Chapter 16 -Drug Therapy 1. The client has a history of gastrointestinal bleeding. What would be the best response by the nurse when the health care provider prescribes Indocin as treatment for rheumatoid arthritis?  Withhold the medication and notify the provider. The most appropriate action of the nurse is to hold the medication and notify the provider of the client's history of GI bleeding. An adverse reaction associated with Indocin is GI bleeding. The nurse cannot discontinue or add medications to the treatment plan without prescriptive authority. 2. A nurse is preparing to present information about ibuprofen at a community health promotion conference. Which actions will the nurse illustrate during the presentation? Select all that apply.  Analgesics, Anti-inflammatory, and Antipyretic. Like the salicylates, the NSAIDS have anti-inflammatory, antipyretic, and analgesic effects. They do not exert antipruritic or antibacterial properties. 3. A client has had minor surgery and asks the nurse what can be used for pain. Which would be most appropriate for the nurse to suggest?  Acetaminophen. After minor or major surgery, the client should avoid salicylates to reduce the risk for bleeding and use acetaminophen for pain control. 4. What is an important nursing action for the administration of colchicine to the patient in the acute care setting?  Administer the medication with a full glass of water at evenly spaced intervals throughout the day. 5. The nurse is conducting a medication reconciliation of a new resident of a long-term care facility. The nurse notes that the resident takes allopurinol on a daily basis for the treatment of gout. What is the primary purpose of this drug?  To balance urate concentration and reduce the symptoms of gout. Uricosuric drugs such as allopurinol help to balance urate levels and thus reduce the symptoms of gout. They do not influence the remodeling of synovial membrane, provide analgesia, or affect the metabolism of purines. 6. A nurse has admitted a 10-year-old to the short-stay unit. The child reports chronic headaches, and his mother states that she gives the child acetaminophen at least twice a day. What will the nurse evaluate?  Hepatic function. The nurse should evaluate the patient's hepatic function. Severe hepatotoxicity can occur from overuse of acetaminophen. Significant interferences do not occur in the kidney, heart, or lung with acetaminophen. 7. A mother asks the nurse how acetaminophen works. What statement best describes the therapeutic action of acetaminophen?  Acting directly on thermoregulatory cells in the hypothalamus. Acetaminophen functions by acting directly on thermoregulatory cells in the hypothalamus to reduce fever. It does not impact kidney function, has no effect on vasodilation, and is not an anti-inflammatory medication. 8. A nurse is performing discharge teaching for a client who is prescribed ibuprofen. After teaching the client about the possible cardiovascular effects of the drug, the nurse determines that additional teaching is needed when the client states which comment?  “My blood pressure won't change.” The client should be counseled that NSAIDs including ibuprofen may result in the following cardiovascular effects: increased or decreased blood pressure, congestive heart failure, cardiac arrhythmias, and myocardial infarction. 9. The nurse teaches the client to do which of the following prior to surgery?  Avoid salicylates. The client should avoid products containing aspirin for at least one week prior to surgery, to decrease the risk of bleeding. Acetaminophen has no effect on bleeding. 10. Patients are often given a daily dose of aspirin for prophylaxis of myocardial infarction (MI), transient ischemic attacks (TIA), and cerebrovascular accident (CVA). What is the recommended daily dose for this purpose?  81-325 mg. The recommended daily dose for prophylaxis of MI, TIA, and CVA is 81-325 mg. The indication stems from aspirin's ability to decrease formation of blood clots. Pg. 309 11. After teaching a local community group about the use of OTC antiinflammatory agents, the nurse determines that the group needs additional teaching when they state:  “These drugs are relatively safe since they don’t have adverse effects.” All anti-inflammatory drugs available OTC have adverse effects that can be dangerous if toxic levels of the drug circulate in the body. Since these drugs are available OTC, there is a potential for abuse and overdosing. In addition, these drugs block the signs and symptoms of a present illness. OTC agents, if combined with other drugs, can induce toxicity. 12. The 56-year-old client is diagnosed with osteoarthritis and reports joint pain and stiffness. Which medication would be identified as appropriate for the client to take?  