Transmission Precautions (Tier Two)

1)​ Transmission precautions (tier two) a)​ Airborne precautions b)​ Use airborne precautions to protect against droplet infections smaller than 5 mcg (measles, varicella, SARS-CoV-2, pulmonary or laryngeal tuberculosis). 2)​ Airborne precautions require: a)​ A private room. b)​ Masks and respiratory protection devices for caregivers and visitors. c)​ Use an N95 or high-efficiency particulate air (HEPA) respirator if the client is known or suspected to have tuberculosis or SARS-CoV-2. d)​ Negative pressure airflow exchange in the room of at least six to 12 exchanges per hour, depending on the age of the structure. e)​ If splashing or spraying is a possibility, wear full face (eyes, nose, mouth) protection. f)​ Clients who have an airborne infection should wear a mask while outside of the room/home. 3)​ Droplet precautions a)​ Droplet precautions protect against droplets larger than 5 mcg and travel 3 to 6 ft from the client (streptococcal pharyngitis or pneumonia, Haemophilus influenzae type B, scarlet fever, rubella, pertussis, mumps, mycoplasma pneumonia, meningococcal pneumonia and sepsis, pneumonic plague). b)​ Droplet precautions require: c)​ A private room or a room with other clients who have the same infectious disease. Ensure that clients have their own equipment. d)​ Masks for providers and visitors. e)​ Clients who have a droplet infection should wear a mask while outside of the room/home. 4)​ Contact precautions protect visitors and caregivers when they are within 3 ft of the client against direct client and environmental contact infections (respiratory syncytial virus, shigella, enteric diseases caused by micro-organisms, wound infections, herpes simplex, impetigo, scabies, multidrug-resistant organisms). a)​ Contact precautions require: b)​ A private room or a room with other clients who have the same infection. c)​ Gloves and gowns worn by the caregivers and visitors. d)​ Disposal of infectious dressing material into a single, nonporous bag without touching the outside of the bag. 5)​ Protective environment 6)​ Protective environment is an intervention (not type of precautions) to protect clients who are immunocompromised. This includes clients who have had an allogeneic hematopoietic stem cell transplant. a)​ A protective environment requires: b)​ Private room. c)​ Positive airflow 12 or more air exchanges/hr. d)​ HEPA filtration for incoming air. e)​ Mask for the client when out of room. 7)​ Allergies to banana or kiwi can indicate the client is at risk for a reaction to latex. 8)​ Postoperative Care Following a Total Hip Arthroplasty a)​ Provide postoperative care and prevent complications. b)​ Check the dressing site frequently, noting any evidence of bleeding. Monitor and record drainage from surgical drains. c)​ Monitor daily laboratory values, including hemoglobin (Hgb) and hematocrit (Hct) levels. Hgb and Hct can continue to drop for 48 hours after surgery. Autologous blood from pre-surgery donation or blood salvaged intraoperatively can be used for postoperative blood replacement.. d)​ Monitor the neurovascular status of the surgical extremity (movement, sensation, color, pulse, capillary refill, and compare with contralateral extremity) every 2 to 4 hours. e)​ Provide medications as prescribed. i)​ Analgesics: Opioids (epidural, PCA, IV, oral), NSAIDs ii)​ Antibiotics: Generally, administered 30-60 minutes before the surgical incision is made as a prophylaxis, and continued for 24 hours postoperatively to prevent infection. iii)​ Anticoagulant: Warfarin, dalteparin, fondaparinux, rivaroxaban, or low-molecular-weight heparin (enoxaparin) f)​ Provide early ambulation. i)​ Transfer the client out of bed from their unaffected side into a chair or wheelchair. ii)​ Weight-bearing status is determined by the orthopedic surgeon and by choice of cemented (usually partial/full weight-bearing as tolerated) vs. non-cemented prostheses (usually only partial or minimal weight-bearing [toe