Homework Respiratory System Fall 2023 PDF

Asthma & Breathalyzer in General x 9 1) Which action would be the most appropriate way for the nurse to evaluate a child’s understanding of how to use an inhaler? A. Asking questions about using the inhaler B. Having the child demonstrate inhaler use C. Explaining how the inhaler will be...

Asthma & Breathalyzer in General x 9 1) Which action would be the most appropriate way for the nurse to evaluate a child’s understanding of how to use an inhaler? A. Asking questions about using the inhaler B. Having the child demonstrate inhaler use C. Explaining how the inhaler will be used at home D. Having the child tell the nurse about the technique that was learned Rationale The nurse can best evaluate teaching by asking the learner for a return demonstration. Behavior, rather than words, more easily shows what has been learned. A child may be too young to know whether he or she has any questions. A demonstration, rather than an explanation, can be evaluated more readily. Telling the nurse about the technique that was learned is difficult for a younger child; the ability to articulate a concept is not that advanced—nor is the vocabulary. 2) A client with chronic obstructive pulmonary disease prepares to take a medication that is delivered via a nebulizer. Which instruction would the nurse provide when teaching about use of the nebulizer? A. 'Hold your breath, spray the medication into your mouth, then inhale deeply.' B. 'Depress the canister as you inhale deeply, then hold your breath for at least 10 seconds.' C. 'Seal your lips around the mouthpiece and breathe in and out, taking slow, deep breaths.' D. 'Inhale the medication from the nebulizer, remove the mouthpiece to exhale and then repeat.' Rationale Sealing the lips around the mouthpiece ensures that medication is delivered on inspiration; slow, deep breaths promote better deposition and efficacy of medication deep into the lungs. The breath should not be held during administration. A nebulizer treatment delivers medication by inhaling it into the mouth through a mouthpiece, not a canister. Removing the mouthpiece from the mouth to exhale allows valuable aerosolized medication to be deposited into the air; therefore the client will not receive the full dose of aerosolized medication. 3) List in order the steps the nurse teaches the client to follow when using a metered-dose inhaler (MDI). 1. Shake the inhaler for 30 seconds. 2. Exhale slowly and deeply to empty the air from the lungs. 3. Hold the inhaler upright in the mouth. 4. Start breathing in and press down on the inhaler once. Answer: 1,2,3,4 Rationale When using an MDI, the medication should be shaken for 30 seconds to ensure that the medication is mixed. Exhaling completely maximizes emptying the lungs. The inhaler should be held upright in the mouth past the teeth with the lips closed around the mouthpiece (closed mouth method) or held upright 1 to 2 cm in front of the open mouth (open mouth method). Inhalation is begun at the same time that the device is compressed to ensure that maximum medication reaches the lungs. 4) Which goal is the priority for a client with asthma who has a prescription for an inhaled bronchodilator? A. Is able to obtain pulse oximeter readings B. Demonstrates use of a metered-dose inhaler C. Knows the health care provider’s office hours D. Can identify triggers that may cause wheezing Rationale Clients with asthma use metered-dose inhalers to administer medications prophylactically or during times of an asthma attack; this is an important skill to have. Home management typically includes self-monitoring of the peak expiratory flow rate rather than pulse oximetry. Although knowing the health care provider’s office hours is important, it is not the priority; during a persistent asthma attack that does not respond to planned interventions, the client should go to the emergency department of the local hospital or call 911 for assistance. Although it is important to be able to identify triggers that may cause wheezing, knowing these cannot prevent all wheezing; therefore, being able to abort wheezing with a bronchodilator is the greater priority. 5) Which method would the nurse recommend when teaching the client with asthma how to determine if an inhaler is empty? A. Track the number of doses taken. B. Taste the medication when sprayed into the air. C. Shake the canister. D. Place the canister in water to see if it floats. Rationale The only way to determine if the canister is empty is to track the number of doses taken. It is wasteful to spray medication into the air; tasting it from the air is not an effective method of determining if the canister is empty. Shaking the canister is not effective; even if there is no more medication, some propellant may be left. It is futile to place the canister in water; the flotation test is ineffective.tory center in the brain. 6) The nurse provides instructions about how to use a metered-dose inhaler (MDI) to a client with chronic obstructive pulmonary disease. The nurse concludes that additional teaching is needed when the client demonstrates which technique? A. Places the tip of the inhaler just past the lips B. Holds the inspired breath for at least 3 seconds C. Activates the inhaler during inspiration D. Inhales rapidly with the lips sealed around the nebulizer opening Rationale The client should inhale slowly rather than rapidly when using a metered-dose inhaler (MDI) to optimize delivery of the nebulized medication into the lungs. If the client has a dry powder inhaler (DPI), then rapid inhaling would be an important action because the powder is not nebulized. The MDI should be gently held in the mouth just past the lips to deliver the medication into the airway. Holding the inspired breath for at least 3 seconds promotes contact of the medication with the bronchial mucosa. The inhaler should be activated during inspiration. 7) Which intervention would the nurse implement for a client admitted for an exacerbation of asthma? A. Determine the client’s emotional state. B. Give prescribed medications to promote bronchiolar dilation. C. Provide education about the effect of a family history. D. Encourage the client to use an incentive spirometer routinely. Rationale Asthma involves spasms of the bronchi and bronchioles as well as increased production of mucus; this decreases the size of the lumina, interfering with inhalation and exhalation. Bronchiolar dilation will reduce airway resistance and improve the client’s breathing. Although identifying and addressing a client’s emotional state is important, maintaining airway and breathing are the priority. In addition, emotional stress is only one of many precipitating factors, such as allergens, temperature changes, odors, and chemicals. Although recent studies indicate a genetic correlation along with other factors that may predispose a person to the development of asthma, exploring this issue is not the priority. The use of an incentive spirometer is not helpful because of mucosal edema, bronchoconstriction, and secretions, all of which cause airway obstruction. 8) A nurse is teaching an 80-year-old client how to use a metered dose inhaler. The nurse is concerned that the client is unable to coordinate the release of the medication during the inhalation phase. Which intervention should improve the delivery of the medication? A. Ask a family member to assist the client with the inhaler. B. Request a home health nurse to visit the client at home. C. Use nebulized treatments at home instead. D. Add a spacer device to the inhaler canister. Rationale: Use of a spacer is especially useful with older adults because it allows more time to inhale and requires less eye-hand coordination. If the client is not using the metered dose inhaler (MDI) properly, the medication can get trapped in the upper airway and lead to dry mouth and throat irritation. Using a spacer will allow more drug to be deposited in the lungs and less in the mouth. 9) The nurse is teaching the client how to properly use a dry powder capsule inhaler. How should the nurse instruct the client to use this type of inhaler? A. Shake inhaler before putting it in mouth B. Seal lips tightly around mouthpiece and inhale rapidly and deeply C. Rinse mouthpiece in hot soapy water after using D. Breathe in medicine slowly and deeply for about 3-5 seconds Rationale: The client should breathe in quickly and deeply for up to 10 seconds when using a dry powder capsule inhaler. The client should not shake this type of inhaler. The mouthpiece can be rinsed with warm water but without soap or detergent. 10) The nurse is teaching a school-aged child and family members about the use of inhalers prescribed for asthma. Which statement made by a family member indicates an understanding of the nurse's instructions? A. "We will keep a chart of daily peak flow meter results." B. "We can rely on our child's self-report of symptoms." C. "Monitoring our child's pulse rate is not necessary." D. "Skin color changes in our child is an early warning sign for airway constriction." Rationale: The peak flow meter can help determine if the symptoms of asthma are in control or are worsening. It works by measuring how fast air comes out of the lungs when the client forcefully exhales (the peak expiatory flow or PEF). The client should record the highest of three readings in an asthma diary daily. Children ages 4 and up should be able to use a peak flow meter. A decrease in PEF is an early warning sign for airway constriction and should be immediately addressed. Family members should monitor the child's pulse rate and changes in skin color is a late sign. 11) The nurse is educating a client about how to use a metered-dose inhaler with spacer. Place each step in the correct order by entering the numbers in order. 1. Release the medication into the spacer 2. Breathe in deeply 3. Remove the mouthpiece from the lips 4. Hold breath for 10 seconds 5. Breathe out slowly Correct Answer: 32451 Question Explanation Rationale: Release the medication into the spacer. Breathe in deeply. Remove the mouthpiece, then hold breath for 10 seconds, then breathe out slowly. Spacers are highly recommended when inhalers are used because they increase the availability of the medication to the client. “BREATH”-terols: albuterol, metaproterenol x 17 1) The nurse administers albuterol to a 4-year-old child. Which intervention would assist the nurse in evaluating the effectiveness of this medication? A. Auscultate breath sounds. B. Collect a sputum sample. C. Conduct a neurological examination. D. Palpate chest excursion. Rationale Albuterol is an adrenergic medication that stimulates beta-receptors, leading to relaxation of the smooth muscles of the airway. The lungs should be auscultated to evaluate the effectiveness of this medication. Albuterol does not affect the consistency of pulmonary secretions. Albuterol will not cause central nervous system stimulation. Albuterol does not affect intercostal contractility; chest excursion is not the appropriate assessment. 2) The nurse administers albuterol to a child with asthma. Which common side effect would the nurse monitor for in the child? A. Flushing B. Dyspnea C. Tachycardia D. Hypotension Rationale Albuterol produces sympathetic nervous system side effects such as tachycardia and hypertension. Pallor, not flushing, is a common side effect. Dyspnea is not a common side effect; this medication is given to decrease respiratory difficulty. Hypertension, not hypotension, is a common side effect. 3) A client is prescribed albuterol to relieve severe asthma. Which adverse effects will the nurse instruct the client to anticipate? Select all that apply. One, some, or all responses may be correct. A. Tremors B. Lethargy C. Palpitations D. Bronchoconstriction E. Decreased pulse rate Rationale Albuterol’s sympathomimetic effect causes central nervous system (CNS) stimulation, precipitating tremors, tachycardia, and palpitations. Lethargy is an adverse effect of medications that cause CNS depression, not CNS stimulation. Albuterol causes bronchodilation, not bronchoconstriction. Albuterol will cause tachycardia, not bradycardia. 