Pharmacology

Archer Review Crash Course

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Antianxiety Agents
● Short acting
○ Midazolam (Versed)
○ Diazepam (Valium)

● Intermediate - Long acting

○ Clonazepam (Klonopin)
○ Alprazolam (Xanax)
○ Lorazepam (Ativan)

Ativan
Therapeutic class: antianxiety agent

Indication: anxiety, sedation, seizures

Action: general CNS depression

Nursing Considerations:
● Avoid alcohol
● Monitor for respiratory depression
● Antidote - flumazenil
NCLEX Question
The nurse is caring for a patient who is experiencing severe, acute anxiety
prior to a scheduled endoscopy procedure. Which of the following
medications is the healthcare provider most likely to order?

A. Oxycodone
B. Midazolam
C. Clonazepam
D. Haloperidol

Answer: B
A is incorrect. Oxycodone is an opioid pain medication prescribed for severe pain. It is not
indicated in an acute anxiety attack.
B is correct. Midazolam is a benzodiazepine used for acute anxiety attacks. Midazolam is
preferred in this setting because of its rapid onset, about 2-5 minutes after IV
administration, and short duration, only 3-8 hours. Midazolam would be the most useful
choice for the patient experiencing an acute anxiety attack before or during a procedure.
C is incorrect. Clonazepam is a long-acting benzodiazepine used for panic disorders, PTSD,
and GAD. For this patient with an acute anxiety attack prior to a procedure, a long-acting
benzodiazepine is not indicated.
D is incorrect. Haloperidol is an antipsychotic used to address severe agitation and
aggression associated with psychiatric disorders such as schizophrenia. It would not be
useful for the patient experiencing a pre-procedural acute anxiety attack.
Antiarrhythmics
● Amiodarone
● Adenosine
● Procainamide

Adenosine
Therapeutic class: Antiarrhythmic

Indication: SVT

Action: Slows conduction through the AV node, interrupts re-entry pathways through AV node,
restoring normal sinus rhythm

Nursing Considerations:

● There will be a period of asystole after administration

● Warn the patient - it will feel like someone kicked them in the chest!
● Warn the family - they will flatline on the monitor!
● Rapid push - or it will not work.
● Use with extreme caution in asthmatics.
Anticoagulants
● Heparin
● Clopidogrel (Plavix)
● Warfarin
● Enoxaparin (Low-molecular weight heparin)

Heparin
● Classification: Indirect Thrombin Inhibitor
○ Anticoagulant!
● How it works
○ Thrombin → converts fibrinogen to fibrin → Fibrin forms clots!
○ Antithrombin III inhibits Thrombin
○ Heparin ENHANCES antithrombin III
○ This stops thrombin from being activated, which therefore prevents clots from forming.
● This is the intrinsic coagulation pathway

End result? SLOWS DOWN CLOTTING.

 Basic Information
● Uses
○ To prevent blood clots
■ Strokes
■ Chronic a-fib
■ Post-operatively
● Administration
○ Subcutaneous
○ Intravenous
● Titration
○ Patients on a heparin drip have aPTT levels drawn q4-6 hours to titrate the drip.

Important Nursing Considerations

● Biggest side effect to monitor for = bleeding!
○ Hematuria - Pink tinged urine
○ Hematemesis - bloody vomitus
○ Bruising
○ Downtrending H&H
● Antidote = protamine sulfate
 Heparin Induced Thrombocytopenia and Thrombosis (HITT)
● Complication of Heparin therapy
● Usually occurs 5-10 days after Heparin exposure
● Suspect in any patient on Heparin who has an unexplained platelet drop
● Clinical manifestations:
○ Skin lesions at heparin injection sites
○ Chills
○ Fever
○ Dyspnea
○ Chest pain
● Complications - clotting!
○ DVT
○ PE
● Treatment
○ Discontinue ALL heparin and start a different anticoagulant!

Warfarin
Therapeutic class: Anticoagulant
Indication: venous thrombosis, pulmonary embolism, A-fib
Action: disrupts liver synthesis of Vitamin K dependent clotting factors
Nursing Considerations:
● Monitor for bleeding
● Monitor PT and INR
○ Therapeutic PT: 1.3-1.5
○ Therapeutic INR: 2.5-3.5
● Antidote: Vitamin K
● Contraindicated during pregnancy
NCLEX Question
The nurse is caring for a pregnant client who is at 16 weeks gestation. She
developed a pulmonary embolism and was initiated on heparin therapy two
days ago. She is getting ready to be discharged. Which of the following
medications do you expect the healthcare provider to order at discharge?

A. Warfarin
B. Rivaroxaban
C. Apixaban
D. Low Molecular Weight Heparin (LMWH)

Answer: D
A is incorrect. Warfarin is contraindicated during pregnancy. It can cause
congenital disabilities, maternal bleeding, stillbirths, and miscarriages.

B and C are incorrect. Rivaroxaban and Apixaban belong to the class of Factor
Xa inhibitors. These are newer anticoagulants and are not safe in pregnancy.