touch] until after a few weeks of bone growth). iii)​ Use assistive (walker) and adaptive (raised toilet seat, grab bars, and shower chairs) devices when caring for the client. QS​​ iv)​ Apply ice to the surgical site following ambulation as a nonpha rmacological measure to decrease pain and discomfort. g)​ Place the client supine with the head slightly elevated and the affected leg in a neutral position. Place a pillow or abduction device between the legs when turning to the unaffected side. The client should not be turned to the operative side, which could cause hip dislocation unless prescribed by agency policy or the provider. h)​ Use total hip precautions (maintain abduction, neutral rotation, limited flexion) to prevent dislocation of the new joint. i)​ Monitor for new joint dislocation: acute onset of pain, reports hearing “a pop,” internal or external rotation of the affected extremity, and shortened affected extremity. 9)​ Strategies to Maintain Skin Integrity a)​ Keep skin clean, dry, and intact. Provide a firm, wrinkle-free foundation with wrinkle-free linens. b)​ Reposition the client in bed at least every 2 hr and every 1 hr in a chair. Document position changes. c)​ Keep the head of the bed at or below a 30° angle (or flat), unless contraindicated, to relieve pressure on the sacrum, buttocks, and heels. QEBP d)​ Raise heels off of the bed to prevent pressure. e)​ Ambulate clients as soon and as often as possible. f)​ Instruct clients who are mobile to shift their weight every 15 min when sitting. g)​ Keep clients from sliding down in bed, as this increases shearing forces that pull tissue layers apart and cause damage. Lift, rather than pull, clients up in bed or in a chair, because pulling creates friction that can damage the outer layer of skin (epidermis). 10)​Risk for Fluid Volume Deficit Following Lumbar Spinal Surgery a)​ Record fluid I&O. b)​ Monitor fluid I&O for clients who have fluid or electrolyte imbalances. i)​ Measure and calculate all fluid I&O in mL (1 oz = 30 mL). ii)​ Fluid intake includes all liquids (oral fluids, foods that liquefy at room temperature, IV fluids, IV flushes, IV medications, enteral feedings, fluid instillations, catheter irrigants, tube irrigants). iii)​ Fluid output includes all liquids (urine, blood, emesis, diarrhea, tube drainage, wound drainage, fistula drainage). c)​ Weigh clients each day at the same time, after voiding, and while wearing the same type of clothes. d)​ If using bed scales, use the same amount of linen each day, and reset the scale to zero, if possible. 11)​Dietary Choices for a Client Who Has Cholelithiasis a)​ Cholecystitis is characterized by inflammation of the gallbladder. b)​ The gallbladder stores and releases bile that aids in the digestion of fats. c)​ Manifestations include pain, tenderness, and rigidity in upper right abdomen. Pain can radiate to the right shoulder or midsternal area. Nausea, vomiting, and anorexia also can occur. If the gallbladder becomes filled with pus or becomes gangrenous, perforation can result. d)​ In clients who have large stones or inability to control the condition with diet modifications, surgery is required. e)​ Pancreatitis and liver involvement can result from uncontrolled cholecystitis. f)​ Fat intake should be limited to reduce stimulation of the gallbladder. g)​ The diet is individualized to the client’s needs and tolerance. 12)​Teaching About Constipation-Predominant Irritable Bowel Syndrome a)​ Bulk-forming laxatives: psyllium, methylcellulose b)​ Expected Pharmacological Action: Bulk-forming laxatives soften fecal mass and increase bulk, which is identical to the action of dietary fiber. c)​ Therapeutic uses i)​ For temporary treatment of constipation. Decrease diarrhea in clients who have diverticulosis and IBS. Control stool for clients who have an ileostomy or colostomy. Isoniazid Isoniazid, commonly referred to as INH, is bactericidal and inhibits growth of mycobacteria by preventing synthesis of mycolic acid