4) A client prescribed albuterol tablets reports nausea every evening with the 9:00 p.m. dose. Which action should the nurse perform to alleviate this side effect? A. Change the time of the dose. B. Hold the 9 p.m. dose. C. Administer the dose with a snack. D. Offer an antiemetic with the dose. Administering oral doses of albuterol with food helps minimize gastrointestinal discomfort such as nausea. 5) The nurse is providing teaching to the client prescribed albuterol for the management of asthma. The nurse is including reportable side effects in the teaching plan. Which of the following side effects is the priority? A. Nervousness B. Headache C. Palpitations D. Muscle aches Rationale: Side effects of albuterol include nervousness, shakiness, headache, throat irritation, and muscle aches. Muscle tremor is the most frequent adverse effect. The main risks with adrenergic bronchodilators, particularly in older adults, are excessive cardiac and central nervous system (CNS) stimulation. Symptoms of cardiac stimulation include angina, tachycardia, and palpitations. Symptoms of central nervous system (CNS) stimulation consist of agitation, anxiety, insomnia, seizures, and tremors. Other reported effects may include serious dysrhythmias and cardiac arrest. 6) The nurse is teaching a pediatric client and family about prescribed albuterol sulfate extended-release tablets. Which statement should be included? A. If you cannot swallow the tablet, it is ok to chew it B. This medication can cause restlessness C. “This medication can cause restlessness.” C. Rinse your mouth after taking this medication D. Oral albuterol can cause an increase in urination Rationale: The adverse reactions to albuterol are the same whether administered orally or via inhalation. The most frequent adverse reactions to albuterol are nervousness, tremors, headache, tachycardia, and palpitations. Less frequent adverse reactions are muscle cramps, insomnia, nausea, weakness, dizziness, drowsiness, flushing, restlessness, irritability, chest discomfort, and difficulty in urination. Extended-release medications should not be chewed or crushed. Doing so can release all of the drug at once, increasing the risk of side effects. Inhaled corticosteroids require the mouth to be rinsed. This medication is not inhaled and is not a corticosteroid. 7) The nurse is educating a client with end stage chronic ob structive pulmonary disease (COPD) about medication management. Which statement by the client indicates an understanding of the teaching? A. “I will use the albuterol in the nebulizer before my other inhalers each morning.” B. “I can use my tiotropium inhaler if I get short of breath.” C. “I will only use the fluticasone inhaler on the days I am really out of breath.” D “The side effects of these medications will be less severe because I’m not taking them by mouth.” Question Explanation Rationale: Medication regimens used to treat COPD are based on disease severity. For grade III or IV (severe and very severe) COPD, medication therapy includes treatment with one or more bronchodilators and inhaled corticosteroids. Clients with COPD experience significant breathlessness and reduced FEV1 upon waking. Use of nebulized albuterol prior to administration of long-acting medications relaxes the airway and allows other medications to get deeper into the lungs. Tiotropium is a long-acting anticholinergic (muscarinic) and is not meant for rescue purposes. Fluticasone prevents inflammation and therefore, must be used every day. Clients with COPD will experience side effects of the medications due to the long duration of use. 8) The nurse is reinforcing the correct use of a metered-dose inhaler (MDI) for a client newly-diagnosed with asthma. The client asks, "how will I know the canister is empty?" What is the best response by the nurse? A. "Contact your pharmacy to find out when to obtain a refill." B. "Drop the canister in water to observe if it floats." C. "Count the number of doses as the inhaler is used." D. "Shake the canister and listen for any fluid movement.” Rationale: Floating an MDI in water, or shaking it to listen for fluid movement to determine how much medication is left, is not recommended. MDIs that count down the number of remaining doses are available, however, these mechanisms are not always accurate. Therefore, it is best to calculate how long the inhaler will last by dividing the number of doses in the container by the number of doses the client takes per day. For example, a client who needs to take two puffs of albuterol, four times a day, will take a total of eight puffs per day. The MDI contains a total of 200 puffs. Divide 200/8 = 25 days. The inhaler in this example will last 25 days. To ensure that the client does not run out of medication, the client should obtain a refill at least 7 to 10 days before it runs out. The pharmacy would not be able to determine if the canister is empty. 9) The nurse is teaching a client diagnosed with asthma about the medication albuterol. Which statement by the nurse demonstrates appropriate teaching? A. "Call your doctor's office if you need to use the drug more often." B. "Use this medication at bedtime to promote rest." C. "Use this medication after other asthma inhalers." D. "Discontinue the inhaler if you feel dizzy." Rationale: Albuterol is a bronchodilator used for the relief of bronchospasm. It is considered a rescue medication for a client during an asthmatic attack. If the client notices the need to use the inhaler more frequently, the health care provider (HCP) should be notified. The client may need to seek emergency medical care, as the medication is no longer effective. In addition, clients should not exceed the recommended dosage, as adverse effects may occur. Be sure the client understands how to correctly use this medication. The client may experience side effects of dizziness, headache, nausea, vomiting, rapid heart rate, anxiety, sweating, flushing and insomnia. Using albuterol at bedtime may lead to insomnia. Albuterol should be used before all other inhalers, as it dilates the bronchi or bronchioles and allows more of the other medication to reach the lower respiratory tract. It would not be appropriate to suddenly discontinue taking a bronchodilator. 10) The nurse is teaching a client with asthma about albuterol. How should the nurse best describe the action of this medication? A. "The medication is given to reduce secretions that block airways." B. "The medication will help to relax smooth muscles in the airways." C. "The medication will stimulate the respiratory center in the brain." D. "The medication will help to prevent pneumonia." Rationale: Albuterol is a bronchodilator and rescue drug of choice to treat asthma. It is a short-acting beta-adrenergic agonist that is used to prevent and treat wheezing, difficulty breathing, and chest tightness. Albuterol works by relaxing and opening the airways to make breathing easier. The medication comes as a tablet, syrup, inhaler and nebulizer. Albuterol does not reduce secretions, stimulate the respiratory center in the brain or prevent pneumonia. 11) The nurse is preparing to administer an albuterol nebulizer treatment to a patient with asthma. Which assessment finding should be brought to the health care provider's attention prior to administering the medication? A. Temperature of 101°F (38.3°C) B. Heart rate of 116 bpm C. Respiratory rate of 28 D. Lower extremity edema Rationale: One of the more common adverse effects of beta-adrenergic medications, such as albuterol, is an increase in heart rate. Normal resting heart rate for children 10-years-old and older is the same as adults: 60 to 100 bpm. The nurse should report the heart rate to the health care provider prior to administering the medication. 12) The nurse is providing discharge education to a client with moderate persistent asthma. The nurse should instruct the client to administer which medication first? A. Bronchodilator B. Glucocorticoid C. Anticholinergic D. Mast cell stabilizer Rationale: Bronchodilators, such as albuterol, are beta-agonist drugs that relieve bronchospasm by relaxing the smooth muscle of the airway. These medications should be inhaled first to open the airways, which will allow the other medications to move more deeply into the lungs and increase their effectiveness. 13) A client with a history of asthma is admitted for a minor surgical procedure. Preoperatively, the peak flow is measured at 480 liters/minute. Postoperatively, the client reports chest tightness and the peak flow is now 200 liters/minute. What should the nurse do first? A. Notify both the surgeon and primary care provider B. Repeat the peak flow reading in 30 minutes C. Administer the PRN dose of albuterol D. Apply oxygen at two liters per nasal cannula Rationale: Peak flow monitoring during exacerbations of asthma is recommended for clients with moderate-to-severe persistent asthma to determine the severity of the exacerbation and to guide the treatment. A peak flow reading of less than 50% of the client's baseline reading is a medical alert condition and a short-acting beta agonist must be taken immediately. Notifying the health care provider is important, but that is not what would be done first. First, the client needs assistance. Oxygen administration will not be effective if the airway constriction is not relieved with the albuterol. Leaving the client and returning in 30 minutes will do nothing to help a client in acute distress. 14) The nurse is evaluating the effectiveness of therapy for a client who received albuterol via nebulizer during an acute episode of shortness of breath due to asthma. Which finding is the best indicator that the therapy was effective? A. Accessory muscle use has decreased. B. Oxygen saturation is greater than 90%. C. Respiratory rate is 16 breaths/minute. D. No wheezes are audible. Question Explanation Rationale: The goal for treatment of an asthma attack is to relieve bronchospasms and keep the oxygen saturation greater than 90%. Albuterol is a short-acting inhaled beta2-adrenergic agonist and the treatment of choice for an acute asthma attack. Pulse oximetry is an objective data point that the nurse should use to determine oxygenation status of the client. The other client data may occur when the client is too fatigued to continue with the increased work of breathing required in an asthma attack and, therefore, should not be used to evaluate effectiveness of treatment. 15) Upon admission to the emergency center, an adult client with acute status asthmaticus is prescribed this series of medications. In which order should the nurse administer the prescribed medications? (Arrange from first to last.) A. Prednisone (Deltasone) orally. B. Gentamicin (Garamycin) IM. C. Albuterol (Proventil) puffs. D. Salmeterol (Serevent Diskus). The correct order is: E. Albuterol (Proventil) puffs. F. Salmeterol (Serevent Diskus). G. Prednisone (Deltasone) orally. H. Gentamicin (Garamycin) IM. Status asthmaticus is potentially a life-threatening respiratory event, so albuterol, a beta2 adrenergic agonist and short acting bronchodilator, should be administered by inhalation first to provide rapid and deep topical penetration to relieve bronchospasms, dilate the bronchioles, and increase oxygenation. In stepwise management of persistent asthma, a long-action bronchodilator, such as salmeterol (Serevent Diskus), with a 12-hour duration of action should be given next. Prednisone, an oral corticosteroid, provides prolonged anti-inflammatory effects and should be given after the client's respiratory distress begins to resolves. Gentamicin, an antibiotic, is given deep IM, which can be painful, and may require repositioning the client, so should be last in the sequence. 16) A health care provider prescribes metaproterenol for a client. For which therapeutic effect would the nurse monitor the client? A. Induced sedation B. Relaxed bronchial spasm C. Decreased blood pressure D. Productive cough Rationale Metaproterenol stimulates beta receptors of the sympathetic nervous system, causing bronchodilation and an increased rate and strength of cardiac contractions. Barbiturates and hypnotics produce sedation. Antihypertensives and diuretics help decrease blood pressure. Expectorants mobilize respiratory secretions, promoting a productive cough. 