nephrotoxic, infusion reactions); azoles (hepatotoxic, many interactions); nystatin (oral candidiasis). Metronidazole: disulfiram-like reaction with alcohol; metallic taste.

Tuberculosis — RIPE regimen

Rifampin: Red-orange body fluids (urine, sweat, tears — stains contacts); potent CYP inducer — ↓ OCPs, warfarin, methadone, antiretrovirals
Isoniazid (INH): Peripheral neuropathy (give vitamin B6/pyridoxine 25–50 mg daily); hepatotoxic (LFTs); avoid alcohol; lupus-like syndrome
Pyrazinamide: Hepatotoxic; hyperuricemia (gout flare); arthralgia
Ethambutol: Optic neuritis — baseline + monthly eye exams (visual acuity, color vision)
Duration: Intensive phase 2 months (all 4), then continuation 4–7 months (rifampin + INH)
Directly observed therapy (DOT): Often used to ensure adherence
Latent TB: INH alone × 6–9 months; or rifampin × 4 months; or INH + rifapentine weekly × 12 doses

Antifungals

Amphotericin B (IV) — "amphoterrible": Systemic fungal infections
• Nephrotoxicity (most serious — preload with NS, monitor BUN/Cr, K+, Mg)
• Infusion reactions: Fever, chills, rigors, hypotension — pretreat with diphenhydramine, acetaminophen, hydrocortisone
• Lipid formulations less toxic
Azoles — Fluconazole, itraconazole, voriconazole, ketoconazole, posaconazole:
• Hepatotoxic; many drug interactions (CYP inhibitors)
• Fluconazole: Vaginal/oropharyngeal candidiasis; PO or IV
Echinocandins — Caspofungin, micafungin, anidulafungin: IV; invasive Candida and Aspergillus
Topical/oral: Nystatin (oral candidiasis — swish and swallow); clotrimazole, miconazole (topical)
Terbinafine: Onychomycosis (toenail fungus); hepatotoxic; long course

Antiparasitic & metronidazole

Metronidazole (Flagyl): Anaerobic bacterial infections, C. difficile (no longer first-line), Trichomonas, giardiasis, amebiasis
Disulfiram-like reaction with alcohol — avoid alcohol during and 48 hr after
Metallic taste, dark urine, peripheral neuropathy
Antimalarials: Chloroquine, hydroxychloroquine (retinal toxicity), mefloquine, doxycycline, atovaquone-proguanil
Antihelminthics: Mebendazole, albendazole, ivermectin, praziquantel

Why must a woman of reproductive age on rifampin be counseled about contraception, and what other drugs are affected?

Rifampin is a potent CYP450 inducer (also induces P-glycoprotein) — it accelerates the metabolism of many drugs, reducing their effectiveness. Counseling: oral contraceptives fail on rifampin — use a non-hormonal backup method (condom, copper IUD) throughout therapy and for ≥1 month after. Other drugs with reduced effect: warfarin (INR drops dramatically — adjust dose), methadone (may precipitate withdrawal — increase dose), antiretrovirals (HIV — major problem), digoxin, beta blockers, sulfonylureas, tacrolimus/cyclosporine, glucocorticoids, theophylline. Also turns urine, sweat, tears orange-red — alert client to expected color and contact-lens staining.

A client on metronidazole for trichomoniasis asks if it's safe to have one drink at dinner. What is the issue, and how long after stopping should they continue to avoid alcohol?

Disulfiram-like reaction — metronidazole inhibits aldehyde dehydrogenase. Drinking even small amounts of alcohol causes severe flushing, throbbing headache, vomiting, palpitations, hypotension, dyspnea. Reaction can occur within minutes. Avoid all alcohol during treatment AND for 48–72 hours after completing the course. Also check for hidden alcohol: mouthwash, cold medicines, vanilla extract, hand sanitizer (if licked/swallowed). Other key metronidazole points: metallic taste, dark urine (harmless), peripheral neuropathy with prolonged use. Same disulfiram-like reaction occurs with certain cephalosporins (cefotetan, cefoperazone) and tinidazole.

Active Learning Scenario

From the book — uses the ATI Active Learning Template: Medication. Practice answering before reviewing the key.

Scenario

A nurse in a public health department is teaching a client who has latent tuberculosis (TB) and a new prescription for isoniazid twice weekly for 6 months. What should the nurse teach the client about this medication? Use the ATI Active Learning Template: medication to complete this item.

THERAPEUTIC USES: Describe the therapeutic use for isoniazid in this client.
COMPLICATIONS: List two adverse effects the client should watch for.
NURSING INTERVENTIONS: Describe one test to monitor for clients taking isoniazid.
CLIENT EDUCATION: Describe two teaching points for clients taking isoniazid.