in the cell wall. Nursing Actions ●​ This medication should be taken on an empty stomach. ●​ Monitor for hepatotoxicity (jaundice, anorexia, malaise, fatigue, and nausea) and neurotoxicity (such as tingling of the hands and feet). ●​ Vitamin B6 (pyridoxine) is often prescribed concurrently to prevent neurotoxicity from isoniazid. ●​ Liver function testing should be completed prior to and monthly after starting INH. Client Education ●​ Do not drink alcohol while taking isoniazid, because it can increase the risk for hepatotoxicity. QS ●​ Report any manifestations of hepatotoxicity. Rifampin Rifampin, commonly referred to as RIF, is a bacteriostatic and bactericidal antibiotic that inhibits DNA-dependent RNA polymerase activity in susceptible cells. Nursing Actions ●​ Observe for hepatotoxicity. ●​ Liver function testing should be completed prior to and at least monthly after starting RIF. Client Education ●​ Urine and other secretions will be orange. ●​ Immediately report pain or swelling of joints, loss of appetite, jaundice, or malaise. ●​ This medication can interfere with the efficacy of oral contraceptives. ●​ Discoloration of contact lenses can occur. Pyrazinamide Pyrazinamide, commonly referred to as PZA, is a bacteriostatic and bactericidal. Its exact mechanism of action is unknown. Nursing Actions ●​ Observe for hepatotoxicity. ●​ Assess for history of gout, as the medication will cause an adverse effect of non-gouty polyarthralgia. ●​ Liver enzymes should be completed baseline and every 2 weeks after starting PZA. Client Education ●​ Drink a glass of water with each dose and increase fluids during the day to help prevent gout and kidney problems. ●​ Immediately report yellowing of the skin or eyes, pain or swelling of joints, loss of appetite, or malaise. ●​ Avoid using alcohol while taking pyrazinamide. Ethambutol ●​ Ethambutol, commonly referred to as EMB, is a bacteriostatic and works by suppressing RNA synthesis, subsequently inhibiting protein synthesis. ●​ This medication should not be given to children younger than 8 years of age. Nursing Actions ●​ Obtain baseline visual acuity tests, and complete monthly after starting treatment. ●​ Determine color discrimination ability before starting treatment, and periodically. ●​ Stop medication immediately if ocular toxicity occurs. 13)​Adverse Effects of Cyclosporine a)​ Monitor BUN and creatinine throughout treatment. b)​ Monitor I&O. 14)​Cardiac tamponade Cardiac tamponade, considered a medical emergency, can result from fluid accumulation in the pericardial sac. ●​ Manifestations include dyspnea, dizziness, report of “tightness” in the chest, increasing restlessness, pulsus paradoxus (a decrease of 10 mm Hg or more in systolic blood pressure during inspiration), tachycardia, muffled heart sounds, and jugular venous distention. ●​ Hemodynamic monitoring reveals intracardiac and pulmonary artery pressures similar and elevated (plateau pressures). Nasal Cannula Tubing with two small prongs for insertion into the nares Fraction of inspired oxygen: Delivers an FiO2 of 24% to 44% at a flow rate of 1 to 6 L/min. Advantages ●​ A cannula is a safe, simple, and easy-to-apply method. ●​ A cannula is comfortable and well-tolerated. ●​ The client is able to eat, talk, and ambulate. Disadvantages ●​ The FiO2 varies with the flow rate, and the rate and depth of the client’s breathing. ●​ Extended use can lead to skin breakdown and dry mucous membranes. ●​ Tubing is easily dislodged.