17) Which intervention would the nurse implement for a client admitted for an exacerbation of asthma? A. Determine the client’s emotional state. B. Give prescribed medications to promote bronchiolar dilation. C. Provide education about the effect of a family history. D. Encourage the client to use an incentive spirometer routinely. Rationale Asthma involves spasms of the bronchi and bronchioles as well as increased production of mucus; this decreases the size of the lumina, interfering with inhalation and exhalation. Bronchiolar dilation will reduce airway resistance and improve the client’s breathing. Although identifying and addressing a client’s emotional state is important, maintaining airway and breathing are the priority. In addition, emotional stress is only one of many precipitating factors, such as allergens, temperature changes, odors, and chemicals. Although recent studies indicate a genetic correlation along with other factors that may predispose a person to the development of asthma, exploring this issue is not the priority. The use of an incentive spirometer is not helpful because of mucosal edema, bronchoconstriction, and secretions, all of which cause airway obstruction. 18) While receiving an adrenergic beta 2 agonist medication for asthma, the client complains of palpitations, chest pain, and a throbbing headache. Which nursing action is the most appropriate? A. Withhold the medication and notify the health care provider. B. Tell the client that these are expected side effects from the medicine. C. Give instructions to breathe slowly and deeply for several minutes. D. Explain that the effects are temporary and will subside as medication tolerance develops. Rationale These medications cause increased heart contraction (positive inotropic effect) and increased heart rate (positive chronotropic effect). If toxic levels are reached and side effects occur, the medication should be withheld until the health care provider is notified. Telling the client that these are expected side effects from the medicine is false reassurance and a false statement; they should not cause chest pain. Controlled breathing may be helpful in allaying a client’s anxiety; however, the medication may be producing adverse effects and should be withheld. “ASTHMA”-phyllines: theophylline, aminophylline x 2 1) The nurse is preparing to discharge a client who presented to the emergency room for an acute asthma attack. The nurse notes that upon discharge the health care provider has prescribed theophylline 300 mg orally to be taken daily at 9:00 AM. The nurse will teach the client to take the medication on which schedule? A. One hour before or 2 hours after eating B. At bedtime C. At the specific time prescribed D. Daily until symptoms are gone Rationale For theophylline to be effective, therapeutic serum levels must be maintained by taking the medication at the prescribed time. If the medication is not taken at the prescribed time, the level may drop below the therapeutic range. The medication will not be effective if it drops below the therapeutic range. Theophylline should be given after a meal and with a full glass of water to decrease gastric irritability. Giving it 2 hours after a meal (on an empty stomach) can result in gastric discomfort. It should not be taken at night, because it can cause central nervous system stimulation resulting in insomnia, restlessness, irritability, etc. Theophylline is used for long-term medication therapy. 2) A client with chronic obstructive pulmonary disease (COPD) is receiving aminophylline 25 mg/hour intravenously (IV). Which finding would be associated with side effects of this medication? A. Flushing and headache B. Restlessness and palpitations C. Decreased urine volume D. Pruritus Rationale: Aminophylline is a bronchodilator often used to treat symptom of asthma, bronchitis, and emphysema. Side effects include restlessness, palpitations, chest pain or discomfort, increased urine volume, vertigo, and vomiting. The other choices are not side effects of this drug. “Breath”-lukast: montelukast x 1 1) The nurse is providing education to the client prescribed montelukast for the treatment of asthma. What medication should the nurse instruct the client to avoid? A. Ibuprofen B. Prednisone C. Amoxicillin D. Formoterol Question Explanation Rationale: Montelukast should not be taken with NSAIDs. It increases the risk of bleeding as well as has the potential to make asthma symptoms worse. Prednisone, amoxicillin, and formoterol are all safe to administer to the client on montelukast. “Corti”-a/isone & “Corti”-onide: prednisone(oral), fluticasone(Inhaler), fludrocortisone, budesonide, hydrocortisone, dexamethasone, beclomethasone x 66 1) Which response to fludrocortisone will the nurse teach a client with adrenal insufficiency to report? Select all that apply. One, some, or all responses may be correct. A. Edema B. Rapid weight gain C. Fatigue in the afternoon D. Unpredictable changes in mood E. Increased frequency of urination Rationale Fludrocortisone has a strong effect on sodium retention by the kidneys, which leads to fluid retention, causing edema and weight gain. Fatigue may occur with adrenal insufficiency and is not related to cortisone therapy. Unpredictable changes in mood commonly occur but are not as serious a threat as fluid retention. Fluid retention, and thus decreased urination, may occur. 2) Which explanation would the nurse provide for administering prednisone to a client with an exacerbation of colitis? A. The client will be protected from getting an infection. B. Symptoms associated with the colitis will decrease slowly over time. C. Although the medication causes anorexia, weight loss may not occur. D. Although the medication decreases intestinal inflammation, it will not cure the colitis. Rationale Prednisone inhibits phagocytosis and suppresses other clinical phenomena of inflammation; this is a symptomatic treatment that is not curative. The medication suppresses the immune response and increases the potential for infection. The response usually is rapid. Appetite is increased; weight gain may result from this or from fluid retention. 3) Which instruction will the nurse include when performing discharge teaching to a client now receiving hydrocortisone by mouth after stabilization of an acute adrenal insufficiency? A. "Eat a diet high in sodium." B. "Take the medication with food." C. "Maintain the same dose indefinitely." D. "Eliminate a dose if side effects occur." Rationale Taking the medication with food minimizes the side effect of gastrointestinal irritation; the health care provider should be notified immediately if abdominal pain or tarry stools occur. The diet should be low in sodium because cortisone can cause fluid retention. The dose may have to be adjusted with health care provider supervision when the client is under physical or emotional stress. Cortisone levels must be maintained; changes in dosage must be supervised by the health care provider. 4) Which information would the nurse provide when administering the first dose of prednisone prescribed to a client with an exacerbation of colitis? A. "Prednisone protects you from getting an infection." B. "The medication may cause weight loss by decreasing your appetite." C. "Prednisone is not curative but does cause a suppression of the inflammatory process." D. "The medication is relatively slow in precipitating a response but is effective in reducing symptoms." Rationale Prednisone inhibits phagocytosis and suppresses other clinical phenomena of inflammation; this is a symptomatic treatment that is not curative. Prednisone suppresses the immune response, which increases the potential for infection. The appetite is increased with prednisone; weight gain may result from the increased appetite or from fluid retention. Generally, the response to prednisone is rapid. 5) Which side effect of prolonged cortisone therapy for adrenal insufficiency would the nurse teach the client and family to expect? Select all that apply. One, some, or all responses may be correct. A. Oliguria B. Anorexia C. Weakness D. Moon face E. Weight gain F. Nervousness Rationale Weakness occurs because of muscle wasting as a result of the catabolic effects of cortisol. Hypokalemia may also cause weakness; potassium is lost in the urine as sodium is retained. Accumulation of adipose tissue occurs in the face (moon face), trunk (truncal obesity), and cervical area (buffalo hump). Weight gain occurs because of increased appetite and fluid retention; 1 liter of fluid is equal to 2.2 pounds (1 kilogram). Cortisone increases sodium and water retention but does not cause oliguria; glucose levels also increase, which, if extreme, will cause polyuria. The appetite usually increases, not decreases. Cortisone increases blood glucose levels, which, if extreme, will cause lethargy, not nervousness. 6) The nurse teaches a client about cortisone therapy. Which statements made by the client indicate the need for further teaching? Select all that apply. One, some, or all responses may be correct. A. 'I should take 3 tablets at a time.' B. 'I should take the tablet twice a week.' C. 'I should take the tablet on an empty stomach.' D. 'I should take the tablet with a meal.' Rationale The client should take the medication as prescribed. The client should not take 3 tablets at a time because this action may lead to drug toxicity. Cortisone therapy involves the administration of 25 to 50 mg of cortisone on a daily basis. Cortisone should be taken with a meal or a snack; taking the medication on an empty stomach would cause gastric irritation. Tablets can be taken with any fluid such as water or fruit juice. 7) A child recovering from a severe asthma attack is given oral prednisone 15 mg twice daily. Which intervention would be a priority for the nurse? A. Having the child rest as much as possible B. Checking the child’s eosinophil count daily C. Preventing exposure of the child to infection E. Offering sips of water when administering the medication Rationale Prednisone reduces the child’s resistance to certain infectious processes and, as an anti-inflammatory medication, masks infection. The child will self-limit activity depending on respiratory status. The eosinophil count is often consistently increased in children with asthma. The child will need adequate hydration to help loosen and expel mucus. 8) The nurse is teaching the parents of a child prescribed a high dose of oral prednisone for asthma. Which information is critical for the nurse to include when teaching about this medication? A. It protects against infection. B. It should be stopped gradually. C. An early growth spurt may occur. D. A moon-shaped face will develop. Rationale Gradual weaning from prednisone is necessary to prevent adrenal insufficiency or adrenal crisis. Prednisone depresses the immune system, thereby increasing susceptibility to infection. The medication usually suppresses growth. A moon face may occur, but it is not a critical, life-threatening side effect. 9) A child with nephrotic syndrome has been receiving prednisone for 1 week. Which information in the child’s record indicates to the nurse that the medication has been effective? Select all that apply. One, some, or all responses may be correct. A. Weight loss B. Lower blood pH C. Decreased lethargy D. Increased urine output E. Decreased blood pressure Rationale Children with nephrotic syndrome are grossly edematous. Those who have the steroid-sensitive form of nephrotic syndrome respond to corticosteroids with diuresis within 7 to 21 days after therapy is started, and the edematous weight is lost. Once the child feels better, lethargy decreases, and the activity level increases. Steroid therapy does not affect the blood pH. There is no increase in the blood pressure of a child with nephrotic syndrome and no change in blood pressure when the child improves. 10) Which complication is an adverse effect of cortisone therapy? A. Hypoglycemia B. Severe anorexia C. Anaphylactic shock D. Behavioral changes Rationale Development of mood swings and psychosis is possible during long-term therapy with glucocorticoids because of fluid and electrolyte alterations. Hypoglycemia, severe anorexia, and anaphylactic shock are not responses to long-term glucocorticoid therapy. 