D is correct. Low Molecular Weight Heparin is the drug of choice for

anticoagulation in pregnancy. It does not cross the placenta and therefore
does not cause fetal harm.
Anticonvulsants
● Phenytoin (Dilantin)
● Carbamazepine
● Divalproex
● Gabapentin
● Lamotrigine
● Levetiracetam (Keppra)

Phenytoin
Therapeutic class: Anticonvulsant
Indication: Seizures
Action: blocks sustained high frequency repetitive firing of action potentials
Nursing Considerations:
● Therapeutic level: 10-20 mcg/mL
● Side effect: gingival hyperplasia
○ Regular dental check-ups
○ Use soft bristle toothbrush
● Antacids can reduce the effect of phenytoin and should be avoided.
NCLEX Question
The nurse is educating a patient who is taking phenytoin. To make sure
phenytoin does not fail, which over-the-counter medication should the nurse
advise the patient not to take at the same time?

A. Acetaminophen
B. Ibuprofen
C. Calcium Carbonate
D. Ranitidine

Answer: C
A is incorrect. Acetaminophen and Phenytoin can be taken together without any concern for
therapeutic failure.
B is incorrect. Ibuprofen and Phenytoin can be taken together without any concern for
therapeutic failure.
C is correct. Calcium Carbonate (Tums) should not be taken at the same time as Phenytoin
because taking them together can decrease the effects of phenytoin. Antacids containing
calcium carbonate reduce the bioavailability of phenytoin by reducing the rate of absorption
and amount of intake. If the patient needs both phenytoin and calcium carbonate, they
should be administered at least 2-3 hours apart.
D is incorrect. Ranitidine and Phenytoin can be taken together without any concern for
therapeutic failure. Instead, Ranitidine can increase the effects of Phenytoin, so the patient
should be monitored for any phenytoin related side effects.
Antidepressants
● SSRIs
○ Fluoxetine
○ Sertraline
○ Escitalopram
○ Citalopram
● TCAs
○ Amitriptyline
○ Nortriptyline
○ Protriptyline
● MAOIs
○ Tranylcypromine
○ Isocarboxazid
○ Phenelzine
○ selegiline

SSRIs
Examples: Fluoxetine, Sertraline, Escitalopram, Citalopram
Indication: Depression
Action: Prevent reuptake of serotonin increasing the availability of serotonin in
the body.
Nursing Considerations:
● Monitor for serotonin syndrome
○ Hypertension, confusion, anxiety, tremors, ataxia, sweating.
● Suicide precautions important for 2-3 weeks
○ When the patient’s mood starts to improve, they are are an inreased risk for suicide
○ Why? They now have the energy to follow through with a plan.
TCA’s
Examples: Amitriptyline, Nortriptyline, Protriptyline
Indication: Depression
Action: Prevents the reuptake of norepinephrine and serotonin increasing
these neurotransmitters in the body..
Nursing Considerations:
● Monitor for anticholinergic side effects
○ Dry mouth, constipation, urinary retention

Monoamine Oxidase Inhibitors

Examples: tranylcypromine, isocarboxazid, phenelzine, selegiline
Indication: Depression
Action: blocks monoamine oxidase enzymes to increase the levels of ALL neurotransmitters
( dopamine, norepinephrine, epinephrine, serotonin)
Nursing Considerations:
● Avoid foods that are high in tyramine.
○ Aged cheeses
○ Wine
○ Pickled meats
● Side effect - hypertensive crisis
Mood Stabilizers
● Lithium

Lithium
Indication: Mania
Action: Inhibits excitatory neurotransmitters such as dopamine and
glutamate, and promotes GABA-mediated neurotransmission.
Nursing Considerations:
● Do not administer with NSAIDS
● Monitor drug levels:
○ Therapeutic level - 0.5-1.5mEq/L
● Encourage adequate fluid intake
● Side effects:
○ Seizures, arrhythmias, fatigue, confusion, nausea, anorexia, hypothyroidism, tremors
Antipsychotics
● Haloperidol
● Quetiapine
● Olanzapine

Haloperidol
Therapeutic class: Antipsychotic
Indication: Schizophrenia, mania, aggressive behavior, agitation
Action: Inhibits the effects of dopamine
Nursing Considerations:
● Monitor for extrapyramidal side effects
● Tardive dyskinesia
● Neuroleptic malignant syndrome
● Can prolong the QT interval
○ Weekly EKG
Antihistamines
● Diphenhydramine
● Promethazine
● Cimetidine
● Famotidine
● Ranitidine

Diphenhydramine
Therapeutic class: Antihistamine

Indication: Allergy, anaphylaxis, sedation

Action: Antagonizes effects of histamine, CNS depression

Nursing Considerations:

● Monitor for drowsiness

● Anticholinergic effects
Antihypertensives
● ACE inhibitors
○ Captopril
○ Enalapril
○ Lisinopril
● Angiotensin II Receptor Blockers
○ Losartan
● Calcium Channel Blockers
○ Amlodipine
○ Diltiazem
○ Nifedipine
○ Verapamil
● Beta-blockers (next class)

Enalapril
Therapeutic class: ACE inhibitor

Indication: Hypertension, CHF

Action: Blocks conversion of angiotensin I to angiotensin II, increases renin

levels and decreases aldosterone leading to vasodilation

Nursing Considerations:

● Can cause a dry cough - should be discontinued if it does.

