The nurse provides teaching about methotrexate to a client with rheumatoid arthritis.

  It is most
important to address which topic regarding this drug?

Methotrexate (Rheumatrex) is classified as a folate antimetabolite, antineoplastic,

immunosuppressant drug used to treat various malignancies and as a nonbiologic disease-
modifying antirheumatic drug (DMARD) used to treat rheumatoid arthritis and psoriasis.
Methotrexate can cause bone marrow suppression resulting in anemia, leukopenia, and
thrombocytopenia.  Leukopenia and its immunosuppressant effects can increase susceptibility
to infection.  Clients should be educated about obtaining routine killed (inactivated) vaccines
(eg, influenza, pneumococcal) and avoiding crowds and persons with known infections.  Live
vaccines (eg, herpes zoster) are contraindicated in clients receiving immunosuppressants, such as
methotrexate.
Alcohol should be avoided in clients taking methotrexate as it is hepatotoxic and drinking
alcohol increases the client's risk for hepatotoxicity.
(Option 1)  Regular eye examinations every 6 months are indicated for clients prescribed the
nonbiological DMARD antimalarial hydroxychloroquine (Plaquenil) as it can cause retinal
damage.  Ethambutol, used to treat tuberculosis, also requires frequent eye examinations.
(Options 2 and 4)  Photosensitivity (common with tetracycline, thiazide diuretics, and
sulfonamides) and nephrotoxicity (common with aminoglycosides, vancomycin, and
nonsteroidal anti-inflammatory drugs) can occur, but immunosuppression is more likely and
potentially fatal.
Educational objective:
Methotrexate is a nonbiologic disease-modifying antirheumatic drug used to treat rheumatoid
arthritis.  The major adverse effects associated with its use include bone marrow suppression,
hepatotoxicity, and gastrointestinal irritation.
The nurse has provided education about proper use of an epinephrine auto-injector to a client
with a history of a severe hypersensitivity reaction to bee stings.  Which of the following client
statements indicate that teaching has been effective?  Select all that apply.

Epinephrine auto-injectors (EAIs) are devices used as an emergency treatment

for anaphylactic reactions to allergens (eg, insect bites, foods, chemicals).  Clients with a
history of anaphylaxis must be properly educated on EAI use because delaying or failing to
administer epinephrine is a frequent cause of death.  Nurses educating clients on EAI use should
include the following information:
 Administer injection at a 90-degree angle into the outer thigh at the first sign of
an allergic reaction (Option 5)
 Hold the auto-injector in place for 10 seconds to ensure delivery of the entire dose
 Seek immediate medical care after an injection because anaphylactic reactions may
resume when the effects of the epinephrine subside (ie, 10-20 minutes) (Option 2)
 Expect to experience tachycardia, palpitations, and/or dizziness after
administration (Option 1)
 Store EAIs at room temperature in a dark place to prevent inactivation by heat or light,
or device failure from cold (Option 3)
(Option 4)  Clients should be instructed to administer EAIs as quickly as possible if symptoms
of anaphylaxis develop.  Skin preparation is not necessary, and delaying administration to
cleanse the injection site increases the risk of death from anaphylactic shock.
Educational objective:
Client education about use of epinephrine auto-injectors (EAIs) includes injecting the EAI into
the outer thigh at a 90-degree angle at symptom onset; seeking immediate medical care after
device use; storing EAIs in a dark place at room temperature; and understanding that
tachycardia, palpitations, and dizziness may occur after injection.

The nurse is preparing medications for the following 4 clients.  Which prescription should the
nurse clarify with the health care provider before administration?

Azathioprine is an immunosuppressant drug that can cause bone marrow depression and

increase the risk for infection.  It is prescribed to treat autoimmune conditions such as
inflammatory bowel diseases (eg, Crohn disease) and to prevent organ transplant rejection. 
Fatigue and nausea can be expected as minor adverse effects or may be associated with the
disease.  However, leukopenia (white blood cell count <4,000/mm3 [4 × 109/L]) can be a severe
adverse effect of the drug and should be reported to the health care provider before administering
the medication due to high risk for infection (Option 2).
(Option 1)  Acetaminophen is a nonopioid analgesic with antipyretic properties.  The client with
a productive cough and fever should be assessed further for infection.  This prescription would
be appropriate.
(Option 3)  Baclofen is an antispasmodic drug commonly prescribed to clients with multiple
sclerosis to relieve uncomfortable spasms and muscular pain.  Dizziness when attempting to
stand or changing positions (ie, orthostatic hypotension) is a common adverse effect but is not a
contraindication.
(Option 4)  Colchicine is prescribed for clients with an acute attack of gout because it decreases
the inflammation and pain associated with deposition of uric acid crystals in the joints.  This is
an appropriate prescription.
Educational objective:
Azathioprine is an immunosuppressant drug that can cause bone marrow suppression and
increase the risk for infection.  Leukopenia, a severe adverse effect of azathioprine, should be
reported to the health care provider before the medication is administered.