​​ Nursing Actions ●​ Assess the patency of the nares. ●​ Ensure that the prongs fit in the nares properly. ●​ Use water-soluble gel to prevent dry nares. ●​ Provide humidification for flow rates of 4 L/min and greater. Simple Face Mask Covers the client’s nose and mouth Fraction of Inspired Oxygen ●​ It delivers an FiO2 of 35% to 60% at flow rates of 5 to 10 L/min. ●​ The minimum flow rate is 5 L/min to ensure flushing of CO2 from the mask. Advantages ●​ A face mask is easy to apply and can be more comfortable than a nasal cannula. ●​ It is a simple delivery method. ●​ It is more comfortable than a nasal cannula. ●​ It provides humidified oxygen. Disadvantages ●​ Flow rates less than 5 L/min can result in rebreathing of CO2. ●​ Clients who have anxiety or claustrophobia do not tolerate it well. ●​ Eating, drinking, and talking are impaired. ●​ Moisture and pressure can collect under the mask and cause skin breakdown. ●​ Face masks pose a greater risk of aspiration. Nursing Actions ●​ Assess proper fit to ensure a secure seal over the nose and mouth. ●​ Make sure the client wears a nasal cannula during meals. ●​ Use with caution for clients who have a high risk of aspiration or airway obstruction. ●​ Monitor for skin breakdown. Partial Rebreather Mask Covers the client’s nose and mouth Fraction of inspired oxygen: Advantages ●​ The mask has a reservoir bag attached with no valve, which allows the client to rebreathe up to ⅓ of exhaled air together with room air. ●​ Allows easier humidification of oxygen. Disadvantages ●​ Complete deflation of the reservoir bag during inspiration causes CO2 buildup. ●​ The FiO2 varies with the client’s breathing pattern. ●​ Clients who have anxiety or claustrophobia do not tolerate it well. ●​ Eating, drinking, and talking are impaired. ●​ The bag can twist or kink easily. Nursing Actions ●​ Keep the reservoir bag from deflating by adjusting the oxygen flow rate to keep the reservoir bag ⅓ to ½ full on inspiration. ●​ Assess proper fit to ensure a secure seal over nose and mouth. Assess for skin breakdown beneath the edges of the mask and bridge of the nose. ●​ Make sure the client uses a nasal cannula during meals. ●​ Use with caution for clients who have a high risk of aspiration or airway obstruction. Non-rebreather Mask​​ Covers the client’s nose and mouth Fraction of inspired oxygen: Advantages ●​ It delivers the highest O2 concentration possible (except for intubation). ●​ A one-way valve situated between the mask and reservoir allows the client to inhale maximum O2 from the reservoir bag. The two exhalation ports have flaps covering them that prevent room air from entering the mask. Disadvantages ●​ The valve and flap on the mask must be intact and functional during each breath. ●​ It is poorly tolerated by clients who have anxiety or claustrophobia. ●​ Eating, drinking, and talking are impaired. ●​ Use with caution for clients who have a high risk of aspiration or airway obstruction. Nursing Actions ●​ Perform an hourly assessment of the valve and flap. ●​ Assess proper fit to ensure a secure seal over the nose and mouth. Assess for skin breakdown beneath the edges of the mask and bridge of nose. ●​ Make sure the client uses a nasal cannula during meals. High-Flow Oxygen Delivery Systems Venturi Mask Covers the client’s nose and mouth Fraction of inspired oxygen: Advantages ●​ It delivers the most precise oxygen concentration with humidity added. ●​ Best for clients who have chronic lung disease. Disadvantages ●​ Use is expensive. ●​ Eating, drinking, and talking are impaired. ●​ The mask and added humidity can lead to skin breakdown. Nursing Actions ●​ Assess frequently to ensure an accurate flow rate. ●​ Assess proper fit to ensure a secure seal over the nose and mouth. Assess for skin breakdown beneath the edges of the mask, particularly on the nares. ●​ Make sure the tubing is free of kinks. ●​ Ensure that the client wears a nasal cannula during meals. Aerosol Mask Face tent: fits loosely around the face and neck Tracheostomy collar: a small mask that covers the surgically created opening of the trachea Fraction of Inspired Oxygen ●​ Delivers an FiO2 of 24% to 100% at flow rates of at least 10 L/min. ●​ Provides high humidification with oxygen delivery. Advantages ●​ Use with clients who do not tolerate masks well. ●​ Useful for clients who have facial trauma, burns, and thick secretions. Disadvantages: Nursing Actions ●​ Empty condensation from the tubing often. ●​ Ensure adequate water in the humidification canister. ●​ Ensure that the aerosol mist leaves from the vents during inspiration and expiration ●​ Make sure the tubing does not pull on the tracheostomy. 