Show key

Therapeutic Uses

A client who has latent tuberculosis has been infected by Mycobacterium tuberculosis and is at risk for (but has not yet developed) active tuberculosis. Some clients who have latent tuberculosis (those who are immunocompromised or who have recently immigrated to the U.S. from a country where active TB is common) can require treatment with isoniazid, with or without rifapentine, in order to prevent the onset of active TB. The client who has latent TB has a positive tuberculin test but a negative sputum culture and negative chest x-ray for TB. The client cannot infect others with tuberculosis unless the infection becomes active.

Complications

Paresthesias in the extremities caused by vitamin B6 deficiency
Hepatotoxicity
Hyperglycemia (if client has diabetes mellitus)

Nursing Interventions

The client who starts isoniazid should have baseline liver function testing and be tested periodically throughout treatment.

Client Education

Teach the client to watch for paresthesias, and to take pyridoxine daily to reverse the effect if they occur.
Teach the client about indications of hepatitis (anorexia, fatigue, nausea, jaundice) and to notify the provider if these occur.
Teach the client to take isoniazid as prescribed, and not to stop until the entire course of treatment is completed.
The client who has latent tuberculosis does not feel ill. The nurse should be sure that the client understands why it is important to continue with treatment.

TL;DR · One-glance summary

HIV — HAART: at least 3 drugs from ≥ 2 classes; lifelong; adherence critical to prevent resistance. NRTIs (zidovudine, tenofovir): bone marrow suppression. Protease inhibitors (ritonavir): metabolic effects, many drug interactions. Integrase inhibitors (dolutegravir): well-tolerated, often first-line. Acyclovir (herpes): ↑ fluids (crystalluria). Oseltamivir (flu): within 48 hr of symptom onset.

HIV antiretrovirals (ART/HAART)

NRTIs (Nucleoside Reverse Transcriptase Inhibitors):
• Zidovudine (AZT/ZDV), tenofovir, emtricitabine, abacavir, lamivudine
• AE: Bone marrow suppression, lactic acidosis, hepatic steatosis
• Abacavir: HLA-B*5701 testing (hypersensitivity)
NNRTIs — Efavirenz, nevirapine, rilpivirine: Hepatotoxic; rash (Stevens-Johnson)
• Efavirenz: CNS effects (dreams, dizziness) — take at bedtime; teratogenic
Protease inhibitors ("-navir") — Ritonavir, atazanavir, darunavir, lopinavir:
• Many CYP450 interactions; metabolic: ↑ glucose, ↑ lipids, lipodystrophy
• Ritonavir often used as "booster" for other PIs
Integrase strand transfer inhibitors (INSTIs) — Dolutegravir, raltegravir, bictegravir, elvitegravir:
• Often first-line — well-tolerated, high barrier to resistance
Entry inhibitors: Maraviroc (CCR5 antagonist), enfuvirtide (fusion inhibitor — SC)
Critical: STRICT ADHERENCE — missed doses → resistance
Post-exposure prophylaxis (PEP): Start within 72 hr; 28-day course
Pre-exposure prophylaxis (PrEP): Tenofovir/emtricitabine daily for high-risk individuals

Herpes, varicella, CMV

Acyclovir, valacyclovir, famciclovir: Herpes simplex (genital, oral), varicella-zoster (shingles, chickenpox)
↑ Fluids with acyclovir IV to prevent crystalluria/AKI
Topical acyclovir: Limited efficacy; wear gloves
Ganciclovir, valganciclovir, foscarnet, cidofovir: CMV (especially immunocompromised, transplant); bone marrow suppression

Influenza, hepatitis, other

Oseltamivir (Tamiflu), zanamivir (inhaled), peramivir (IV), baloxavir: Influenza A and B
Start within 48 hours of symptom onset for best effect
Hepatitis B: Tenofovir, entecavir (NRTIs); interferon alfa; pegylated interferons
Hepatitis C: Direct-acting antivirals (DAAs) — sofosbuvir, ledipasvir, glecaprevir/pibrentasvir; cure rates > 95%
Ribavirin: RSV (inhaled), Hep C combo; hemolytic anemia; Category X — teratogenic
Remdesivir: SARS-CoV-2 (COVID-19); IV

A client newly diagnosed with HIV is starting antiretroviral therapy. Why is adherence the single most critical teaching point?