11) A client with rheumatoid arthritis asks the nurse why it is necessary to inject hydrocortisone into the knee joint. Which reason would the nurse include in a response to this question? A. Lubricates the joint B. Reduces inflammation C. Provides physiotherapy D. Prevents ankylosis of the joint Rationale Steroids have an anti-inflammatory effect that can reduce arthritic pannus formation. Injecting hydrocortisone into the joint does not provide lubrication. Injection of a medication into a joint is not physiotherapy. Ankylosis refers to fusion of joints. It is only indirectly influenced by steroids, which exert their major effect on the inflammatory process. 12) Hydrocortisone is prescribed for a client with Addison's disease. Which response is a therapeutic effect of this medication? A. Supports a better response to stress B. Promotes a decrease in blood pressure C. Decreases episodes of shortness of breath D. Controls an excessive loss of potassium Rationale Hydrocortisone is a glucocorticoid that has anti-inflammatory action and aids in metabolism of carbohydrates, fats, and proteins, causing elevation of the blood glucose level. Thus it enables the body to adapt to stress. It may promote fluid retention that results in hypertension and edema. Shortness of breath (dyspnea) is caused by hypovolemia and decreased oxygen supply; neither is affected by hydrocortisone. It may cause potassium depletion. 13) The nurse is caring for a client who is scheduled for a bilateral adrenalectomy. Which medication would the nurse expect to be prescribed for this client? Methimazole Regular insulin Pituitary extract Hydrocortisone Rationale Hydrocortisone is a glucocorticoid. A client undergoing bilateral adrenalectomy must be given adrenocortical hormones so that adjustment to the sudden lack of these hormones that occurs with this surgery can take place Methimazole is used to treat a client with hyperthyroidism, not a client with a bilateral adrenalectomy. Because the surgery involves the adrenal glands, not the pituitary gland, secretion of pituitary hormones will not be affected. Regular insulin is not necessary. Insulin is produced by the pancreas, and its function is not altered by this surgery. 14) Which effect explains the purpose for gradual dosage reduction of glucocorticoids such as dexamethasone? A. Builds glycogen stores in the muscles B. Produces antibodies by the immune system C. Allows the increased intracranial pressure to return to normal D. Promotes return of cortisone production by the adrenal glands Rationale Hormone therapy must be withdrawn slowly to allow the adrenal glands to adjust and resume production of their hormone. Building glycogen stores in the muscles, producing antibodies by the immune system, and allowing the increased intracranial pressure to return to normal are not reasons for the gradual withdrawal of dexamethasone. 15) A client has refused prescribed cortisone. The nurse continues to administer the cortisone while evading the client’s questions. When the client later discovers that cortisone continued to be administered, the client decides to sue the nurse. Which elements must be considered in a legal action? Select all that apply. One, some, or all responses may be correct. A. Clients have a right to refuse treatment. B. Nurses are required to answer clients truthfully. C. The health care provider should have been notified. D. The client had insufficient knowledge to make such a decision. E. Legally prescribed medications are administered despite a client’s objections. Rationale Clients who are mentally competent have the right to refuse treatment; this right takes precedence over the health care provider’s prescription and the nurse must respect this right. A client’s questions must always be answered truthfully. The nurse would explore the client’s reasons for refusal and then notify the health care provider to plan an alternative treatment. A client’s insufficient knowledge is not an acceptable reason for using deliberate deception to administer a treatment that the client has refused. 16) Dexamethasone has been prescribed for a client after a craniotomy for a brain tumor. Which physiological response is responsible for this medication’s therapeutic effect? A. Reduced cell growth B. Reduced cerebral edema C. Increased renal reabsorption D. Increased response to sedation Rationale Dexamethasone is a corticosteroid with anti-inflammatory effects, which will reduce cerebral edema. Dexamethasone will not keep the tumor from growing; it will reduce fluid content and therefore cell size, not the number of cells. Dexamethasone does not promote fluid reabsorption, which is undesirable because it increases fluid retention and therefore cerebral edema. Dexamethasone does not promote sedation; sedation is not desired because it may mask the client’s adaptations to the craniotomy. 17) A female client receiving cortisone therapy for adrenal insufficiency expresses concern that she is developing facial hair. How would the nurse respond? A. 'It is just another sign of adrenal insufficiency.' B. 'This side effect will disappear after therapy.' C. 'This is not important as long as you are feeling better.' D. 'The medication contains a hormone that causes male characteristics.' Rationale Some cortisol derivatives possess 17-keto-steroid (androgenic) properties, which result in hirsutism. Facial hair is not a sign of the illness; it results from androgens that are present in cortisol. Hirsutism will be a long-term problem because therapy is provided on a long-term, usually lifelong, basis. The response 'This is not important as long as you are feeling better' doesn’t address the client’s concerns. 18) A client with systemic lupus erythematosus is taking prednisone. Which foods would the nurse encourage the client to eat while receiving treatment to prevent hypokalemia? A. Broccoli B. Oatmeal C. Fried rice D. Cooked carrots Rationale Potassium is plentiful in green leafy vegetables; broccoli provides 207 mg of potassium per half cup. Oatmeal provides 73 mg of potassium per half cup. Rice provides 29 mg of potassium per half cup. Cooked fresh carrots provide 172 mg of potassium per half cup; canned carrots provide only 93 mg of potassium per half cup. 19) Which side effect would the nurse assess for in a child receiving prednisone? A. Alopecia B. Anorexia C. Weight loss D. Mood changes Rationale Mood swings may result from steroid therapy. Alopecia does not result from steroid therapy. An increased appetite, not anorexia, results from steroid therapy. Weight gain, not weight loss, results from steroid therapy. 20) Which nursing assessment is important for a school-age child undergoing long-term steroid therapy? A. Monitoring pulse for irregularities B. Testing of stools for occult blood C. Inspection of urine for mucous threads D. Check of oral mucous membranes for ulcers Rationale Because steroids decrease production of prostaglandins that have a role in protecting the stomach, gastrointestinal bleeding may occur; stools should be checked for frank and occult blood. Steroids do not cause pulse irregularities, mucus in the urine, or ulceration of mucous membranes. 21) The client who was admitted with exacerbation of ulcerative colitis has developed hyperglycemia. Which medication that the client was prescribed most likely caused this adverse drug effect? A. Dicyclomine B. Acetaminophen C. Prednisone D. Diphenoxylate/atropine Question Explanation Rationale: Prednisone is a corticosteroid, specifically a glucocorticoid. Corticosteroid therapy may be prescribed during exacerbations of ulcerative colitis to decrease inflammation. Common adverse effects include hyperglycemia, osteoporosis, peptic ulcer disease and an increased risk for infection. The nurse should monitor clients who are receiving prednisone for hyperglycemia. Dicyclomine hydrochloride and diphenoxylate with atropine are cholinergic blocking drugs prescribed for gas (flatus) and diarrhea, commonly seen with ulcerative colitis. Acetaminophen is a non-narcotic analgesic given for mild-to-moderate pain. None of those drugs are known to cause an elevated blood sugar. 22) The nurse is preparing a client with rheumatoid arthritis (RA) for discharge to an assisted living facility. Which statement about the prescribed oral glucocorticoid is correct? A. "The medication will reverse the joint deterioration of RA." B. "You will be taking the medication for several years." C. "It is normal to experience some memory loss or hallucinations." D. "The medication will be gradually tapered off over 5 to 7 days." Question Explanation Rationale: RA is an autoimmune, inflammatory disease that affects the joints. It is a progressive disease that causes joint deterioration and destruction, joint deformities and functional limitations for affected clients. The main goal of pharmacotherapy for RA is symptom relief. Glucocorticoids are anti-inflammatory drugs, which can relieve symptoms of RA and may also delay disease progression. For generalized symptoms related to RA, oral glucocorticoids are indicated. The most commonly employed oral glucocorticoids are prednisone and prednisolone. Glucocorticoids can slow disease progression, but will not reverse it. Treatment with glucocorticoids for RA is usually limited to short courses. Adverse psychological reactions such as hallucinations, memory loss or other psychoses must be reported to the provider and may require discontinuation of the glucocorticoid. To minimize adrenal insufficiency when glucocorticoids are discontinued, doses should be tapered very gradually. 23) A child is prescribed fluticasone after an acute asthma attack. Which instruction would the nurse give the family about the administration of this medication? A. 'Fluticasone needs to be taken with food or milk.' B. 'Fluticasone is primarily used to treat acute asthma attacks.' C. 'The child should suck on hard candy to help relieve dry mouth.' D. 'Watch for white patches in the mouth and report to the health care provider.' Rationale Fluticasone is a steroid commonly administered by way of inhalation for long-term control of asthma symptoms. Oral thrush is a side effect that manifests as white patches. Fluticasone is administered via inhalation so food or milk is not needed before administration. Dry mouth is not a side effect of fluticasone. 24) A health care provider prescribes dexamethasone for a client with head trauma. The nurse recognizes that it reduces swelling in the brain by which process? A. Acts as a hyperosmotic diuretic B. Increases resistance to infection C. Reduces the inflammatory response of tissues D. Decreases the formation of cerebrospinal fluid Rationale Corticosteroids act to decrease inflammation, which decreases edema. Dexamethasone is an anti-inflammatory agent, not a diuretic. Resistance to infection is decreased, not increased, with a corticosteroid. The client’s problem is not with increased cerebrospinal fluid. 25) A client is receiving dexamethasone to treat acute exacerbation of asthma. For which side effect would the nurse monitor the client? A. Hyperkalemia B. Liver dysfunction C. Orthostatic hypotension D. Increased blood glucose Rationale Dexamethasone increases gluconeogenesis, which may cause hyperglycemia. Hypokalemia, not hyperkalemia, is a side effect. Liver dysfunction is not a side effect. Hypertension, not hypotension, is a side effect. 26) A beclomethasone inhaler would be prescribed for which purpose? A. Prevents atelectasis B. Decreases inflammation C. Relaxes smooth muscle in the airways D. Reduces bacteria in the respiratory tract Rationale Beclomethasone reduces the inflammatory response in bronchial walls by suppression of polymorphonuclear leukocytes and fibroblasts and the reversal of capillary permeability. Beclomethasone does not prevent atelectasis. Beclomethasone does not cause smooth muscle relaxation in the airways. Beclomethasone is not an antibiotic. 