15)​Assisting With a Thoracentesis a)​ Position the client sitting upright with arms and shoulders raised and supported on pillows and/or on an overbed table and with feet and legs well-supported. 16)​ 17)​Equipment Needs for a Client Following Total Hip Arthroplasty a)​ Use raised toilet seats, and assistive items (long-handled shoehorn, dressing sticks) to prevent strain on the prosthesis/flexion > 90 degrees. 18)​Expected Reference Ranges for Blood Diagnostic Procedures EXPECTED REFERENCE RANGE RBC Females: 4.2 to 5.4 million/uL Males: 4.7 to 6.1 million/uL INTERPRETATION OF FINDINGS Elevated level: Erythrocytosis, polycythemia vera, severe dehydration Decreased level: Anemia, hemorrhage, kidney disease WBC 5,000 to 10,000/mm3 Elevated level: Infection, inflammation. Decreased level: Immunosuppression, autoimmune disease MCV 80 to 95 fL Elevated level: Macrocytic (large) RBCs, megaloblastic anemia. Decreased level: Microcytic (small) RBCs, iron deficiency anemia. MCH 27 to 31 pg/cell Elevated/decreased level: Same as above for MCV TIBC 250 to 460 mcg/dL Elevated level: Iron deficiency anemia, polycythemia vera Decreased level: Malnutrition, cirrhosis, pernicious anemia IRON Females: 60 to 160 mcg/dL Males: 80 to 180 mcg/dL Elevated level: Hemochromatosis, iron excess, liver disorder, or lead toxicity. Decreased level: Iron deficiency anemia, chronic blood loss, inadequate dietary intake of iron. PLATELETS 150,000 to 400,000 mm3 Increased level: Malignancy, polycythemia vera, rheumatoid arthritis. Decreased level: Enlarged spleen, hemorrhage, leukemia HGB Females: 12 to 16 g/dL Males: 14 to 18 g/dL Elevated level: Erythrocytosis, COPD, severe dehydration Decreased level: anemia, hemorrhage, kidney disease HCT Females: 37% to 47% Males: 42% to 52% APTT 30 to 40 seconds (1.5 to 2.5 times the control value if receiving heparin therapy) Elevated /decreased level: Same as above for Hgb Increased time: Vitamin K deficiency, disseminated intravascular coagulation (DIC), liver disease, heparin administration Decreased time: Extensive cancer PT 11 to 12.5 seconds, 85% to 100%, or 1:1.1 client-control ratio Increased time: Clotting factors II, V, VII, or X, liver disease, warfarin therapy, disseminated intravascular coagulation Decreased time: Vitamin K excess, pulmonary embolus, thrombophlebitis INR 0.8 to 1.1 (desired goal of 2 to 3 on warfarin therapy) Measures the mean of PT to provide a universally recognized value. Elevated level: Warfarin therapy Decreased level: Cancer disorders D-DIMER Less than 0.4 mcg/mL Positive result: Disseminated intravascular coagulation, malignancy Negative result: Can rule out pulmonary embolus or deep vein thrombosis FIBRINOGEN LEVELS 200 to 400 mg/dL Elevated level: Acute inflammation, acute infection, heart disease Decreased levels: Liver disease, advanced cancer, malnutrition FIBRIN DEGRADATION PRODUCTS Less than 10 mcg/mL Elevated level: Disseminated intravascular coagulation, massive trauma resulting in fibrinolysis Decreased level: Anticoagulation therapy 19)​Identifying Findings Consistent With Myocardial Infarction or Angina a)​ Angina: ST depression and/or T-wave inversion indicates presence of ischemia. b)​ MI: T-wave inversion indicates ischemia; ST-segment elevation indicates injury; abnormal Q-wave indicates necrosis. i)​ NSTEMI: no significant ECG changes or persistent ST elevations ii)​ STEMI: ST segment elevations in 2 separate leads 20)​Laboratory Tests a)​ Myoglobin: Earliest marker of injury to cardiac or skeletal muscle. Levels no longer evident after 24 hr. b)​ Creatine kinase-MB: Peaks around 24 hr after onset of chest pain. Levels no longer evident after 3 days. c)​ Troponin I or T: Any positive value indicates damage to cardiac tissue and should be reported. i)​ ​Troponin I and Troponin T: Levels no longer evident for