Celecoxib. Celecoxib is a COX-2 inhibitor used to treat pain related to osteoarthritis. Eletriptan, sumatriptan, and ergotamine are medications used to treat migraines. A nurse is caring for a patient who has been 13. administered ibuprofen for fever reduction. Which should the nurse monitor the patient for?  Dyspepsia. The nurse should check for dyspepsia when caring for a patient administered with ibuprofen. Administration of ketoprofen may cause diarrhea. Administration of etodolac may cause rash or tinnitus. A client with acute joint inflammation tells the 14. nurse, “I’ve been taking acetaminophen as it’s ordered on the bottle, but my swelling and inflammation doesn’t seem to be getting better.” What should the nurse teach the client?  "Acetaminophen has no effect on inflammation.” Acetaminophen has antipyretic and analgesic properties, but no antiinflammatory properties. Acetaminophen does not increase a person’s risk for bleeding. Relief of pain and fever occurs quickly. 15. While providing client teaching relative to inflammatory disorders, the nurse would explain the presence of inflammation as:  an attempt by the body to remove the damaging agent and repair the damaged tissue. Inflammation is the normal body response to tissue damage from any source, and it may occur in any tissue or organ. Local manifestations are redness, heat, edema, and pain. Inflammation may be a component of virtually any illness. Inflammation can be a result of an infection, which may require antibiotic therapy. 16. An 80-year-old male client presents to the health care provider’s office with reports of fatigue and a change in the color of stools. He self-administers ibuprofen 400 mg each night for general discomfort. The provider orders a stool test for guaiac, which yields positive results. The provider discontinues the ibuprofen. The nurse is responsible for a client education plan. The client should be educated regarding what as a risk with chronic use of NSAIDs?  GI bleed. Older clients on long-term NSAID therapy should be evaluated for GI blood loss, renal dysfunction, edema, hypertension, and drug–drug or drug–disease interactions (level A). Use of gastroprotective agents is recommended for people at risk of upper GI bleeding events (level B). COX-2 inhibitors may be preferred in older adults, because they are less likely to cause gastric ulceration and bleeding; however, this benefit must be weighed against the increased risk of cardiovascular events. 17. A nurse is providing care to a client who is receiving NSAIDs. The nurse would be especially alert for which assessment finding? Select all that apply.  polyuria, dysuria, oliguria, hematuria. Clients receiving NSAIDs should be monitored for the following renal adverse effects: polyuria, dysuria, oliguria, hematuria, cystitis, elevated BUN, and acute renal failure. 18. A parent has sought care from the nurse practitioner to treat a child’s fever. The nurse practitioner is most likely to recommend what nonsalicylate drug?  Acetaminophen. Acetaminophen is the most frequently used drug for managing fever and pain in children. Ibuprofen and naproxen are both effective treatments for pain and fever in children but they are not the most commonly used medications. Indomethacin is not indicated for fever control. 19. A nurse is assessing a client after administering aspirin for pain. Which finding should the nurse prioritize?  Flushing. Flushing is one of the symptoms of salicylism that the nurse should monitor for. Tachycardia, not bradycardia, is a symptom of salicylism. Sleeplessness and constipation are not symptoms of salicylism. 20. Aspirin (ASA) is an over-the-counter drug that is found in many other drugs. What is the mechanism of action for aspirin?  Blocking the transmission of pain impulse. Aspirin acts both centrally and peripherally to block the transmission of pain impulses. Aspirin does not increase adrenal function or blood cell production. Aspirin does not suppress the function of the hypothalamus. Pg. 308 21. A 60-year-old client with rheumatoid arthritis reveals to the nurse the recent use of an OTC NSAID. The nurse should point out the client is at an increased risk for developing which disorder related to the use of NSAIDs?  Ulcer disease. Age appears to increase the possibility of adverse reactions to NSAIDs. The risk of serious ulcer disease in adults older than 65 years is increased with higher doses of NSAIDs. CNS disorders, hearing impairment, and blindness are not effects associated with using NSAIDs on a long-term basis in older clients. 22. A 60-year-old man has told the nurse that he has been treating his joint pain with regular doses of ibuprofen. In order to ascertain the man's risks of experiencing adverse effects, the nurse should assess the patient's  alcohol intake. Heavy alcohol use may predispose a patient to hepatic dysfunction. Calcium intake, BMI, and skin integrity are not central assessments with regard to potentially adverse effects. Pg. 317 23. A patient with muscular pain has been prescribed an NSAIDs. What advice should the nurse give the patient to promote an optimal response to NSAID therapy?  