27) When a client is receiving dexamethasone for adrenocortical insufficiency, which action would the nurse take to monitor for an adverse effect of the medication? A. Auscultate for bowel sounds. B. Assess deep tendon reflexes. C. Culture respiratory secretions. D. Measure blood glucose levels. Rationale Corticosteroids, such as dexamethasone, have a hyperglycemic effect, and blood glucose levels should be monitored routinely. Assessing bowel sounds is unnecessary; corticosteroids are not known to precipitate cessation of gastrointestinal activity. Although corticosteroids may increase the risk of developing an infection, routine culturing of respiratory secretions is unnecessary. Culturing respiratory secretions becomes necessary when the client exhibits adaptations of a respiratory infection. Monitoring deep tendon reflexes is required when administering magnesium sulfate, not dexamethasone. 28) Which action would the nurse perform when administering fluticasone propionate to a client with asthma? Select all that apply. One, some, or all responses may be correct. A. Assessing heart rate and rhythm B. Monitoring liver function blood tests C. Rinsing the oral cavity with water after use D. Obtaining blood glucose levels before meals E. Giving stool softeners to prevent constipation Rationale Clients using inhaled glucocorticoids are at an increased risk for oral candidiasis. The nurse would instruct the client to rinse the mouth with water after using the inhaler. The nurse would monitor heart rate and pattern in clients taking beta 2 agonists such as albuterol, which can lead to tachydysrhythmias. Liver function is monitored in clients taking leukotrienes such as zileuton. Blood glucose monitoring is necessary for clients taking oral and intravenous glucocorticoids. Stool softeners are given to clients taking tiotropium because of the medication’s anticholinergic side effect of constipation. 29) The nurse admits a client with tumor-induced spinal cord compression. Which medication should the nurse anticipate to be prescribed to offer the best palliative treatment for this client? A. Morphine sulfate. B. Ibuprofen. C. Amitriptyline. D. Dexamethasone. Rationale Dexamethasone is a palliative treatment modality to manage symptoms related to compression due to tumor growth. Morphine sulphate is an opioid analgesic used in oncology to manage severe or intractable pain. Ibuprofen, a nonsteroidal antiinflammatory drug (NSAID), provides relief for mild to moderate pain, suppression of inflammation, and reduction of fever. Amitriptyline, a tricyclic antidepressant, is often prescribed for pain related to neuropathic origin and provides a reduction in opioid dosage. 30) The nurse is educating a client on self-administration of a fluticasone inhaler. What statement indicates an understanding of the teaching? A. I will rinse my mouth with water after using the inhaler B. Disinfectant wipes can be used to clean the spacer C. I need to wait 15 minutes between puffs D. This inhaler should be used before the others Rationale: To prevent thrush, the client should rinse his or her mouth with water and spit it out. The spacer should be washed with warm water and dish detergent. The client may need two puffs but does not have to wait 15 minutes between. Bronchodilators should be used before corticosteroids. 31) A nurse is teaching a client with asthma about the correct use of the fluticasone inhaler. Which statement, if made by the client, would indicate that the teaching was effective? A. "The inhaler can be used when I feel short of breath." B. "If I forget a dose, I will double the next dose." C. "I should rinse my mouth after using the inhaler." D. "I should not use a spacer with my inhaler." Rationale: Fluticasone is an inhaled corticosteroid used to prevent asthma attacks. After using the inhaler, the client should rinse away any residue in the mouth to reduce the risk of an oral fungal infection. Fluticasone is not a bronchodilator and should not be used as needed for shortness of breath. The client should not double the dose of this medication and should use a spacer with this inhaler. 32) The nurse is providing discharge education to a client newly diagnosed with chronic obstructive pulmonary disease. The client is prescribed the diskus inhaler fluticasone propionate and salmeterol. The client asks, "How will I know when the inhaler is empty?" How should the nurse respond? A. Shake the canister to detect any fluid movement B. The number of doses that remain will be on the inhaler C. Drop the canister in water to observe floating D. Estimate how many doses are usually in the canister Rationale: There are several methods to monitoring the contents of an inhaler. New MDIs such as diskus inhalers often have counters on them. The counters record the number of doses left in the canister. If the MDI does not have this feature, the client should write the date a refill is needed. This can be done directly on the canister in a permanent marker. Manufacturers do not recommend floating inhalers. The shaking or estimation method will not be accurate. 33) Which symptom would the nurse expect to decrease in response to corticosteroid therapy prescribed for a client with multiple sclerosis? A. Emotional lability B. Muscular contractions C. Pain in the extremities D. Visual impairment Rationale Corticosteroids decrease the inflammatory process around the optic nerve, thus improving vision; visual impairment is the most common physiological manifestation of multiple sclerosis. Steroids are associated with increased emotional lability. Steroids are not effective in easing muscle contractions. Pain in the extremities is not common unless spasms are present; steroids do not relieve spasms. 34) Which statement regarding mealtime administration by a client who has arthritis and is prescribed corticosteroid medication indicates that the teaching was effective? A. "This will decrease gastric irritation." B. "This will serve as a reminder to take the medication." C. "The presence of food will enhance absorption." D. "The medication is ineffective in an acid medium." Rationale The presence of food limits the irritating effect of steroids on the gastric mucosa. Taking the medication at mealtime may help the client remember to take the medication, but it is not the reason for taking it with meals. Food does not increase or decrease absorption of steroids. The medication is not affected by an acid environment. 35) Which times for the medication schedule would a nurse teach when corticosteroid therapy is prescribed for a client with an exacerbation of ulcerative colitis? A. At bedtime with a snack B. Three times a day with meals C. In the early morning with food D. One hour before or 2 hours after eating Rationale Taking the medication in the early morning mimics usual adrenal secretions; food helps reduce gastric irritation. Diurnal rhythms may be altered, and steroids are ulcerogenic; they should be taken with more than just a snack. Steroids cause gastric irritation and should be taken with food. Although food helps decrease gastric irritation, dividing the dose and taking it throughout the day may alter regular diurnal rhythms; it should be taken in the early morning with food. 36) Which action is the primary purpose of a topical steroid application to a basal cell carcinoma surgical site? A. Preventing infection of the wound B. Increasing fluid loss from the skin C. Reducing inflammation at the surgical site D. Limiting itching around the area of the lesion Rationale Steroids are used for their anti-inflammatory, vasoconstrictive, and antipruritic effects. Steroids increase the incidence of infections because they are anti-inflammatory agents and mask the symptoms of infection. Steroids increase fluid retention because they promote the reabsorption of sodium from the tubular fluid into the plasma. Although steroid ointments have an antipruritic effect, their major purpose after surgery is their systemic anti-inflammatory effect. 37) Which intervention would the nurse anticipate providing teaching on when a client presents with extensive lesions caused by psoriasis? A. Advising sunscreen and special clothing B. Topical application of steroids C. Potassium permanganate baths D. Débridement of necrotic plaques Rationale Steroids are applied locally, and the lesions usually are covered with plastic wrap at night to reverse the inflammatory process. Solar rays may be used for treatment, but other forms of ultraviolet light are preferred. Potassium permanganate is an antiseptic astringent used on infected, draining, or vesicular lesions. The plaques are not necrotic and do not require débriding. 38) Which action will a nurse take when a male client receiving prolonged steroid therapy complains of always being thirsty and urinating frequently? A. Have the client assessed for an enlarged prostate. B. Obtain a urine specimen from the client to test for ketonuria. C. Perform a finger stick to test the client’s blood glucose level. D. Assess the client’s lower extremities for the presence of pitting edema. Rationale The client has signs of an increased serum glucose level, which may result from steroid therapy; testing the blood glucose level is a method of gathering more data. The symptoms are not those of benign prostatic hyperplasia. The blood glucose level, not the amount of ketones in the urine, should be assessed. The symptoms presented are not those of fluid retention but of hyperglycemia. 39) A 6-year-old child with asthma is prescribed an inhaled corticosteroid. The nurse would conclude the mother understands teaching about the medication side effects when the mother makes which statement? A. 'I’ll watch for frequent urination.' B. 'I’ll check for white patches in the mouth.' C. 'I’ll be alert for short episodes of not breathing.' D. 'I’ll monitor for an increased blood glucose level.' Rationale Oral candidiasis is a potential side effect of inhaled steroids because of steroids’ anti-inflammatory effect; the child should be taught to rinse the mouth after each inhalation. Frequent urination is not a side effect of steroid therapy. Apneic episodes are not a side effect of steroid therapy. Hyperglycemia is not a side effect of inhaled steroid therapy; it may occur when steroids are administered for a systemic effect. 40) A child who has nephrotic syndrome is prescribed steroid therapy. Which explanation would the nurse give the parents regarding the goal of this treatment? A. Prevents infection B. Stimulates diuresis C. Provides hemopoiesis D. Reduces blood pressure Rationale Although the exact mechanism is unknown, steroids produce diuresis in most children with nephrotic syndrome. Steroids will not prevent infection and will mask the signs and symptoms of infection. Steroids have no effect on the production of red blood cells. Steroids do not reduce hypertension, and hypertension is not a common finding in children with nephrotic syndrome. 41) A child undergoing prolonged steroid therapy takes on a cushingoid appearance. The nurse would expect to find which of these manifestations during further assessment? Select all that apply. One, some, or all responses may be correct. A. Truncal obesity B. Thin extremities C. Increased linear growth D. Loss of hair on the body E. Decreased blood pressure Rationale An increase in appetite results in deposition of fat on the abdomen and trunk. Muscle wasting results in thin extremities. Increased excretion of calcium causes retardation of linear growth and a resulting short stature. Because of the excess production of androgens, virilization and hirsutism occur. Increased salt and water retention cause hypertension and hypernatremia. 42) A client with myasthenia gravis is to receive immunosuppressive therapy with corticosteroids. Which mechanism of action assures the nurse that this therapy will be effective? A. Inhibits the breakdown of acetylcholine at the neuromuscular junction B. Stimulates the production of acetylcholine at the neuromuscular junction C. Decreases the production of autoantibodies that attack acetylcholine receptors D. Promotes the removal of autoantibodies that impair the transmission of impulses Rationale Steroids decrease the body’s immune response, limiting the production of antibodies that attack acetylcholine receptors at the neuromuscular junction. Inhibiting the breakdown of acetylcholine at the neuromuscular junction is the action of anticholinergic medications. Stimulating the production of acetylcholine at the neuromuscular junction is not the action of immunosuppressives. Promoting the removal of autoantibodies that impair the transmission of impulses is the rationale for plasmapheresis. 