approximately after 10 days. 21)​Lactulose: Used to promote excretion of ammonia from the body… a)​ Lactulose: Used to promote excretion of ammonia from the body through the stool Squamous cell (epidermis) Characteristics ●​ Initially appears as a rough, scaly lesion with central ulceration and crusting ●​ Bleeding (possible) ●​ Usually present on sun-exposed areas Course: Localized; can metastasize. Basal cell (basal epidermis or nearby dermal cells) Characteristics ●​ Open lesion that does not heal within 4 weeks ●​ Small, waxy nodule with superficial blood vessels, well-defined borders ●​ Erythema and ulcerations ●​ Usually present on sun-exposed areas Course: Invades local structures (nerves, bone, cartilage, lymphatic and vascular tissue); rarely metastatic but high rate of recurrence. Malignant melanoma (cancer of melanocytes) Characteristics ●​ Irregular shape and borders with multiple colors ●​ New moles or change in an existing mole (can occur in intestines or any other body structure that contains pigment cells) ●​ Itching, cracks, ulcerations, or bleeding (possible) ●​ Common on upper back and lower legs, and on palms and soles for clients who have dark skin Course: Rapid invasion and metastasis with high morbidity and mortality 22)​Assessment/Data Collection First a)​ Use the nursing process to gather pertinent information prior to deciding on a plan of action. For example, determine if additional information is needed prior to calling the provider to ask for pain medication for a client. 23)​Selective norepinephrine reuptake inhibitor a)​ Select Prototype Medication: Atomoxetine Complications QS​​ Appetite/growth suppression, weight loss Nursing actions ●​ Monitor height and weight and compare to baseline. ●​ Administer medication with or after meals. ●​ Encourage children to eat at regular meal times and avoid unhealthy food choices. GI effects (nausea, vomiting, upper abdominal pain) Client education: Take the medication with food if GI effects occur. Suicidal ideation (in children and adolescents) 24)​Caring for a Client Who is Taking Infliximab a)​ Invasive fungal infections (histoplasmosis, TB, reactivation of hepatitis B) b)​ Nursing Actions: Test for hepatitis B and TB. 25)​Acute vs. Chronic, Urgent vs. Nonurgent, Stable vs. Unstable a)​ A client who has an acute problem takes priority over a client who has a chronic problem. b)​ A client who has an urgent need takes priority over a client who has a nonurgent need. c)​ A client who has unstable findings takes priority over a client who has stable findings. 26)​Primary hypertension (exact mechanism unknown: long-term use causes reduction in peripheral vascular resistance). High-ceiling loop diuretics Select Prototype Medication: Furosemide Other Medications ●​ Ethacrynic acid ●​ Bumetanide ●​ Torsemide Purpose Expected Pharmacological Action High-ceiling loop diuretics work in the loop of Henle. ●​ Block reabsorption of sodium and chloride and prevent reabsorption of water ●​ Cause extensive diuresis even with severe renal impairment ●​ Increase kidney excretion of water, potassium, sodium, chloride, magnesium, calcium Anaphylaxis is a rapid systemic reaction following an allergic response to an allergen. Common sources are medications, dyes, foods, and insect bites and stings. ●​ Initial manifestations of anaphylaxis include GI cramping and apprehension, with generalized itching and hives following, progressing to angioedema and intensely large, itchy hives. ●​ Respiratory manifestations following inflammation and mucous production include lung crackles, wheezing, decreased breath sounds, a feeling of a lump in the throat, hoarseness, and stridor. The client can develop respiratory failure and death. ●​ Cardiovascular manifestations include weak, thready pulse, tachycardia, and hypotension. ●​ Allergic asthma can have a similar progression following exposure to an allergen and can become life-threatening. 