● Monitor BP
● Contraindicated during pregnancy
Losartan
Therapeutic class: Angiotensin II receptor blocker (ARB)

Indication: hypertension, DM neuropathy, CHF

Action: inhibits vasoconstrictive properties of angiotensin II

Nursing Considerations:

● Monitor BP
● Monitor fluid levels
● Monitor renal and liver status
● Contraindicated during pregnancy

Amlodipine
Therapeutic class: Calcium channel blocker
Indication: Hypertension, angina
Action: Blocks transport of calcium into muscle cells inhibiting excitation and
contraction, causes peripheral vasodilation
Nursing Considerations:
● Avoid grapefruit
○ Blocks the enzyme involved in metabolizing calcium channel blockers, causing their levels
to increase.
● Monitor BP - orthostatic hypotension
● Can cause gingival hyperplasia
NCLEX Question
The nurse is providing discharge instructions to a client with accelerated hypertension who has been
newly started on Nifedipine. His home medications include calcium supplements for osteoporosis,
omeprazole for heartburn, furosemide, and lisinopril. Which statement(s) by the client demonstrates
the need for additional teaching regarding Nifedipine? Select all that apply.

a. “My gums may swell because of this medication.”

b. “I will avoid getting up too quickly from sitting or lying position.”
c. “I will stop taking calcium supplements since they may negate the effects of Nifedipine.”
d. “It is highly likely that I will get constipated from this drug”
e. “If I get cough and tongue swelling, I will hold Nifedipine”

Answer: A and B
A is correct. Gum/ gingival hyperplasia is a common side effect with extended-standing use of Nifedipine.

B is correct. The patient should avoid getting up too quickly from sitting or lying position. Because of peripheral
vasodilation, Nifedipine causes postural or orthostatic hypotension. So, the client should be aware of getting up
slowly from the lying/ sitting position so they do not become dizzy.

C is incorrect. The patient should not stop taking their calcium supplements. There is no evidence to say oral calcium
supplements will reduce the effects of CCBs. Also, this client needs calcium supplements for his osteoporosis.
Therefore, this does not reflect correct understanding by the client and needs additional teaching.

D is incorrect. There is a less than 2% chance that the person can get constipated from Nifedipine, it is not true that
the client is highly likely to get constipated from Nifedipine. Therefore, this statement does not reflect correct
understanding by the client and needs additional teaching.

E is incorrect. The patient should not hold Nifedipine if they get cough and tongue swelling. Cough and tongue
swelling (Angioedema) are common side effects seen with ACE inhibitors, not with CCBs. The client is also on
Lisinopril (ACEI), which may lead to this side effect, so the nurse will need to explain this to the client.
Beta Blockers
● Propranolol
● Atenolol
● Metoprolol

Propranolol
Therapeutic class: antiarrhythmic

Indication: hypertension, angina, arrhythmias, MI, cardiomyopathy, alcohol

withdrawal, anxiety

Action: blocks Beta 1 and 2 adrenergic receptors slowing the heart rate

Nursing Considerations:

● Do not discontinue abruptly, discontinue them slowly,

● Can mask the signs of hypoglycemia; important to monitor blood sugars.
NCLEX Question
The nurse is working with a patient who has been experiencing multiple
episodes of chest pain. The patient has a strong family history of heart
disease. The patient is prescribed a medication to prevent myocardial
infarction. Which of the following medications is appropriate for this
condition?

a. Indomethacin
b. Loperamide
c. Ibuprofen
d. Propranolol

Answer
D is correct. Propranolol is a beta blocker that is used to treat hypertension, angina, arrhythmias,
and heart attacks.

A is incorrect. Indomethacin is an antirheumatic medication that is used for patients with

rheumatoid arthritis. It would not be used in a patient to prevent heart attacks.

B is incorrect. Loperamide is an anti-diarrheal. It would not be used in a patient to prevent heart

attacks.

C is incorrect. Ibuprofen is a non-steroidal anti-inflammatory agent. It treats mild to moderate pain

and inflammation. It would not be used in a patient to prevent heart attacks.
 Break! Back at 11:00 CST

Cardiac glycosides
● Digoxin
Digoxin
Therapeutic class: Cardiac glycoside

Indication: Heart failure, a-fib, a-flutter, CHF, cardiogenic shock

Action: Increases contractility (how strong the heart pumps), and decreases the rate (how fast the
heart beats). Acts on the cellular sodium-potassium ATPase, making the heart more efficient!