43) A client is scheduled for a craniotomy to remove a brain tumor. To prevent the development of cerebral edema after surgery, the nurse anticipates the use of medications from which class? A. Glucocorticoids B. Anticholinergics C. Anticonvulsants D. Antihypertensives Rationale Glucocorticoids are used for their anti-inflammatory action, which decreases the development of cerebral edema. Anticholinergics are not used to prevent cerebral edema. Anticonvulsants prevent seizure activity, not cerebral edema. Antihypertensives control hypertension, not cerebral edema. 44) Long-term corticosteroid therapy has been initiated for a client with myasthenia gravis who experiences inadequate symptomatic control with pyridostigmine bromide. Which action is important for the nurse to take? A. Request a high-sodium diet. B. Establish protective isolation. C. Decrease the client’s total daily fluid intake. D. Monitor the client for an exacerbation of symptoms. Rationale Exacerbation of myasthenia gravis may occur temporarily at the beginning of steroid therapy, causing respiratory embarrassment and dysphagia. Increasing sodium intake is contraindicated because corticosteroids increase sodium retention. Although clients should avoid contact with persons who have upper respiratory infections, protective isolation (neutropenic precautions) is not required. Decreasing total daily fluid intake is unnecessary; adequate fluid intake should be maintained. 45) A client receiving corticosteroid therapy states, 'I have difficulty controlling my temper, which is so unlike me, and I don’t know why this is happening.' How will the nurse respond? A. Tell the client it is nothing to worry about. B. Reassure that everyone does this at times. C. Instruct the client to attempt to avoid situations that cause irritation. D. Inquire about mood swings. Rationale Corticosteroids increase the excitability of the central nervous system, which can cause labile emotions manifested as euphoria and excitability or depression. Telling the client it is nothing to worry about or that it is normal denies the value of the client’s statement and offers false reassurance. The client has already stated the problem and does not know why this is happening. Instructing the client to attempt to avoid situations that cause irritation is impractical because the mood swings may occur without an overt cause. 46) A client who recently started receiving oral corticosteroids for a severe allergic reaction is instructed that the dosage will be reduced gradually until all medication is stopped at the end of 2 weeks. Which reason would the nurse provide for this gradual reduction in dosage? A. Discontinuing the medication too fast will cause the allergic reaction to reappear. B. Slow reduction of the medication will prevent a physiological crisis because the adrenal glands are suppressed. C. The health care provider is attempting to determine the minimal dose that will be effective for the allergy. D. Sudden cessation of the medication will cause development of serious side effects, such as moon face and fluid retention. Rationale The body’s natural corticosteroid production has been suppressed during treatment; avoiding abrupt cessation of the medication will give the body time to adjust to less and less of the exogenous source and to resume secretion of endogenous corticosteroid. Not completing the course of therapy, rather than stopping it quickly, may cause signs and symptoms of the allergy to recur. The health care provider has already determined the correct dosage, and it has been prescribed. Moon face and fluid retention are associated with long-term steroid use, not with the cessation of therapy. 47) A client is admitted to the hospital for an adrenalectomy. Before the client’s replacement steroid therapy is regulated fully, the nurse will monitor the client for which complication? A. Hypotension B. Hypokalemia C. Hypernatremia D. Hyperglycemia Rationale Because of instability of the vascular system and the lability of circulating adrenal hormones after an adrenalectomy, hypotension frequently occurs until the hormonal level is controlled by replacement therapy. Hyperglycemia is a sign of excessive adrenal hormones; after an adrenalectomy, adrenal hormones are not secreted. Sodium retention is a sign of hyperadrenalism; it does not occur after the adrenals are removed. Potassium excretion is a response to excessive adrenal hormones; after an adrenalectomy, adrenal hormones are decreased until replacement therapy is regulated. 48) A client who is on long-term corticosteroid therapy after an adrenalectomy is admitted to the surgical intensive care unit after being involved in a motor vehicle crash. Which statement is an important concern for client safety? A. The dosage of steroids will have to be tapered down slowly to prevent acute adrenal crisis. B. Steroid therapy will need to be increased to avert a life-threatening crisis. C. Osteoporosis secondary to long-term corticosteroids increases fracture risk. D. The client is at risk for Cushing syndrome if taking long-term corticosteroid therapy. Rationale Clients with adrenocorticoid insufficiency who are receiving steroid therapy require increased amounts of medication during periods of stress because they are unable to produce the excess needed by the body. With severe stress, a failure to ensure adequate corticosteroid levels can be life-threatening. Increased stress requires an increase, not a decrease, in glucocorticoids. Although osteoporosis may have contributed to fractures secondary to trauma, this does not present a current risk. Cushing syndrome is a problem with excess corticosteroid therapy, but after an adrenalectomy, the corticosteroid is given in amounts sufficient to replace what the body cannot produce. 49) Immediately after a bilateral adrenalectomy, a client is receiving corticosteroids that are to be continued after discharge from the hospital. Which statement by the client indicates to the nurse that additional education is needed? A. 'I need to have periodic tests of my blood for glucose.' B. 'I am glad that I only have to take the medication once a day.' C. 'I must take the medicine with meals.' D. 'I should tell my health care provider if I am overly restless or have trouble sleeping.' Rationale Usually a larger dose is given at 8:00 AM and the second dose is given before 4:00 PM to mimic expected hormonal secretion and prevent insomnia. Having periodic blood tests for glucose is necessary because long-term administration of steroids leads to elevated blood glucose levels and possible steroid-induced diabetes. Oral corticosteroids should be taken with food or antacids to prevent gastric irritation and gastric hemorrhage. Neurological and emotional side effects, such as euphoria, mood swings, and sleeplessness, are expected. 50) Which information from the client’s history would the nurse identify as a risk factor for developing osteoporosis? A. Takes estrogen therapy B. Receives long-term steroid therapy C. Has a history of hypoparathyroidism D. Engages in strenuous physical activity Rationale Increased levels of steroids will accelerate bone demineralization. Hyperparathyroidism, not hypoparathyroidism, accelerates bone demineralization. Weight-bearing that occurs with strenuous activity promotes bone integrity by preventing bone demineralization. Estrogen promotes deposition of calcium into bone which may prevent, not cause, osteoporosis. Test-Taking Tip: Multiple-choice questions can be challenging, because students think that they will recognize the right answer when they see it or that the right answer will somehow stand out from the other choices. This is a dangerous misconception. The more carefully the question is constructed, the more each of the choices will seem like the correct response. 51) A client with rheumatoid arthritis has been taking a corticosteroid medication for the past year. Prolonged use of corticosteroids puts this client at increased risk for which complication? A. Decreased white blood cells B. Increased C-reactive protein C. Increased sedimentation rate D. Decreased serum glucose levels Rationale Prolonged use of steroids may cause leukopenia as a result of bone marrow depression. C-reactive protein and sedimentation rate are elevated in acute inflammatory diseases; steroids help decrease them. Serum glucose levels increase with steroid use. 52) A client is scheduled for an adrenalectomy. Which action would the nurse expect in the plan of care? A. Provide a low-protein diet. B. Administer parenteral corticosteroids. C. Collect a preoperative 24-hour urine specimen. D. Withhold all medications 48 hours before surgery. Rationale Steroid therapy usually is given intravenously or intramuscularly preoperatively and continued intraoperatively to prepare for the acute adrenal insufficiency that follows surgery. The diet must supply ample protein and potassium. A 24-hour urine specimen is unnecessary. Corticosteroids must be administered preoperatively to prevent adrenal insufficiency during surgery, so withholding all medications for 48 hours before surgery is contraindicated. 53) A client is scheduled for a bilateral adrenalectomy. Which rationale describes why steroids are administered to the client? A. To foster accumulation of glycogen in the liver B. To increase the inflammatory action to promote healing C. To facilitate urinary excretion of salt and water after surgery D. To compensate for sudden lack of these hormones after surgery Rationale Adrenal steroids help an individual adjust to stress. Unless received from external sources, there is no hormone available to cope with surgical stresses after an adrenalectomy. Glucose stores (glycogen) will be used by the body to adapt to surgery. Insulin is the hormone that facilitates conversion of glucose to glycogen. Steroids do not increase inflammatory reactions. Steroids will result in fluid retention, not loss. 54) A client is admitted to the hospital for an adrenalectomy. When teaching the client about the prescribed medications, which advice will the nurse emphasize? A. Medication therapy will be given in conjunction with insulin. B. Once regulated, the dosage will remain the same for life. C. Medications will need to be held for surgery or other invasive procedures. D. Salt intake may have to be restricted. Rationale Administration of adrenocortical hormones causes sodium retention; dietary intake of salt should be limited. Because pancreatic function is unimpaired, insulin therapy is not indicated. Dosages will likely need to be adjusted over time. The dosage will need to be increased for surgery and severe infections; not doing this can cause a life-threatening crisis. 55) A male client receiving prolonged steroid therapy complains of always being thirsty and urinating frequently. Which is the nurse’s initial action? A. Have the client assessed for an enlarged prostate. B. Obtain a urine specimen from the client to test for ketonuria. C. Perform a finger stick to test the client’s blood glucose level. D. Assess the client’s lower extremities for the presence of pitting edema. Rationale The client has signs of an increased serum glucose level, which may result from steroid therapy; testing the blood glucose level is a method of gathering more data. The symptoms are not those of benign prostatic hyperplasia. The blood glucose level, not the amount of ketones in the urine, should be assessed. The symptoms presented are not those of fluid retention but of hyperglycemia. 56) A client presents with extensive lesions caused by psoriasis. Which intervention would the nurse anticipate providing teaching on? A. Advising sunscreen and special clothing B. Topical application of steroids C. Potassium permanganate baths D. Débridement of necrotic plaques Rationale Steroids are applied locally, and the lesions usually are covered with plastic wrap at night to reverse the inflammatory process. Solar rays may be used for treatment, but other forms of ultraviolet light are preferred. Potassium permanganate is an antiseptic astringent used on infected, draining, or vesicular lesions. The plaques are not necrotic and do not require débriding. 