Suggest the patient take the NSAID with food and milk. The nurse should suggest that the patient take the drug with food and milk to promote an optimal response to NSAID therapy; this helps minimize the risk of GI effects. The patient does not need to take an NSAID with fiber-rich food or with calcium supplements. Pg. 317 24. A nurse caring for a patient administered an NSAID for fever reduction records a decrease in urinary output for the patient. Which of the following should the nurse consider as a probable reason for the patient's condition?  Prolonged temperature elevation. If temperature elevation is prolonged while on NSAID therapy, hot, dry, flushed skin and a decrease in urinary output may develop; consequently, dehydration can occur. Prolonged immobility, reduced intake of fibrous food, and intake of food with antacids do not cause a decrease in urinary output. Pg. 317 25. Acetaminophen is frequently used as a substitute for aspirin. What effects of aspirin are absent in acetaminophen?  Anti-inflammatory and antiplatelet effects. Acetaminophen is commonly used as an aspirin substitute because it lacks aspirin's antiplatelet effects. It also lacks aspirin's anti-inflammatory effect. Acetaminophen has antipyretic and analgesic effects equal to those of aspirin. Pg. 308 26. Which drugs would be the safest to prescribe a client with a high risk for bleeding? Select all that apply.  COX-2 inhibitors, acetaminophen. Acetylsalicylic acid and nonselective nonsteroidal anti-inflammatory drugs (NSAIDs) have antiplatelet effects that differ in mechanism and extent. Most other NSAIDs bind reversibly with platelet COX-1 so that antiplatelet effects occur only while the drug is present in the blood. Thus, acetylsalicylic acid has greater effects, but all the drugs except acetaminophen and the COX-2 inhibitors inhibit platelet aggregation, interfere with blood coagulation, and increase the risk of bleeding. Pg. 302 27. What effects are exerted by aspirin? (Select all that apply.) Analgesic, Antipyretic, and Anti-inflammatory. Aspirin is a salicylate. Salicylates are useful in pain management because of their analgesic, antipyretic, and anti-inflammatory effects. Pg. 308 28. A patient comes to the clinic reporting throbbing pain that started at night and intolerance to covers on the foot. The nurse observes swelling at the site of the first metatarsophalangeal (MTP) joint. For what disorder does the nurse anticipate the patient will be treated?  Acute gouty arthritis.  The onset of acute gouty arthritis is rapid. The pain frequently starts during the night and is often described as throbbing, crushing, or excruciating. The affected joints show signs of warmth, redness, and tenderness. In more than half of the initial attacks, the onset is in the first MTP, and overall 90% of patients have the MTP affected at some point. Pg. 307 29. The nurse reviews the medication administration record for a client with osteoarthritis. Which new medication would the nurse question giving the client?  IbuprofenIbuprofen should be questioned because it is a nonsteroidal anti-inflammatory drug (NSAID). The antiplatelet effects of aspirin are decreased with ibuprofen. There is a potential for decreased antihypertensive effects of beta blockers such as metoprolol if taken with an NSAID. There is often decreased diuretic effect when an NSAID is taken with a loop diuretic such as furosemide. Taking an NSAID with ginkgo biloba can increase the risk of bleeding. Colchicine should not be taken with CYP3A4 inhibitors. Auranofin is a gold salt used to treat rheumatoid arthritis. Auranofin should not be combined with penicillamine, antimalarials, cytotoxic drugs, or immunosuppressive agents. Etanercept is a tumor necrosis factor blocker used to treat progressive arthritis. Etanercept is not to be taken with other immunosuppressants or live vaccines. Pg. 317 30. Which client is at highest risk for developing hepatotoxicity related to the use of acetaminophen?  A male 30 years old, who drinks four beers a day. Clients who consume more than three drinks per day habitually are at increased risk for developing hepatotoxicity. Aspirin should be used cautiously in clients with a vitamin K deficiency and hypoprothrombinemia. Pg 313 31. The nurse administers ibuprofen to adult clients experiencing a variety of health disorders. Following administration, the nurse should assess for therapeutic effects related to what symptoms? Select all that apply.  