Nursing Considerations:

● Monitor for toxicity

○ Vision changes, blurred vision, yellow/green vision

Toxicity
Monitor for toxicity in any patient taking digoxin!
Narrow therapeutic range!! → Therapeutic lab level: .5-2ng/mL

● Signs/symptoms:
○ Nausea & vomiting
○ Anorexia
○ Vision changes - yellow/green halos
○ Bradycardia → arrhythmias

Monitor for these signs and symptoms and report them to the health care
provider early!
 Risk factors for toxicity
● Patients with hypokalemia (K<3.5)
○ **If your patient is on a loop diuretic, and digoxin, they are more likely to become toxic!**
○ Licorice extract acts like aldosterone (Na/water retention & K loss) → hypokalemia → Dig
Toxicity. Licorice extract is in black licorice.
● Patients with hypomagnesemia (Mg<1.8)
● Patients with hypercalcemia (Ca>10.5)
● The elderly!
○ These patients have decreased renal and liver function, making it harder for them to clear
any drugs, so digoxin levels can build up and become toxic more quickly!

Important Nursing Consideration

When should you HOLD your digoxin dose??

In general, if the pulse is less than 60, you should hold digoxin. This will be
slightly different in different age groups. Always check your order!
NCLEX Question
A nurse is caring for a client receiving digoxin. The client’s most recent serum
digoxin level was 2.5 ng/mL. Which of the following priority nursing actions
should the nurse take? Select all that apply.

A. Withhold the client’s scheduled dose

B. Administer the dose as prescribed
C. Assess the client's urinary output
D. Assess the client's most recent sodium level
E. Assess the client’s heart rate and rhythm

Answer: A and E
The client’s digitalis level of 2.5 ng/mL is indicative of toxicity. Digoxin has a narrow therapeutic index, which
means it can cause significant side effects, such as cardiac arrhythmias (e.g., bradycardia, heart block,
ventricular arrhythmias), even at plasma concentrations only twice the therapeutic plasma concentration
range. Normal corrective serum digoxin levels range from 0.5 - 2 ng/mL. A level higher than two ng/mL is
considered toxic. The nurse is correct to withhold the scheduled dose (Choice A) and assess the client’s heart
rate and rhythm (Choice E) as the client is likely to be experiencing bradycardia.

Choice B, C, D, and F are incorrect. It would be wrong to administer the next dose, as this would exacerbate
the toxicity. An assessment of the urinary output and sodium is not relative to digitalis toxicity and is not the
priority here. Calling the physician to notify regarding the toxic level is appropriate, but there is no reason to
obtain a 2D echocardiogram. A 2D echocardiogram will not add any additional information at this point.
Instead, an electrocardiogram must be obtained to look for any rhythm disturbances due to digoxin toxicity.
NCLEX Question
The nurse is providing a client with discharge instructions on his newly initiated Digoxin. Which of the
following statements by the client indicates he correctly understood the instructions? Select all that
apply.

a. “If I note color vision changes, I will call my doctor right away.”
b. “I will check my pulse before each dose and if the pulse is less than 100 bpm, I will hold
Digoxin and call my doctor.”
c. “I will increase my calcium intake significantly.”
d. “I will make sure I get enough potassium in my daily diet.”
e. “The water pills that I am on may increase the risk of side effects with Digoxin.”
f. “I should avoid medications that have licorice extract.”

Answer: A, D, E, F
A is correct. One of the early side effects of Digoxin is visual aberrations such as yellowish-green color changes or halos.
Therefore if the patient notes color vision changes, they should call the doctor right away.”

B is incorrect. The first cardiac side effect of digoxin toxicity is bradycardia, but cardiac arrhythmias can follow later. It is
essential to monitor for these early side effects, so the next dose of Digoxin can be held, and the physician can be notified.
The patient should check their pulse before each dose and if the pulse is less than 60 bpm hold Digoxin and call the
doctor.

C is incorrect. Hypercalcemia can cause digoxin toxicity, therefore the patient should not increase their calcium intake
significantly.

D is correct. Because hypokalemia can cause digoxin toxicity, the patient should make sure they get enough potassium in
their daily diet.

E is correct. If the patient is on a loop diuretic such as furosemide, they increase the risk of side effects with Digoxin due to
losses of potassium and subsequent hypokalemia. These patients should be monitored more closely for toxicity.