57) The nurse provides client teaching on the administration of a topical steroid application to a basal cell carcinoma surgical site. The nurse evaluates the teaching as effective when the client identifies which action as the primary purpose of the medication? A. Preventing infection of the wound B. Increasing fluid loss from the skin C. Reducing inflammation at the surgical site D. Limiting itching around the area of the lesion Rationale Steroids are used for their anti-inflammatory, vasoconstrictive, and antipruritic effects. Steroids increase the incidence of infections because they are anti-inflammatory agents and mask the symptoms of infection. Steroids increase fluid retention because they promote the reabsorption of sodium from the tubular fluid into the plasma. Although steroid ointments have an antipruritic effect, their major purpose after surgery is their systemic anti-inflammatory effect. 58) A pediatric client is prescribed an intravenous infusion of methylprednisolone. Which clinical manifestation requires immediate intervention during administration of the initial dose? A. Polyuria B. Tinnitus C. Drowsiness D. Hypotension Rationale Intravenous administration of a steroid can cause a rapid increase in the blood glucose level. One early sign of hyperglycemia is increased urine output. Blood glucose should be checked frequently, and insulin administered as needed. Tinnitus is associated with some antibiotics and with aspirin, not steroids. Drowsiness is associated with sedatives, not steroids. Hypertension, not hypotension, is associated with steroid administration. 59) A client is receiving methylprednisolone 40 mg IV daily. The nurse should monitor which laboratory value closely? A. Serum glucose. B. Serum calcium. C. Red blood cells. D. Serum potassium. Methylprednisolone is a corticosteroid with glucocorticoid and mineralocorticoid actions. These effects can lead to hyperglycemia (must monitor closely), which is reflected as an increase in the serum glucose value. The client taking methylprednisolone is also at risk for hypocalcemia and hypokalemia (but not severely). These medications also alter the some of the body's immune responses by suppressing the migration of white blood cells decreasing inflammation response. 60) The nurse is teaching a client about newly prescribed inhaled budesonide. The nurse should teach the client to report which finding to the healthcare provider? A. Rounded face B. Bradycardia C. Increased thirst D. Cough Rationale: Respiratory disorders, such as asthma, status asthmatic, chronic obstructive pulmonary disease (COPD), and rhinitis, may all be treated with corticosteroids, including budesonide. Corticosteroids have many common side effects including cushingoid features, such as “moon face” due to redistribution of fat. Fluid retention is also common when using corticosteroids. Increased thirst may be an indication of hyperglycemia and should be reported. Corticosteroids can increase heart rate. A cough is normal with corticosteroids as the airway is dilated. 61) A client is started on long-term corticosteroid therapy for an autoimmune disorder. Which statement by the client indicates the need for more teaching by the nurse? A. "For 1 week each month I will stop taking the medication." B. "I will keep a record of my weight each week." C. "The medication needs to be taken with food." D. "I will be sure to eat foods that are high in potassium." Rationale: Corticosteroids should never be stopped abruptly, they should always be weaned. To suddenly stop this medication may result in a sudden drop in the blood pressure from a loss in fluid volume associated with adrenal crisis. Clients should be warned not to abruptly stop taking the medication. Corticosteroids can lower the amount of potassium in the body so the client should eat more potassium rich foods. Weight gain is an expected effect of corticosteroid therapy. Clients should regularly keep track of their weight. Generally, corticosteroid medications are taken with breakfast. 62) The client has been treated with long-term glucocorticoid therapy. While completing the physical assessment, which finding should the nurse expect? A. Jaundice B. Peripheral edema C. Buffalo hump D. Increased muscle mass Rationale: The most common side effects of glucocorticoid therapy include increased appetite including weight gain, increased blood glucose, acne, thinning of the skin, easy bruising and change in body shape (increase in fatty tissue on the trunk with thinner legs and arms). The client may also develop a hump behind the shoulders due to the accumulation of fat on the back of the neck. This is referred to as a buffalo hump. Jaundice, peripheral edema and increased muscle mass are not side effects of glucocorticoid therapy. 63) Which increased risk would the nurse consider when assessing a client with diabetes who is receiving long-term corticosteroid therapy and is admitted with leg ulcers? A. Weight loss B. Hypoglycemia C. Decreased blood pressure D. Inadequate wound healing Rationale Because the anti-inflammatory response is depressed as a result of increased cortisol levels, the wounds of clients receiving long-term corticosteroid therapy tend to heal slowly. A common finding associated with long-term corticosteroid use is weight gain, caused not only by fluid retention but also by alterations in fat, carbohydrate, and protein metabolism. Persistent hyperglycemia (steroid diabetes) occurs because of altered glucose metabolism. Hypertension, not hypotension, occurs as a result of sodium and fluid retention. 64) Which outcome would the nurse expect when caring for a child receiving adrenocorticosteroid therapy? A. Accelerated wound healing B. Development of hyperkalemia C. Increased antibody production D. Suppressed inflammatory process Rationale Because of the suppression of the inflammatory process, the nurse must be alert to the subtle symptoms of infection, such as changes in appetite, sleep patterns, and behavior. Adrenocorticosteroid therapy delays (not accelerates) wound healing. Adrenocorticosteroid therapy may cause hypokalemia, not hyperkalemia, because of the accompanying retention of sodium and fluid. Adrenocorticosteroid therapy decreases (not increases) the production of antibodies. 65) The nurse is caring for a child undergoing chemotherapy for acute lymphoid leukemia. The parents ask why the child needs prednisone. Which response by the nurse would be correct? A. 'It decreases inflammation.' B. 'It suppresses the production of lymphocytes.' C. 'It increases appetite and a sense of well-being.' D. 'It may decrease skin irritation and edema.' Rationale Prednisone is a synthetic glucocorticoid that exerts an active anti-inflammatory effect by stabilizing lysosomal membranes, thereby inhibiting proteolytic enzyme release. Prednisone does not affect the lymphocytes. Although prednisone increases the appetite and creates a sense of well-being, these are not the reasons it is administered. There is no indication the child is receiving radiation. 66) The nurse is caring for a child receiving prednisone. Which consideration is most important for the nurse to remember when administering adrenocorticosteroid therapy? A. It suppresses inflammation. B. It may produce hyperkalemia. C. Wound healing is accelerated. D. Antibody production increases. Rationale Because of suppression of the inflammatory manifestations of infection, such as increase in body temperature, the nurse must be alert to the subtle signs and symptoms of infection (e.g., changes in appetite, sleep patterns, and behavior). Adrenocorticosteroid therapy may cause hypokalemia, not hyperkalemia, because of the retention of sodium and fluid. Adrenocorticosteroid therapy delays, not accelerates, wound healing. Adrenocorticosteroid therapy decreases, not increases, the production of antibodies. Diphenhydramine “Crazy Ben…benadryl”, cetirizine, loratadine, hydroxyzine ; “All Rhyme with Anti-Histamine” x 8 1) The nurse is monitoring an older adult client prescribed diphenhydramine for contact dermatitis related to poison ivy exposure. Which finding should be reported to the provider as a potential drug-related side effect? A. Confusion B. Hypertension C. Incontinence D. Bradypnea Rationale: Diphenhydramine and other first-generation H1 receptor antagonists may cause confusion (with impaired thinking, judgment, and memory), dizziness, hypotension, sedation, syncope, unsteady gait, and paradoxical central nervous system stimulation in older adults. Older adults may experience urinary retention, especially those with prostatic hypertrophy. Some of these adverse reactions derive from the anticholinergic effects of the drugs and are likely to be more severe if the patient is also taking other drugs with anticholinergic effects. Diphenhydramine is sometimes prescribed as a sleep aid for occasional use in older adults. As with many other drugs, smaller-than-usual dosages are indicated. 2) A nurse notes an abrupt onset of confusion in an 85-year-old client. Which newly prescribed medication most likely caused this change in the client's mental status? A. Warfarin B. Metoprolol C. Pantoprazole D. Diphenhydramine Question Explanation Rationale: Older adults are susceptible to the side effect of anticholinergic medications, such as antihistamines. Diphenhydramine is a first-generation histamine blocker. Older antihistamines often cause confusion, especially at higher doses. In fact, first-generation antihistamines are included in the Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. Metoprolol (a beta blocker), pantoprazole (a proton pump inhibitor) and warfarin (an anticoagulant) are not known to cause mental status changes. 3) The nurse is evaluating the plan of care for a client with benign prostatic hyperplasia (BPH). For which prescribed medication should the nurse notify the health care provider (HCP)? A. Diphenhydramine B. Finasteride C. Terazosin D. Metoprolol Question Explanation Rationale: Diphenhydramine is a first generation histamine1 receptor antagonist or antihistamine, commonly used for relief from symptoms of mild to moderate allergic disorders. H1 blockers have anticholinergic effects or atropine-like responses and can cause urinary hesitancy or retention. A client with BPH is already at risk for urinary retention and should not receive an antihistamine such as diphenhydramine without clarification from the HCP first. Metoprolol is a beta blocker, which does not affect the bladder. Finasteride and terazosin are drugs commonly used to treat BPH. 4) The nurse is caring for a client with a sore throat who developed urticaria after the administration of prescribed antibiotics. The client is now receiving cetirizine. Which finding indicates that the cetirizine is having the intended effect? A. The client reports less itching. B. The tonsils are decreasing in size. C. The client reports less muffled hearing. D. The pain rating is decreased. Rationale: Cetirizine is a second-generation H1 receptor antagonist (antihistamine). Cetirizine binds preferentially to peripheral rather than central H1 receptors. This selectivity reduces the occurrence of drowsiness and CNS depression. Second-generation antihistamines are now commonly used to treat pruritis in urticaria. Almost any drug can lead to an allergic response, especially in the case of sore throats, which can be mononucleosis misdiagnosed as strep throat. A characteristic of infectious mononucleosis is that up to 90 percent of the time that amoxicillin or ampicillin is taken, a rash then develops. The pattern of the rash is commonly maculopapular in appearance. It is very itchy. 