HIV mutates rapidly. Missing doses → drug levels drop below MIC → resistance develops within weeks, and resistance to one drug often extends to the entire class. Each subsequent regimen is more complex and toxic. Goal: ≥ 95% adherence for sustained viral suppression. Strategies: simplified regimens (often single-tablet once-daily integrase combos like Biktarvy), pill boxes, smartphone reminders, address barriers (cost, mental health, substance use), regular viral load monitoring. PEP within 72 hr (28-day course) after exposure; PrEP daily for high-risk individuals. U=U: undetectable viral load = untransmittable sexually.

Active Learning Scenario

From the book — uses the ATI Active Learning Template: Medication. Practice answering before reviewing the key.

Scenario

A nurse is caring for a client who is immunocompromised and has a new prescription for ganciclovir iV twice per day to prevent cytomegalovirus. What should the nurse teach the client about this medication? Use the ati active learning template: Medication to complete this item.

THERAPEUTIC USES: Identify for ganciclovir in this client.
COMPLICATIONS: Identify two adverse effects.
NURSING INTERVENTIONS: Describe two for clients taking ganciclovir, and two tests the nurse should monitor.

Show key

Therapeutic Uses

Ganciclovir prevents reproduction of viral dna and thus prevents viral cell replication. it is used is to prevent or treat cytomegalovirus in clients who are immunocompromised.

Complications

Minor discomforts (fever, headache, and nausea)
Suppresses the bone marrow, causing a decrease in WBcs, especially granulocytes
Causes thrombocytopenia frequently
The client should report any discomforts and be sure to report new onset of fatigue, easy bruising, or sore throat.
Advise the client to report manifestations of infection or bleeding, and to avoid crowds or individuals who have respiratory infections.

Nursing Interventions

Monitor client blood counts, especially WBc, absolute neutrophil count, and thrombocyte count. expect ganciclovir therapy to be interrupted for an absolute neutrophil count less than 500/mm3 or a thrombocyte count less than 25,000/mm3.
Monitor blood counts.
Prepare to administer granulocyte colony-stimulating factors for a low absolute neutrophil count.
Monitor i&o, and encourage the client to increase fluid intake.
Avoid direct contact with the powder from oral ganciclovir or the iV solution, and wash well if contact occurs.
Advise clients to use a barrier contraception (condoms) during treatment and for 3 months following treatment.

TL;DR · One-glance summary

CAM products are NOT FDA-regulated as drugs; quality and potency vary. Major interactions: St. John's wort = CYP450 inducer (↓ OCPs, warfarin, digoxin, antiretrovirals); garlic, ginkgo, ginger, ginseng = bleeding risk (avoid with anticoagulants/antiplatelets); kava + valerian = hepatotoxic with sedatives. Always ask about supplement use during med reconciliation. Discontinue most herbals 2 weeks before surgery.

Common herbal supplements

Echinacea: Cold/flu prevention (evidence weak); avoid in autoimmune disease, immunosuppression
Ginkgo biloba: Memory, peripheral circulation; ↑ bleeding (avoid with anticoagulants, antiplatelets)
Ginseng: Energy, immune; ↓ blood glucose (caution with diabetes meds); ↑ bleeding
Garlic: ↓ BP, ↓ cholesterol; ↑ bleeding
Ginger: N/V; ↑ bleeding at high doses
St. John's wort: Depression; POTENT CYP3A4 inducer — ↓ OCPs (pregnancy risk), warfarin, digoxin, antiretrovirals, cyclosporine; serotonin syndrome with SSRIs/MAOIs
Valerian: Sleep; ↑ effects of CNS depressants
Kava: Anxiety; hepatotoxic — avoid
Black cohosh: Menopausal symptoms; hepatotoxic; avoid with breast cancer history
Saw palmetto: BPH symptoms; may affect PSA levels; bleeding risk

Other CAM categories

Glucosamine/chondroitin: Osteoarthritis (evidence mixed); shellfish allergy caution (glucosamine often from shellfish)
Probiotics: Restore GI flora; especially with antibiotic use; avoid in severely immunocompromised
Melatonin: Sleep, jet lag; may interact with anticoagulants, immunosuppressants
Coenzyme Q10: May help statin-induced myopathy; may ↓ warfarin effect
Fish oil (omega-3): Triglyceride reduction; ↑ bleeding at high doses
Megavitamins: Fat-soluble (A, D, E, K) accumulate — toxicity possible

Nursing implications

ALWAYS ask about supplements/herbals during med reconciliation
Discontinue most herbals 2 weeks before elective surgery (bleeding risk)
Document supplement use; report to provider
Pregnancy/breastfeeding: Most supplements not studied — avoid unless specifically recommended
Children: AVOID most herbal supplements
Quality issues: Look for USP verification mark
Teach clients that "natural" does NOT mean "safe"

A woman on combined OCPs and warfarin reports taking St. John's wort for mild depression. What are the consequences, and what other drug classes interact?