F is correct. The patient should avoid medications that have licorice extract. Licorice extract acts like the hormone
aldosterone - causing sodium and water retention and growing potassium loss. Hypokalemia, in turn, precipitates digoxin
toxicity.
Anti-Infectives
● Aminoglycosides ● Anti-viral
○ Gentamicin ○ Acyclovir
● Fluoroquinolones ● Antifungal
○ Ciprofloxacin ○ Amphotericin B
○ Levofloxacin ○ Metronidazole
● Macrolides ○ Nystatin
○ Erythromycin
○ Azithromycin
● Vancomycin
● Penicillins & Cephalosporins
○ Amoxicillin
○ Ampicillin
○ Ancef

Gentamycin
Therapeutic class: Anti-infective; aminoglycoside

Indication: Gram negative infections

Action: Inhibition of bacterial protein synthesis

Nursing Considerations:

● Monitor for tinnitus

● Do not administer with penicillin
Ciprofloxacin
Therapeutic class: Anti-infective; fluoroquinolone

Indication: Infection

Action: Inhibits synthesis of bacterial DNA

Nursing Considerations:

● Can cause QT prolongation

● Decreases effects of phenytoin

Vancomycin
Therapeutic class: Anti-infective; glycopeptide antibiotics

Indication: Infection; sepsis

Action: kills bacteria in the intestines

Nursing Considerations:

● Monitor for ototoxicity and nephrotoxicity

● Red-man syndrome
● Administer over at least 60 minutes; central line preferred.
Amoxicillin
Therapeutic class: Anti-infectives; aminopenicillin

Indication: Infections; skin, respiratory, endocarditis

Action: Inhibits synthesis of bacterial cell wall leading to cell death

Nursing Considerations:

● Monitor for rash

● Monitor kidney function
○ BUN, Cr

NCLEX Question
While caring for a patient on a general medicine floor, the nurse prepares to administer a
cephalosporin antibiotic for a sinus infection. Which of the following side effects does the
nurse monitor for while administering this medication? Select all that apply.

A. Diarrhea
B. Hypoactive bowel sounds
C. Nephrotoxicity
D. Tinnitus
Answer: A and C
A is correct. Diarrhea is a side effect of cephalosporin antibiotics. This
antibiotic will kill off a large amount of the good bacteria in the gut, which
often leads to hyperactive bowel sounds, abdominal cramping, and diarrhea.
B is incorrect. The patient taking a cephalosporin antibiotic is more likely to
have hyperactive bowel sounds.
C is correct. Nephrotoxicity is a known potential side effect of cephalosporins.
The nurse should monitor the patient's BUN and Cr closely to evaluate kidney
function.
D is incorrect. Tinnitus is a side effect of aminoglycosides, not cephalsporins.

NCLEX Question
The nurse is doing admission documentation on a new patient. While reviewing his allergies,
he states he has a reaction called “red man’s syndrome”, but he doesn’t know which drug it is
that he’s allergic to. The nurse documents which of the following medications as the patient’s
allergy?

a. Ciprofloxacin
b. Vancomycin
c. Gentamicin
d. Amoxicillin
Answer: B
A in incorrect. Ciprofloxacin does not cause ‘red man’s syndrome’. Ciprofloxacin is a fluoroquinolone
antibiotic. It can cause QT prolongation and decrease the effects of some medications, such as phenytoin.

B is correct. Vancomycin is the drug that causes the reaction known as ‘red man’s syndrome’. This is a very
serious allergic reaction which the entire body itches and a red rash appears on the face, neck, and torso. It
commonly occurs if the infusion is run too quickly; vancomycin should always go over at least one hour.

C is incorrect. Gentamicin does not cause ‘red man’s syndrome’. Gentamicin is an aminoglycoside antibiotic.
Important side effects to monitor for include tinnitus.

D is incorrect. Amoxicillin does not cause ‘red man’s syndrome’. Amoxicillin is a penicillin antibiotic. While it
can cause a rash, it is not similar to the red man syndrome rash vancomycin can cause. The nurse should
also know to monitor kidney function labs while the patient is taking amoxicillin.

Autonomic Nervous System Medications

● Dobutamine
● Dopamine
● Atropine
● Benztropine
Atropine
Therapeutic class: Antiarrhythmic; anticholinergic

Indication: excessive secretions, sinus bradycardia, heart block

Action: Inhibition of acetylcholine, increasing the HR, causing bronchodilation,

and decreasing secretions.

Nursing Considerations:

● Monitor for urinary retention and constipation

● Avoid in patients with glaucoma

Respiratory Medications
● Rescue meds
○ Albuterol
○ Ipratropium
● Long-term control meds
○ Guaifenesin → Expectorant
○ Montelukast → Leukotriene modifier
○ Theophylline → Phosphodiesterase Enzyme Inhibitor
Albuterol
Therapeutic class: Bronchodilator; short acting beta 2 agonist

Indication: Asthma, COPD

Action: Binds to Beta2 adrenergic receptors in the airway leading to relaxation

of the smooth muscles in the airways

Nursing Considerations:

● Be very cautious when using in patients with heart disease, diabetes,

glaucoma, or seizures.
● Causes tachycardia

NCLEX Question
Which of the following medication classes are considered ‘quick-relief’ or rescue medications for a
child having an acute asthma attack? Select all that apply.

a. Corticosteroids
b. Leukotriene modifiers
c. Short-acting beta 2 agonists
d. Anticholinergics
Answer: C and D
C is correct. Short-acting beta-2 agonists are "rescue" medications used for bronchodilation in an acute asthma
attack. Examples include albuterol and salbutamol. A "rescue" medication is the one that can provide relief even after
bronchospasm is triggered.