5) An adolescent prescribed loratadine 10 mg daily for hay fever is concerned the medication will cause drowsiness during the school day. Which action would the school nurse take? A. Explain this medication rarely causes drowsiness. B. Advise to take half a tablet in the morning before school. C. Suggest skipping the next day’s dose if hay fever is better. D. Recommend contacting the allergist for a prescription containing a stimulant. Rationale Loratadine causes little or no drowsiness or anticholinergic side effects. Even if the medication did cause drowsiness, the nurse does not have the legal authority to alter the prescribed dose. It is not necessary to call the allergist because loratadine rarely causes drowsiness. 6) An adolescent with hay fever has been taking a prescribed first-generation antihistamine every 8 hours for the past 2 days. The adolescent tells the nurse, 'This medicine is making me sleepy.' Which response by the nurse would be most appropriate? A. 'Take half a tablet before school.' B. 'Try omitting the early morning dose.' C. 'The drowsiness usually decreases after several days.' D. 'I’ll write your teacher a note to explain your inability to concentrate in class while taking this medicine.' Rationale Telling the adolescent that the drowsiness will likely disappear after a few days addresses the adolescent’s concern; central nervous system depressant effects may diminish or spontaneously disappear after several days of therapy; however, if this does not occur, a second-generation antihistamine may be warranted. Nurses do not have the legal authority to instruct a client to alter the dosage of a prescribed medication. The side effect of drowsiness often diminishes within several days, so it would be inappropriate to write a note that addresses the duration of treatment until it is determined that this will be a problem. 7) The nurse is administering hydroxyzine to a client. The nurse would monitor the client for which side effect of this medication? A. Ataxia B. Drowsiness C. Vertigo D. Slurred speech Rationale Hydroxyzine suppresses activity in key regions of the subcortical area of the central nervous system; it also has antihistaminic and anticholinergic effects. Ataxia, vertigo and slurred speech are not associated with hydroxyzine. 8) The nurse is caring for an 83-year-old client who is experiencing a sudden onset of confusion. Which medication most likely contributed to this change? A. Cardiac glycoside B. Anticoagulant C. Liquid antacid D. Antihistamine Rationale: Older adults are more susceptible to the side effects of anticholinergic medications, such as antihistamines. Antihistamines often cause confusion in the older adult, especially at high doses. Cardiac glycosides, anticoagulants and antacids are not associated with confusion or mental status changes in the older adult. “Anti-Homer fights drippy Noses;” pseudoephedrine, phenylephrine, oxymetazoline x 3 1) The nurse is collecting the health history of a client who reports taking over-the-counter pseudoephedrine for nasal congestion. Which statement by the client would require follow-up by the nurse? A. I take this medication at night before I go to bed B. I have to use a normal saline nasal spray since I started this medication C. I avoid drinking beverages with caffeine while taking the medication D. I chew gum when I take this medication to help with my dry mouth Rationale: Pseudoephedrine is a nasal decongestion that causes vasoconstriction in the respiratory mucosa and bronchodilatation making it easier for the client to breathe. The medication is a stimulant, so clients should avoid taking the medication before bed to prevent insomnia. The use of caffeine will exacerbate the alpha-adrenergic effect of this drug. Chewing gum helps alleviate dry mouth that accompanies respiratory mucosa constriction that occurs when taking this medication. This medication can dry mucus membranes, so clients may use a normal saline nasal spray. 2) An adolescent is prescribed phenylephrine nasal spray. The nurse would determine teaching has been effective when the adolescent identifies which complication that may occur if the spray is used more frequently or longer than recommended? A. Tinnitus B. Nasal polyps C. Bleeding tendencies D. Increased nasal congestion Rationale Frequent and continued use of phenylephrine can cause rebound congestion of mucous membranes. Tinnitus is not a side effect of phenylephrine nasal spray; however, hypotension, tachycardia, and tingling of the extremities may occur. Nasal polyps may be associated with allergies but are unrelated to phenylephrine nasal spray. Bleeding tendencies are unrelated to the use of phenylephrine nasal spray. 3) Which effect would the nurse assess a teenager for if more than the recommended dose of oxymetazoline nasal spray is taken? A. Nasal polyps B. Ringing in the ears C. Bleeding tendencies D. Increased nasal congestion Rationale With frequent and continued use, oxymetazoline can cause rebound congestion of mucous membranes. Nasal polyps may be associated with allergies but are unrelated to nasal spray use. Ringing in the ears (tinnitus) is not associated with oxymetazoline, although this medication may cause hypotension, tachycardia, and dizziness. Bleeding tendencies are related to inadequate clotting mechanisms, which are not associated with the use of this nasal spray. 4) The nurse is providing education to the client with sinusitis who has asked about taking over-the-counter pseudoephedrine. Which of the following statements is appropriate? A. If you take pseudoephedrine and phenylephrine together, you will get more relief B. Continue the medication until your congestion resolves C. Using these kinds of medications may make you jittery and restless D. It is safe to chew over the counter medications if you have trouble swallowing pills Rationale: Do not combine two drug preparations containing the same or similar active ingredients. For example, pseudoephedrine is the nasal decongestant component of most prescription and over-the-counter (OTC) sinus and multi-ingredient cold remedies. Taking more than one preparation containing pseudoephedrine (or phenylephrine, a similar drug) may increase the dosage to toxic levels and cause irregular heartbeats and extreme nervousness. Oral OTC decongestants should not be used longer than one week. Excessive or prolonged use may damage nasal mucosa and produce chronic nasal congestion. Common side effects include tachycardia, impaired coordination, dizziness, excitability, headache, insomnia, restlessness, seizures, vertigo, dysuria, urinary retention, urinary difficulty, and thrombocytopenia. Anti-coagulants in General x 1 1) The spouse of a client with an intracranial hemorrhage asks the nurse, 'Why aren’t they administering an anticoagulant?' How will the nurse respond? A. 'It is not advisable because bleeding will increase.' B. 'If necessary, it will be started to enhance circulation.' C. 'If necessary, it will be started to prevent pulmonary thrombosis.' D. 'It is inadvisable because it masks the effects of the hemorrhage.' Rationale An anticoagulant should not be administered to a client who is bleeding because it will interfere with clotting and will increase hemorrhage. Anticoagulants are unsafe and will not be used to enhance the circulation or prevent pulmonary thrombosis. The response 'It is inadvisable because it masks the effects of the hemorrhage' is not the reason why it is contraindicated; if given, it will increase, not mask, the effects of the hemorrhage. The Blood Thin -arins: Warfarin x 31 1) The laboratory report establishes that the client has a warfarin overdose. Which antidote would the nurse anticipate administering? A. Physostigmine B. Vitamin K C. Iron dextran D. Protamine sulfate Rationale Warfarin inhibits formation of vitamin K–dependent clotting factors. Its effect is overcome by increasing vitamin K. Iron dextran is an iron supplement, not an antidote for warfarin. Protamine sulfate is the antidote for heparin overdose. Physostigmine is an antidote for anticholinergic overdose. 2) Which antidote would the nurse anticipate administering to a client whose laboratory report establishes a warfarin overdose? A. Physostigmine B. Vitamin K C. Iron dextran D. Protamine sulfate Rationale Warfarin inhibits formation of vitamin K–dependent clotting factors. Its effect is overcome by increasing vitamin K. Physostigmine is an antidote for anticholinergic overdose. Iron dextran is an iron supplement, not an antidote for warfarin. Protamine sulfate is the antidote for heparin overdose. 3) Which statement about appropriate foods to consume when taking warfarin would indicate that the client needs further teaching? A. "Eggs provide a good source of iron, which is needed to prevent anemia." B. "Yellow vegetables are high in vitamin A and should be included in the diet." C. "Dark green leafy vegetables are high in vitamin K, so I should eat them more often." D. "Milk and other high-calcium dairy products are necessary to counteract bone density loss." Rationale Foods high in vitamin K should be limited to the usual amounts eaten by the client when establishing the prothrombin time/international normalized ratio because vitamin K is part of the body’s blood-clotting mechanism and will counter the effects of warfarin if eaten in excess. Foods containing protein and iron are permitted because they are unrelated to blood clotting. Foods containing vitamin A are permitted because vitamin A is unrelated to blood clotting. Foods containing calcium are permitted because calcium is unrelated to blood clotting. 4) Which drink would a nurse teach a client on warfarin to avoid? A. Apple juice B. Grape juice C. Orange juice D. Cranberry juice Rationale The antioxidants in cranberry juice may inhibit the mechanism that metabolizes warfarin, causing elevations in the international normalized ratio, resulting in hemorrhage. Apple juice, grape juice, and orange juice are fine to drink. 5) Which information would the nurse include when teaching a client about warfarin? A. Periodic blood testing is necessary. B. Increase intake of green leafy vegetables. C. Limit the amount of daily physical activity. D. It should be continued for minor surgical procedures. Rationale Testing is essential to determine dosing; a therapeutic prothrombin time (PT) ranges from 1.3 to 1.5 times greater than the control and is equal to an international normalized ratio (INR) of 2 to 3 times control. Green leafy vegetables are high in vitamin K, which may decrease medication effectiveness if eaten in large amounts. Physical activities do not need to be limited; however, the type (e.g., contact sports such as football) may need to be restricted. Warfarin will need to be stopped for most dental, medical, and surgical procedures; the provider should be contacted regarding the need to hold the medication. 6) The nurse provides discharge medication education to a client who has a prescription for warfarin. Which client statement indicates to the nurse that teaching was effective? A. 'I will avoid taking aspirin and nonsteroidal anti-inflammatory drugs [NSAIDs].' B. 'I will need to develop a more sedentary routine.' C. 'I will need to have regular complete blood counts to guide warfarin dosage.' D. 'Before going to the dentist, I will ask my health care provider for antibiotics.' Rationale Acetaminophen should be used when an analgesic is required because it does not interfere with platelet aggregation. Acetylsalicylic acid (aspirin) should be avoided because it interferes with platelet aggregation. Immobility causes venous pooling and can predispose the client to deep vein thrombosis. Antibiotics are not necessary when going to the dentist; this is done when clients have cardiac problems, such as rheumatic fever or cardiac surgery. A prothrombin time (PT) or international normalized ratio (INR), not a complete blood count, needs to be done periodically. 7) Which medication is often contraindicated when taking warfarin? A. Atenolol B. Ferrous sulfate C. Chlorpromazine D. Acetylsalicylic acid Rationale Acetylsalicylic acid can cause decreased platelet aggregation, increasing the risk for undesired bleeding that may occur with administration of anticoagulants. It should not be administered unless specifically prescribed, usually by a cardiologist or other specialist, to manage serious risks of thrombosis. Ferrous sulfate does not affect warfarin; it is used for r