St. John's wort is a POTENT CYP3A4 inducer — accelerates the metabolism of many drugs, dramatically reducing their effectiveness. Critical interactions: ↓ oral contraceptives → unintended pregnancy; ↓ warfarin → INR drops → thromboembolism; ↓ digoxin, antiretrovirals, cyclosporine/tacrolimus, certain chemo agents (life-threatening reductions in transplant or HIV patients). Pharmacodynamic risk: serotonin syndrome when combined with SSRIs, SNRIs, MAOIs, triptans, tramadol. Counseling: stop St. John's wort; discuss safer prescribed antidepressants with provider; check INR; ensure backup contraception until next cycle off the herb.

A client is scheduled for elective surgery in 3 weeks and takes garlic, ginkgo, ginger, ginseng, and fish oil supplements. What is the pre-operative advice and why?

Discontinue most herbal supplements ≥ 2 weeks before elective surgery — the "4 G's" (garlic, ginkgo, ginger, ginseng) plus ginger, vitamin E, and high-dose fish oil all increase bleeding risk by inhibiting platelet aggregation. Other surgical concerns: kava and valerian → ↑ effect of anesthetics (oversedation); ephedra → cardiovascular instability (banned but variants exist); St. John's wort → many anesthetic drug interactions. Always include supplements in medication reconciliation at every encounter; teach clients "natural ≠ safe," look for USP verification, and report ALL supplements to anesthesia and surgical teams.

Active Learning Scenario

From the book — uses the ATI Active Learning Template: Medication. Practice answering before reviewing the key.

Scenario

A nurse is educating a client about the use of the dietary herbal supplement St. John's Wort. What should the nurse include in the teaching? Use the ATI Active Learning Template: medication to complete this item.

THERAPEUTIC USE: Describe the potential uses of this supplement.
COMPLICATIONS: Identify four potential adverse effects of this supplement.
MEDICATION INTERACTIONS: Identify four medication interactions that can occur with this supplement.

Show key

Therapeutic Use

Affects serotonin, producing antidepressant effects
Mild depression
Oral analgesic to relieve pain and inflammation
Applied topically to treat infection

Complications

Mild adverse effects, including dry mouth, lightheadedness, constipation, GI discomfort
Skin rash with client exposure to sunlight

Interactions

Can cause serotonin syndrome when combined with other antidepressants, amphetamine, and cocaine
Decreases effectiveness of oral contraceptives, cyclosporine, warfarin, digoxin, calcium channel blockers, steroids, HIV protease inhibitors, and some anticancer medications

Pharmacology for Nursing

Pharmacokinetics and Routes of Administration

TL;DR · One-glance summary

The four phases (ADME)

Key concepts

Important kinetic concepts

Absorption & Routes of Administration

Absorption pattern

Nursing considerations

Pattern

Teaching

Absorption

Uses

Absorption pattern

MDI with spacer technique

Patterns

Transdermal patch teaching

Absorption

IM sites & technique

Properties

Risks

Distribution

Conditions that impair distribution

What crosses easily

Implications

Key concepts

Metabolism (biotransformation)

Factors that ↓ metabolism (require ↓ dose)

Factors that ↑ metabolism (require ↑ dose)

Routes that bypass first-pass effect

Examples

Excretion

Key points

Routes

Half-life, Steady State, and Therapeutic Index

Implications

Loading dose

Low-TI medications (require monitoring)

Peak vs trough monitoring

Active Learning Scenario

Scenario

Indications

Client Education — Steps for MDI with Spacer

Practice · Application Exercises

Safe Medication Administration and Error Reduction

TL;DR · One-glance summary

Rights of medication administration

Error prevention

Controlled substances, errors & reporting

Six Rights of Medication Administration

Core six rights

Additional rights

Acceptable identifiers

Special situations

Error Prevention

Tools

Best practices

Do NOT crush or chew

Other cautions

Common tall-man pairs

Common forbidden abbreviations

Controlled Substances

Schedule II — high abuse potential, accepted medical use

Schedule III — moderate abuse potential

Schedule IV — lower abuse potential

Schedule V — lowest abuse potential

Nursing responsibilities

Medication Reconciliation & Pregnancy Categories

When to reconcile

What to include

FDA letter categories

PLLR (current) sections

Active Learning Scenario

Scenario

Description of Skill — Verifying the Right Client

Indications for Use of Two Identifiers

Considerations

Practice · Application Exercises

Dosage Calculation

TL;DR · One-glance summary