D is correct. Anticholinergics are rescue medications used for the relief of acute bronchospasm. Examples include
Ipratropium and Tiotropium.

A is incorrect. Corticosteroids are long term control medications used to reduce inflammation. They are not
immediately useful as "rescue" medications but are useful in long term management of persistent asthma.

B is incorrect. Leukotriene modifiers are long term control medications used to prevent bronchospasm and
inflammatory cell infiltration. They are often used as prophylactic agents before a triggering event, for example, in
exercise-induced asthma. They are not useful as a "rescue" once bronchospasm occurs. For example, Montelukast is
indicated to be used " as needed" before exercising in patients who do not require daily bronchodilator. Montelukast
is taken at least two hours before the initiation of exercise.

Diuretics
● Loop diuretics
○ Bumetanide
○ Furosemide
○ Torsemide
● Potassium sparing diuretics
○ Triamterene
○ Amiloride
○ Spironolactone
● Thiazide diuretics
○ Chlorothiazide
○ Chlorthalidone
○ Hydrochlorothiazide
○ Indapamide
Loop Diuretics
● Examples:
○ Bumetanide, Furosemide, Torsemide
● Mechanism of action:
○ Act on the loop of Henle to increase urine output by affecting sodium reabsorption within
the nephron.
○ Inhibits the sodium potassium chloride cotransporter causing sodium to be excreted in
the urine therefore increasing diuresis.
● Uses:
○ Increase urinary output, edema, CHF, blood pressure management.
● Nursing considerations:
○ Monitor potassium levels
● These are the most effective of all diuretics.

Potassium Sparing Diuretics

● Examples:
○ Triamterene, Amiloride, Spironolactone, Eplerenone
● Mechanism of action:
○ Inhibit sodium and potassium exchange via sodium channels in the distal parts of the
nephron.
○ This ‘spares’ potassium!!
● Uses:
○ Hypertension, edema, swelling, hypokalemia.
● Nursing considerations:
○ Monitor potassium levels
● These medications are not as strong as other diuretics, so are often
combined with a loop or thiazide diuretic!
Thiazide Diuretics
● Examples: Chlorothiazide, Chlorthalidone, Hydrochlorothiazide,
Indapamide, Metolazone.
● Mechanism of action:
○ These diuretics act on the distal convoluted tubule to inhibit the sodium-chloride
cotransporter.
○ This increases sodium in the filtrate causing an increased amount of water reabsorption
and therefore increased urinary output.
● Uses:
○ Hypertension, CHF
● Nursing Considerations:
○ Monitor electrolyte levels
○ Monitor BP

GI Medications
● Bisacodyl
● Lactulose
● Metoclopramide
● Ondansetron
● Omeprazol
● Pantoprazole
Ondansetron
Therapeutic class: Antiemetic

Indication: Nausea/vomiting

Action: blocks effects of serotonin on vagal nerve and CNS

Nursing Considerations:

● Administer slowly. Fast push can cause QT prolongation and VT.

Omeprazole
Therapeutic class: Proton-pump inhibitor

Indication: GERD, ulcers

Action: prevents the transport of H ions into the gastric lumen by binding to
gastric parietal cells to decrease gastric acid production

Nursing Considerations:

● Administer 30-60 minutes before meal

● Report black, tarry stools
 Dose Calc
Pull up your cheat sheet to learn the basics, and then work through the
worksheet! We will review it together at 12:00 CST.

Non-opioid Analgesics
● Acetaminophen
● NSAIDS
○ Aspirin
○ Ibuprofen
○ Naproxen
Acetaminophen
Therapeutic class: antipyretic, non-opioid analgesic

Indication: Pain, fever

Action: Inhibit the synthesis of prostaglandins which play a role in

transmission of pain signals and fever response

Nursing Considerations:

● Max daily dose = 4g

● Monitor liver function
● Antidote = n-acetylcysteine

NSAIDS - Non-steroidal anti-inflammatory drugs

Examples: Aspirin, ibuprofen, ketoprofen, naproxen

Indication: Pain, inflammation, fever

Action: Block prostaglandin which causes inflammation, pain, and fever.

Nursing Considerations:

● Can cause prolonged bleeding

○ Typically avoided in trauma and surgical patients
● Can cause peptic ulcers
NCLEX Question
Your patient is receiving a nonsteroidal anti-inflammatory medication in
addition to a narcotic analgesic. The client asks you why they are getting an
NSAID when the narcotic analgesic works so much better. Which of the
following responses are appropriate?
A. I don’t know why. I suggest you ask your doctor the next time you see her.
B. You are getting the NSAID because we are trying to wean you off of the
narcotic analgesic for your moderate to severe pain.
C. You are getting the NSAID so the effect of the narcotic analgesic is more
effective.
D. You are getting the NSAID as a placebo to help with your severe pain.

Answer: C
A is incorrect. It would not be appropriate to say “I don’t know why. I suggest you ask your
doctor the next time you see her.” This response is not appropriate because the nurse
should know why the NSAID is being given, and be able to address the patient’s question.