27)​ Caring for a Client Who Is Receiving Midazolam a)​ IV: Administer flumazenil to counteract sedation and reverse adverse effects. 28)​ Beta1 Blockade: metoprolol, propranolol a)​ Monitor pulse. If below 50/min, hold medication and notify the provider. b)​ Use cautiously in clients who have diabetes mellitus. This medication can mask tachycardia, an early manifestation of low blood glucose. Advise clients to monitor blood glucose to detect hypoglycemia. 29)​ Evaluating a Client's Understanding of Cromolyn Mast cell stabilizers (cromolyn) ●​ Long term control Monoclonal antibodies (omalizumab, reslizumab) are used to treat moderate to severe persistent allergic asthma uncontrolled by inhaled corticosteroids in children 12-years-old and older. 30)​Administer amantadine (releases and uptakes DA) to decrease dyskinesias. 31)​ 32)​ Nursing Interventions for a Client Who Has a Prescription for Diclofenac a)​ Take medication with food or with an 8 oz glass of water or milk. 33)​ Monitoring Laboratory Tests When Administering Epoetin Alfa a)​ Obtain baseline blood pressure. In clients who have chronic kidney disease, control hypertension before the start of treatment. QEBP b)​ Monitor blood pressure frequently, because adjustments in antihypertensive medication can also be required as treatment progresses. c)​ Administer by subcutaneous or IV bolus injection. Dosage is based on the client’s weight. d)​ Do not agitate the vial of medication. Use each vial for one dose, and do not put the needle back into the vial when withdrawing the medication. e)​ Do not mix the medication with any other medication in the syringe. f)​ Dosing is usually three times per week, but can be once per week with some types of chemotherapy. g)​ Monitor iron levels, and implement measures to ensure an iron level that is within the expected reference range. RBC growth depends on adequate quantities of iron, folic acid, and vitamin B12. Without adequate levels of these, erythropoietin is significantly less effective. h)​ Monitor Hgb and Hct once weekly (darbepoetin) or at least twice per week (erythropoietin) until they reach the target range. i)​ Ensure that clients receive the FDA’s Risk Evaluation and Mitigation Strategy medication guide that explains risks and benefits of ESAs. The medication guide also discusses ways clients can help minimize risks of the medication. QPCC​ j)​ The longer-acting forms are administered less frequently. 34)​ 35)​ Contraindications for Sumatriptan a)​ ​Warnings i)​ Pregnancy: Use only if maternal benefit outweights fetal risk. ii)​ Lactation: Use only if maternal benefit outweighs fetal risk. iii)​ Reproductive: Recommend the use of contraceptive measures to avoid pregnancy while taking this medication. b)​ Contraindicated in clients who have liver failure, ischemic heart disease, a history of myocardial infarction, uncontrolled hypertension, and other heart diseases. 36)​ 37)​ Treatment for Adverse Effects of Topotecan a)​ Nursing actions: Administer antiemetic (ondansetron in combination with dexamethasone, granisetron, or metoclopramide) before beginning chemotherapy. 38)​ 39)​Adverse Effects of Combination Oral Contraceptives a)​ Does not protect against STIs. b)​ Can increase the risk of thromboembolism, stroke, heart attack, hypertension, gallbladder disease, and liver tumor. c)​ Exacerbates conditions affected by fluid retention (migraine, epilepsy, asthma, kidney or heart disease). d)​ Adverse effects include headache, nausea, breast tenderness, and breakthrough bleeding. (Estrogen can cause nausea, breast tenderness, fluid retention. Progestin can cause increased appetite, fatigue, depression, breast tenderness, oily skin and scalp, and hirsutism.) 40)​Teaching About Adverse Effects of Hydrochlorothiazide a)​ Hyperglycemia b)​ Nursing actions: Monitor for an increase in blood glucose levels. 41)​Priority Finding to Report for a Client Receiving Ketorolac a)​ Impaired kidney function b)​ Decreased urine output, weight gain from fluid retention, increased BUN, and creatinine levels c)