Fever, moderate pain and inflammation. Ibuprofen is used to relieve mild to moderate pain or inflammation related to rheumatoid arthritis or osteoarthritis. In addition, it is effective in reducing fever. During initial attacks of acute gout, ibuprofen may be administered, but it does not directly reduce uric acid levels. Pruritus (itching) management is not a primary indication for ibuprofen use. Pg. 314-315 32. A client is alarmed to be prescribed celecoxib (Celebrex), stating, “I heard on TV that Celebrex causes heart attacks.” How should the nurse best respond?  “This drug hasn’t been definitively proven to be unsafe, so it’s still available.” Celecoxib remains on the market despite a 2 to 3 times increase in CV events because further research called into question these findings and the drug continues to be monitored. There is no promise of a decision in 2018. The media played a role in the public response, but did not wholly create the controversy. 33. The development of gout has three distinct phases. Place in order each phase of the development of gout.  Acute gouty arthritis, Intercritical gout, and chronic tophaceous gout. Gout has three distinct phases: acute gouty arthritis (flares), intercritical gout (interval between flares), and chronic tophaceous gout (uncontrolled hyperuricemia with chronic arthritis tophi). Pg. 307 34. What information should be provided to a client diagnosed with an acetylsalicylic acid allergy?  Non aspirin form of nonsteroidal anti-inflammatory drugs (NSAIDs) should be avoided. In people who have demonstrated hypersensitivity to acetylsalicylic acid, all non aspirin NSAIDs are also contraindicated because cross-hypersensitivity reactions may occur with any drugs that inhibit prostaglandin synthesis. This makes all the other options incorrect. Pg. 309 35. A client was given 400 mg ibuprofen PO at approximately 1000 hours for the treatment of back pain. The client would most likely feel peak effects of the drug at which time?  1130 Ibuprofen peaks in 1 to 2 hours so the client should be experiencing the peak effect by 12 p.m. Peak effects would not be experienced by 10:30 a.m. Peak effects would have subsided by 2 or 4 p.m. pg. 314 36. A client receiving magnesium salicylate is reporting gastric upset to the nurse. Which intervention should the nurse prioritize for this client?  Administer antacids to minimize GI distress. The nurse may administer antacids to minimize GI distress. Instead of orange juice, the nurse may administer the drug with milk to alleviate gastric upset. The nurse can also administer the drug with food to relieve gastric upset instead of giving the drug 3 hours before a meal. Including fiber-rich food in the client's diet will not significantly relieve gastric upset. 37. The nurse is caring for a client with gout that is taking colchicine. In addition to the administration of this medication, what education can the nurse provide to help with the prevention of future episodes of gout?  Follow low purine diet. The nurse should encourage the client to follow a low-purine diet which would exclude items such as any alcohol products, organ and game meat, sardines, anchovies, scallops, asparagus, spinach, and peas. Alcohol should not be used at all even in moderation to avoid future attacks of gout. For acute gouty flare-ups, take one dose and the second dose 1 hour later. The dose should not be doubled. Although severe diarrhea may occur, it is not an expected or therapeutic response and should be immediately reported to the health care provider. Pg. 325 38. A nurse is preparing a presentation for a local community group about overthe-counter analgesics, including NSAIDs. Which possible reaction would the nurse integrate into the presentation as a serious risk with this class of drugs?  Cardiovascular thrombosis. A serious risk involved with the use of NSAIDs is cardiovascular thrombosis. Increased granulocyte count, increased WBC count, or sickle cell anemia is not caused by NSAIDs. Sickle cell anemia results from an inherited abnormality of hemoglobin. NSAIDs may cause decreased granulocyte count, decreased WBC count, or aplastic anemia. 39. A nurse is assessing the medical records of several female clients. With which clients would the nurse question the use of an NSAID? Select all that apply.  Lactating, hypersensitivity to aspirin, and third trimester of pregnancy. NSAIDs are contraindicated in clients with a hypersensitivity to aspirin. In general, NSAIDs are contraindicated during the third trimester of pregnancy (because they can induce labor) and during lactation. 40. A nurse is preparing to teach a client about the adverse effects of the prescribed NSAID therapy. Which system would the nurse include as being involved?  