The nurse reviews the serum laboratory results and medication administration records for
assigned clients.  Which prescriptions should the nurse question and validate with the health care
provider before administering?  Select all that apply.

Bumetanide is a potent loop diuretic (eg, furosemide, torsemide) used to treat edema associated

with heart failure and liver and renal disease.  The diuretic inhibits reabsorption of sodium and
water from the tubules and promotes renal excretion of water and potassium.  The nurse should
question the bumetanide prescription as the client with heart failure has hypokalemia (potassium
<3.5 mEq/L [3.5 mmol/L]) and is already at increased risk for life-threatening cardiac
dysrhythmias associated with this electrolyte imbalance (Option 1).
Isoniazid is a first-line antitubercular drug used to treat latent or active tuberculosis.  The nurse
should question this prescription as increased liver function tests (eg, alanine aminotransferase,
aspartate aminotransferase) can indicate development of drug-induced hepatitis (Option 4).
(Option 2)  Calcium acetate (PhosLo) is a phosphate binder used to treat hyperphosphatemia
(normal phosphorous: 2.4-4.4 mg/dL [0.78-1.42 mmol/L]) in clients with chronic kidney
disease.  Calcium acetate lowers the serum phosphorous level by binding to dietary phosphate
and excreting it in feces.
(Option 3)  Carvedilol (Coreg) is a beta blocker used to improve cardiac output and slow the
progression of heart failure.  B-type natriuretic peptide (BNP) (normal: <100 pg/mL [100
pmol/L]) is secreted from the ventricles in response to the increased ventricular stretch.  Elevated
BNP is expected in a client with heart failure; the nurse need not question this prescription.
(Option 5)  Metronidazole (Flagyl) is the first-line anti-infective drug used to treat infectious
diarrhea caused by Clostridium difficile.  Leukocytosis is expected with this bacterial infection.
Educational objective:
Loop diuretics (eg, bumetanide, furosemide, torsemide) can cause hypokalemia (potassium <3.5
mEq/L [3.5 mmol/L]).  Elevated liver enzymes in clients receiving the antitubercular drug
isoniazid can indicate development of drug-induced hepatitis.

A nurse is caring for a client with a diagnosis of fibromyalgia.  During care, the client reports
having suicidal thoughts.  What currently prescribed medication should the nurse question in
regard to this new finding?
Fibromyalgia is a chronic, nonspecific pain disorder.  Common sequelae include fatigue, sleep
disturbances, emotional distress (eg, anxiety, depression), and even mild cognitive impairments
(eg, forgetfulness, difficulty concentrating).
Treatment is focused on symptom management and often includes:
 Muscle relaxers (eg, cyclobenzaprine)
 Narcotic analgesics (eg, tramadol, hydrocodone)
 Nonsteroidal anti-inflammatory drugs (eg, ibuprofen, naproxen, celecoxib)
 Neuropathic pain relievers (eg, pregabalin, gabapentin)
 Antidepressants such as selective serotonin reuptake inhibitors (eg, fluoxetine,
duloxetine) and tricyclic antidepressants (eg, amitriptyline).
Antidepressants can cause suicidal ideation and behaviors, especially during the initial few
weeks of therapy.  This risk is even higher for young adults (age 18-24).  The nurse must assess
for this adverse effect and alert the provider (Option 1).
(Options 2, 3, and 4)  Celecoxib, cyclobenzaprine, and hydrocodone are not known to
cause suicidal ideation.
Educational objective:
Fibromyalgia is treated using a variety of medications.  Nurses must be aware of the risks
associated with medications, specifically antidepressants that may increase suicidal behaviors
during the first few weeks of therapy.  Any indication of such effects requires immediate
intervention by the nurse (eg, alert health care provider).

The nurse is assessing a client with rheumatoid arthritis who is being considered
for adalimumab therapy.  Which statement made by the client needs further investigation?

Infliximab, adalimumab, and etanercept are tumor necrosis factor (TNF) inhibitors that