B is incorrect. It would not be appropriate to say “You are getting the NSAID because we
are trying to wean you off of the narcotic analgesic for your moderate to severe pain.” The
NSAID is being given for another reason, so this response is incorrect.

C is correct. Telling the patient they are getting the NSAID so the effect of the narcotic
analgesic is more effective is appropriate. The NSAID is an adjuvant medication that is used
in combination with narcotic analgesics to treat moderate to severe pain.

D is incorrect. It would not be appropriate to say “You are getting the NSAID as a placebo to
help with your severe pain.” This statement is not true or accurate.
Acetylsalicylic Acid (Aspirin)
Therapeutic class: Antipyretic, non-opioid analgesic
Indication: Pain - arthritis. Stroke and MI prophylaxis
Action: Inhibits the production of prostaglandins which leads to a reduction of
fever and inflammation, decreases platelet aggregation leading to a decrease
in ischemic diseases
Nursing Considerations:
● Risk of bleeding
○ Don’t administer with other anticoagulants
○ D/c 5-7 days prior to surgery
● Caution with pediatric patients
○ Reye’s syndrome can occur with viral infections

NCLEX Question
A nurse is conducting preoperative teaching to a client who will undergo
surgery in 1 week. Which response by the client would prompt the nurse to
give additional teaching?

A. “Aspirin can possibly cause bleeding even after surgery”

B. “Aspirin can adversely affect my clotting ability”
C. “I should stop Aspirin one day prior to my surgery”
D. “It is important that I talk to my physician about the possibility of stopping
aspirin before the surgery.”
Answer: C
A is incorrect. The statement “Aspirin can possibly cause bleeding even after surgery” reflects
accurate understanding by the patient about Aspirin and noes not require additional teaching.

B is incorrect. The statement “Aspirin can adversely affect my clotting ability” reflects accurate
understanding by the patient about Aspirin and noes not require additional teaching.

C is correct. The statement I should stop Aspirin one day prior to my surgery” requires further
teaching. Aspirin alters the platelet’s ability to aggregate and therefore impairs clotting. The
effects of aspirin last for 5-7 days. Aspirin therapy should be stopped 5 to 7 days before the
surgery.

D is incorrect. The statement “It is important that I talk to my physician about the possibility
of stopping aspirin before the surgery.” reflects accurate understanding by the patient about
Aspirin and noes not require additional teaching.

Opioids
● Morphine
● Fentanyl
● Hydromorphone
● Methadone
● Oxycodone
Morphine
Therapeutic class: Opioid analgesic
Indication: Pain
Action: Binds to opiate receptors in the CNS and alters perception of pain
while producing a general depression of the CNS.
Nursing Considerations:
● Common side effect: constipation
● CNS depressant
○ Decreased respiration, decreased heart rate, etc.
○ Monitor respiratory rate
● Antidote = naloxone

NCLEX Question
The nurse is caring for a client receiving Morphine sulfate for severe pain. The
nurse should implement all of the following actions except:

A. Administer Morphine only when the client complains of pain

B. Ensure Naloxone is always available
C. Check the client’s respirations before giving Morphine
D. Provide a high fiber diet
Answer: A
A is correct. Morphine should be given at times prescribed by the doctor to ensure
adequate serum levels for optimum pain relief. Waiting to give it until the client
experiences pain may lead to sub-optimal pain control. The doctor may additionally
order PRN doses of morphine for breakthrough pain on top of scheduled doses.
B is incorrect. Naloxone should always be available as the antidote to morphine in
case of overdose and respiratory depression.
C is incorrect. One of the significant side effects of morphine is respiratory
depression. Checking the client’s respirations before giving Morphine should always
be done.
D is incorrect. Morphine results in constipation for most clients. A high fiber diet
should be given to prevent illness.

Obstetric Medications
● Tocolytics - slow contractions
○ Terbutaline
○ Magnesium-sulfate
○ Indomethacin (prostaglandin inhibitor)
○ Nifedipine (CCB)
● Oxytocics - stimulate contractions
○ Oxytocin
○ Ergometrine (Methergine)
○ Misoprostol
Magnesium-sulfate
Therapeutic class: Electrolyte

Indication: Hypomagnesemia, torsade de point, pre-eclampsia, preterm labor,

seizures, asthma exacerbation

Nursing Considerations:

● Monitor for hypermagnesemia

○ Confusion, dizziness, weakness, decreased reflexes
● Give IV slowly

Terbutaline
Therapeutic class: Tocolytic & beta-agonist

Indication: Preterm labor

Nursing Considerations:
● Monitor the client’s blood sugar levels; increases BG.
● Monitor for hypotension
● Monitor for tachycardia
● Monitor for hypokalemia
Oxytocin
Therapeutic class: Hormones; tocolytic
Indication: Induction of labor; PPH
Action: Stimulates uterine smooth muscle causing it to contract
Nursing Considerations:
● Monitor contractions
● Monitor fetus
● Warn mother contractions will be more painful
● Monitor BP, HR, glucose, and K