Gastrointestinal. The most common adverse reactions caused by the NSAIDs involve the GI tract, including the stomach, leading to GI bleed and/or possible ulceration. The lungs are not specifically affected by NSAIDs; however, pain associated with respiratory insults such as pneumonia can be relieved. Peripheral nerve pain can also be treated with NSAIDs. There is no injury noted to the liver or hepatobiliary system while taking NSAIDs. Pg. 317 41. Mr. Conn, age 65, is taking probenecid for treatment of chronic gouty arthritis. When providing patient and family education, what should a nurse advise the patient to do if he misses a dose and it is almost time for the next dose?  Advise the patient to take only the second dose and ignore the missed dose. If a patient misses a dose, it should be taken as soon as possible. If it is almost time for the next dose, however, only that dose should be taken; the patient should never take double or extra doses. It is not essential to undergo blood or urine tests or stop the medication unless symptoms of any adverse effects occur. 42. A group of nursing students are reviewing the pain-relieving action of NSAIDs. The students demonstrate understanding of the information when they identify which actions as being blocked to achieve pain relief?  cyclooxygenase 2Blocking COX-2 is responsible for the painrelieving effects of NSAIDs. COX-1 is an enzyme that helps to maintain the stomach lining; inhibition of COX-1 would cause unwanted gastrointestinal (GI) reactions such as stomach irritation and ulcers. The antipyretic action of aspirin may be mediated by inhibition of COX-3 in hypothalamic endothelial cells. No data are obtained on the discovery of COX-4. Pg. 302 43. A male client is taking aspirin 81 mg by mouth each day for prevention of recurrent myocardial infarction. He makes a dentist appointment for a tooth extraction. He calls the health care provider’s office and asks the nurse if he is at risk for bleeding. Which response is correct?  “Yes, low doses of aspirin may increase your risk of bleeding; I will call you with your new prescriber's orders.” If a client has a history of taking aspirin, including the low doses prescribed for antithrombotic effects, there is a risk of bleeding from common therapeutic procedures (e.g., intramuscular injections, venipuncture, insertion of urinary catheters or GI tubes) or diagnostic procedures (e.g., drawing blood, angiography). Pg. 311 44. An older adult male patient has begun treatment for gout after an extensive diagnostic workup. The nurse who is contributing to the patient's care should understand that gout is a result of what pathophysiological process?  Hyperuricemia causes crystals to precipitate in the synovial fluid. Gout occurs when hyperuricemia forms monosodium urate crystals. These precipitate into the synovial fluid and cause an inflammatory response. Gout does not primarily result from mechanical damage, lack of mobility, or autoimmune processes. Pg 307 45. A 15-year-old client is brought to the emergency department by his friends. He reports visual changes, drowsiness, and tinnitus. He is confused and hyperventilating. These symptoms may be attributable to which condition?  Salicylate intoxication. Symptoms of salicylate intoxication include nausea, vomiting, fever, fluid and electrolyte deficiencies, tinnitus, decreased hearing, visual changes, drowsiness, confusion, and hyperventilation. The scenario described does not suggest acetaminophen poisoning, ibuprofen overdose, or caffeine abuse. Pg 309 46. While assessing the medication history of an older adult client, the nurse notes the client takes acetaminophen daily. The nurse will further question the client to determine how much and how often the client does not exceed what daily amount?  3 grams. 47. A client prescribed allopurinol denies any current symptoms of gout. What response should the nurse provide when the client asks why the medication has been prescribed?  “Allopurinol is used to prevent or treat hyperuricemia, which commonly occurs with gout.” Allopurinol is used to prevent or treat (but not cure) hyperuricemia, which occurs with gout and with antineoplastic drug therapy. Allopurinol prevents formation of uric acid. The drug promotes resorption of urate deposits and prevents their further development. Allopurinol is among the first-line drugs used in the treatment of gout but does not cure the condition. Pg. 326 48. Prior to administering NSAIDs, the nurse asks the client about an allergy to:  Aspirin. Aspirin allergy is a contraindication for all NSAIDs. Antibiotics and acetaminophen allergies do not affect NSAID use. Analgesics include a wide variety of medications. 49. A nurse is preparing a discharge teaching for a client who is to continue taking NSAIDs at home. Which important point should the nurse prioritize in the teaching?  