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What action does the nurse take during the intervention stage of the nursing process related to drug therapy? (Select all that apply)
- A. Analyze the data collected.
- B. Collect a nursing history.
- C. Determine medication effectiveness.
- D. Document the medication.
- E. Administer the medication.
Correct Answer: C,D,E
Rationale: During the intervention stage of the nursing process related to drug therapy, the nurse's actions include determining medication effectiveness (C) to ensure the treatment is achieving its intended outcomes. Documenting the medication (D) is crucial for maintaining accurate records of administration and monitoring. Administering the medication (E) is essential for providing the prescribed treatment to the patient. Analyzing data (A) is typically done during the assessment phase, not the intervention phase. Collecting a nursing history (B) is part of the assessment phase. Other choices are not directly related to the intervention stage of drug therapy.
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A patient asked the nurse what cardiac glycosides do to improve his condition. What is the nurse's best response?
- A. They increase heart rate.
- B. They decrease the force of myocardial contractions.
- C. They decrease conduction velocity.
- D. They help renal blood flow and increase urine output.
Correct Answer: D
Rationale: The correct answer is D because cardiac glycosides, such as digoxin, help improve heart failure by increasing renal blood flow and urine output. This occurs by inhibiting the sodium-potassium pump, leading to increased intracellular calcium levels, which in turn enhances cardiac contractility and renal perfusion. Choices A, B, and C are incorrect because cardiac glycosides do not increase heart rate, decrease the force of myocardial contractions, or decrease conduction velocity. These medications actually have a positive inotropic effect, increasing the force of myocardial contractions.
The nurse is conducting an admission assessment on a patient. When collecting data relating to the medications, the nurse asks “What medications are you taking?†After collecting that information, what other queries should the nurse ask? Select all that apply.
- A. Do you take any medication?
- B. Do you take this medication?
- C. Do you take medications safely when you take them?
- D. Do you take any herbs, vitamins or supplements?
- E. What OTC medications do you take?
Correct Answer: D,E
Rationale: The correct answers are D and E. Asking about herbs, vitamins, and supplements (D) is crucial as these can interact with prescribed medications. Inquiring about over-the-counter (OTC) medications (E) is important as they can also have interactions. Choices A, B, and C are vague and redundant, as they do not provide specific information about medications. Asking about medication safety (C) is assumed in the context of a healthcare setting. Choice F and G are not provided in the question.
The nurse is caring for a patient that has seizure disorder. The nurse notes that the patient has reddened gums that bleed when oral care is given. The nurse recognizes this finding as:
- A. A sign of poor self-care.
- B. A drug interaction with aspirin.
- C. An adverse effect of the phenytoin.
- D. A symptom of hepatotoxicity.
Correct Answer: C
Rationale: The correct answer is C: An adverse effect of phenytoin. Phenytoin is an antiepileptic drug known to cause gingival hyperplasia, leading to reddened and bleeding gums. This is a common side effect of phenytoin due to its effect on gingival tissues. Poor self-care (choice A) may contribute to gingival issues, but in this case, the patient's gums are affected by a medication side effect. There is no indication in the question of aspirin use (choice B) or hepatotoxicity (choice D) causing the gum issues. Therefore, the most likely explanation is the adverse effect of phenytoin.
The nurse is caring for a patient who is receiving a high dose of intravenous azithromycin to treat an infection. The patient is also taking acetaminophen for pain. The nurse should expect to review which lab value when monitoring for this drug side effect?
- A. Complete blood count.
- B. Urinalysis.
- C. Electrolytes.
- D. Liver enzymes.
Correct Answer: D
Rationale: The correct answer is D: Liver enzymes. Azithromycin can cause liver toxicity as a side effect. Monitoring liver enzymes such as AST and ALT levels is crucial to detect any signs of liver damage. Acetaminophen is also metabolized in the liver, so combining it with azithromycin may increase the risk of liver injury. Checking liver enzymes helps the nurse assess the patient's liver function and adjust the medication regimen if necessary.
A: Complete blood count is not typically affected by azithromycin or acetaminophen.
B: Urinalysis is not relevant for monitoring liver toxicity.
C: Electrolytes are important but not specifically related to the side effects of azithromycin or acetaminophen in this scenario.
The nurse is providing teaching to a patient who is prescribed an HMG-CoA reductase inhibitor. What will be an important teaching point for this patient?
- A. Use barrier contraception to avoid pregnancy.
- B. Report any changes in vision.
- C. Follow a cholesterol-lowering diet.
- D. Report any respiratory symptoms.
Correct Answer: A
Rationale: The correct answer is A: Use barrier contraception to avoid pregnancy. HMG-CoA reductase inhibitors are known to cause birth defects if taken during pregnancy. Therefore, it is crucial for the patient to use effective barrier contraception to prevent pregnancy while on this medication. Reporting changes in vision (B) is not directly related to HMG-CoA reductase inhibitors. Following a cholesterol-lowering diet (C) is important but not the most critical point for this specific medication. Reporting respiratory symptoms (D) is important but not specific to this medication.