Steroids
● Betamethasone
● Dexamethasone
● Cortisone
● Fluticasone
● Methylprednisolone
Methylprednisolone
Therapeutic class: Corticosteroids
Indication: Inflammation, allergy, autoimmune disorders
Action: Suppress inflammation and normal immune response
Nursing Considerations:
● Monitor for too much steroids
○ Cushing’s symptoms; buffalo hump
● Side effects
○ Immunosuppression
○ Hyperglycemia
○ Osteoporosis
○ Delayed wound healing

Wrap up
Questions
NCLEX Question
While working in a pediatric intensive care unit, the nurse receives
orders to administer aspirin to a 12-month-old child who is febrile. The
nurse knows to question this order due to the high risk of _________'s
syndrome when aspirin is administered to a child.

Answer: Reye’s
Reye’s syndrome is a very serious illness that has been associated with aspirin
administration in children. It is a viral encephalopathy and usually follows a
virus infection. It causes cerebral edema as well as liver disease and can be
fatal. Aspirin administration should always be avoided in the pediatric
population.
NCLEX Question
The nurse is answering phones in the general practice clinic and receives a call from a patient who is
experiencing leg pain after starting atorvastatin. Which of the following instructions, when given by
the nurse, is the best course of action?

a. Continue taking the medication as this is an expected side effect

b. Discontinue the medication and schedule an appointment for the next week
c. Stretch for 20 minutes or take a warm shower
d. Discontinue the medication and visit the clinic as soon as possible

Answer: D
The correct answer is D. Leg pain, and muscle aches, which occur after taking
atorvastatin, may indicate a severe muscular myopathy known as rhabdomyolysis. The
nurse would be most accurate to have this patient discontinue their medication and
come to the clinic as soon as possible.

Choice A is incorrect. This patient should be seen in the clinic to rule out potentially
fatal health problems like rhabdomyolysis.

Choice B is incorrect. While this medication should be discontinued, waiting for

treatment could delay necessary treatment.

Choice C is incorrect. Stretching for 20 minutes or taking a warm shower could delay
necessary treatment.
 NCLEX Question
The nurse is preparing to administer a prescribed dose of lactulose 20 grams orally
QID to a client with portal-systemic encephalopathy. The medication is available at
3.33 grams per 5ml oral solution. She plans to administer 30 ml per dose to the
client QID. When the nurse approaches the client, the client states, I understand
that I can not take other laxatives with lactulose. After checking, the nurse should:

a. Withhold the lactulose.

b. Give only 3 ml lactulose instead of 30 ml.
c. Give 30 ml lactulose with juice and monitor blood ammonia.
d. Give 30ml lactulose and correct the client that he may take additional
laxatives.

Answer: C
Choice C is correct. The client has been prescribed Lactulose for portal-systemic encephalopathy, not for constipation. The
prescribed dose is 20 grams every 4 hours. Since each 5 ml has 3.33 grams in it, the accurate dosage to be administered is 30 ml
every 4 hours. Lactulose does not have a palatable taste; therefore, it can be mixed with fruit juice, water, or milk to improve flavor.
The nurse should monitor blood ammonia levels and watch for any side effects. Side effects include belching, flatulence, or
abdominal cramping. Lactulose belongs to the class of "Osmotic Laxatives" and may be used to treat constipation. Being an
osmotic laxative, it draws water into the colonic lumen and softens the stool. Lactulose is also used in hepatic (portal-systemic)
encephalopathy because it inhibits intestinal ammonia production. Lactulose is metabolized by intestinal bacteria and converted
to lactic acid. Because of lactic acid, the pH in the colonic lumen is reduced (acidified), and this promotes the conversion of
ammonia (NH3) to ammonium (NH4+). This ionized form of the ammonia is unable to diffuse across the gut membrane into the
blood, and thereby, blood ammonia levels decrease. Decreasing blood ammonia levels results in improved mental status in PSE.
When used in hepatic encephalopathy, the Lactulose dose needs to be carefully adjusted so the client averages 2 to 3 loose stools
per day. If other laxatives are used in conjunction, it gets challenging to determine the optimal dose of Lactulose using the above
definition of 2-3 loose stools/ day. Therefore, the client should be educated not to use additional laxatives.

Choice A is incorrect. The client needs his prescribed dose Lactulose for his portal-systemic encephalopathy.

Choice B is incorrect. The prescribed dose is 20 grams, which is equivalent to 30 ml as per the calculation above. Administering
3ml instead of 30ml is inappropriate.

Choice D is incorrect. The client has correct understanding already. It is inappropriate to tell the client with hepatic
encephalopathy to take additional laxatives while on Lactulose. Lactulose dose needs to be carefully adjusted, so the client
averages 2 to 3 loose bowel movements per day. If other laxatives are used in conjunction, it gets challenging to determine the
optimal dose of Lactulose.
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