Call your health care provider if you have no relief after 2 weeks. The nurse should instruct the client to consult the primary health care provider if the pain, swelling, inflammation, or tenderness is not relieved after 2 weeks. The drug takes several days to relieve the discomfort, so it is important for the client to give the drug time to work. The nurse should instruct the client to avoid the use of aspirin. The drug should be taken with a full glass of water or with food. It is not necessary to take NSAIDs strictly with a glass of juice or milk. These drugs are not to be used on a regular basis unless the client is strictly instructed to do so by the primary health care provider. 50. A nurse is presenting an educational event for a group of new parents. A participant has asked about the safe use of acetaminophen in children. What should the nurse teach the parents?  “Check the label of over-the-counter medications carefully to see if they include acetaminophen.” Inadvertent overdose with acetaminophen frequently occurs because of the combining of OTC drugs that contain the same ingredients. Parents should be taught to carefully check the labels of OTC products and follow the dosage guidelines. A prescription is not required for acetaminophen. Dosage guidelines are the best guide to follow to prevent overdose; doses should not be “matched” to the severity of a fever. Pg. 312 Level 5 51. Temperature regulation occurs in the hypothalamus. Normally, when the body temperature increases the body will respond by causing vasodilation in the periphery. What physiologic change is occurring with fever that allows the body's temperature to increase?  Fever occurs as a result of increased synthesis of prostaglandin in the hypothalamus. Fever is the result of fever-inducing substances called pyrogens, which activate certain monocytes/macrophages, which in turn secrete cytokines. Cytokines increase the synthesis and secretion of prostaglandin E2 (PGE2) in the hypothalamus, and PGE2 stimulates the hypothalamus to reset the regulating mechanism to tolerate a higher body temperature. Pg 303 52. A client has a sulfonamide allergy. Which drug would the nurse identify as being contraindicated?  Celecoxib is contraindicated in clients with a sulfonamide allergy. Ibuprofen, ketorolac, and meloxicam are not contraindicated. Pg 323 53. A patient with gout has been prescribed colchicine, which he is to take orally each day. When providing relevant health education for this patient, the nurse should emphasize the need to avoid  Sardines. The patient should be encouraged to follow a low-purine diet by avoiding beer, alcohol, organ and game meats, sardines, anchovies, scallops, asparagus, spinach, and peas.. Salt, food additives, and simple sugars should always be eaten in moderation, but none is contraindicated with colchicine therapy. Pg 325 54. The client states that aspirin is no longer working for the joint pain. To best determine the ineffectiveness of the aspirin therapy, the nurse assesses for the possible co-use of which drug classification?  Antacids. Antacids decrease the effectiveness of salicylates. There is increased risk of bleeding when salicylates are combined with anticoagulants. There is increased risk for salicylism when used with carbonic anhydrase inhibitors. There is no interaction between aspirin and antipyretics. Pg 310 55. The nurse administers ibuprofen to adult clients experiencing a variety of health disorders. Following administration, the nurse should assess for therapeutic effects related to what symptoms? Select all that apply.  Fever, Inflammation, moderate pain. Ibuprofen is used to relieve mild to moderate pain or inflammation related to rheumatoid arthritis or osteoarthritis. In addition, it is effective in reducing fever. During initial attacks of acute gout, ibuprofen may be administered, but it does not directly reduce uric acid levels. Pruritus (itching) management is not a primary indication for ibuprofen use. Pg 314-15 56. A 78-year-old male client calls the clinic and reports severe pain and swelling in his right great toe. The client states that the pain is worse at night and has been present for at least 2 weeks. The nurse understands that this client has what type of inflammatory disorder?  Gout. Severe pain and swelling in the great toe that is worse at night and lasts longer than 10 days is most likely gout. Pg 307 57. A nurse is caring for several pediatric clients. The nurse would question an order for aspirin for a client with which disorder?  Chickenpox. Children or teenagers with influenza or chickenpox should not take salicylates, particularly aspirin, because their use appears to be associated with Reye syndrome. 58. A client with dysmenorrhea has been prescribed naproxen 1250 mg PO b.i.d. What is the nurse’s best action?  Question prescriber about dose. For adults, naproxen is given 250–500 mg PO b.i.d. As a result, the nurse should question the prescriber about the dose before proceeding. Pg 316