suppress the inflammatory response in autoimmune diseases such as rheumatoid arthritis, Crohn
disease, and psoriasis.  Due to the immunosuppressive action of TNF inhibitors, clients taking
these drugs are at increased risk for infection.  A client with current, recent, or chronic infection
should not take a TNF inhibitor (Option 1).
(Option 2)  The immunosuppressive action of TNF inhibitors can activate
latent tuberculosis (TB).  Therefore, a tuberculin skin test (TST) should be administered prior to
beginning TNF inhibitor therapy, and clients who test positively for latent TB must also undergo
treatment for TB before starting therapy.  Clients should have a TST every year while receiving
the drug.
(Option 3)  Clients taking immunosuppressive TNF inhibitors (eg, adalimumab) should receive
an annual inactivated (injectable) influenza vaccine to reduce the risk of contracting the flu
virus.  Clients taking TNF inhibitors or other immunosuppressants are at risk for infection and
therefore should not receive live attenuated vaccines.
(Option 4)  Many clients with rheumatoid arthritis use nonsteroidal anti-inflammatory
medications (eg, celecoxib, naproxen) in conjunction with antirheumatic and/or targeted
therapies (eg, methotrexate, adalimumab, etanercept) to effectively treat pain and minimize
inflammation.
Educational objective:
Clients with infection should not take tumor necrosis factor (TNF) inhibitors (eg, infliximab,
adalimumab, etanercept) as these suppress the immune response.  Before starting drug therapy,
clients should be tested for tuberculosis and receive the inactivated (injectable) influenza
vaccine.  Clients taking TNF inhibitors should avoid live vaccines.

The nurse provides teaching about methotrexate to a 28-year-old client with rheumatoid
arthritis.  Which client statement indicates the need for further instruction regarding this drug?

Methotrexate (Rheumatrex) is classified as a folate antimetabolite,

antineoplastic, immunosuppressant drug to treat various malignancies and as a nonbiologic
disease-modifying antirheumatic drug (DMARD) to treat rheumatoid arthritis and psoriasis.
The client's statement about getting an eye examination every 6 months indicates that further
teaching is necessary as these examinations are not indicated for clients prescribed
methotrexate (Option 3).  However, frequent eye examinations are required for clients
prescribed the nonbiologic antimalarial DMARD hydroxychloroquine (Plaquenil) as it can cause
retinal damage.
(Option 1)  Methotrexate is an immunosuppressant and can cause bone marrow suppression. 
Clients are at risk for infection.  They should avoid crowded places and individuals with known
infection and should receive appropriate killed (inactivated) vaccines (eg, influenza,
pneumococcal).  Live vaccines (eg, herpes zoster) are contraindicated.
(Option 2)  Clients should not become pregnant while taking methotrexate or for at least 3
months after it is discontinued as the drug is teratogenic and can cause congenital abnormalities
and fetal death.
(Option 4)  Clients taking methotrexate should avoid alcohol as the prescription drug
is hepatotoxic and drinking alcohol increases the risk for hepatotoxicity.
Educational objective:
Methotrexate is a disease-modifying antirheumatic drug used to treat rheumatoid arthritis and
psoriasis.  The major adverse effects associated with methotrexate include bone marrow
suppression, hepatotoxicity, congenital abnormalities, and fetal death.

A client is prescribed long-term pharmacologic therapy with hydroxychloroquine to treat

systemic lupus erythematosus.  Which intervention related to the drug's adverse effects should
the nurse include in the teaching plan?

Hydroxychloroquine (Plaquenil) is an antimalarial drug, but it is more commonly prescribed to

reduce fatigue and treat the skin and arthritic (eg, joint inflammation, pain) manifestations of
systemic lupus erythematosus (SLE).  Hydroxychloroquine can also help to reduce lupus
exacerbations in clients with inactive to mild disease, but several months can pass before its
therapeutic effects become apparent.
Although rare, serious adverse drug reactions such as retinal toxicity and visual
disturbances can occur with hydroxychloroquine.  Therefore, clients are instructed to undergo
regular ophthalmologic examination every 6-12 months (Option 1).
(Option 2)  Hydroxychloroquine should be taken with food to decrease gastrointestinal upset
(common side effect).
(Option 3)  Some clients with severe SLE are prescribed long-term corticosteroid (prednisone)
therapy to prevent organ damage and are at risk for adverse reactions, such as accelerated
osteoporosis.  Osteoporosis is not an adverse reaction of hydroxychloroquine, and vitamin D and
calcium supplementation is not required.
(Option 4)  There are no effects of hydroxychloroquine that would require wearing a MedicAlert
bracelet.
Educational objective:
Hydroxychloroquine (Plaquenil) is used to treat the skin and arthritic manifestations of SLE. 
Taking the medication with food can help alleviate gastrointestinal upset.  Serious adverse drug
reactions include retinopathy and visual disturbances; therefore, regular ophthalmologic
examination every 6-12 months is required.

A client with ulcerative colitis is prescribed the drug sulfasalazine.  Which information should
the nurse discuss with the client concerning this drug?  Select all that apply.

Sulfasalazine (Azulfidine) is a sulfonamide (salicylate and sulfa antibiotic) and nonbiologic

disease-modifying antirheumatic drug (DMARD) used for mild to moderate chronic
inflammatory rheumatoid arthritis (RA) and inflammatory bowel disease (eg, ulcerative colitis). 
It inhibits the production of prostaglandin, a mediator in the body's inflammatory response.
Most "sulfa" medications (eg, trimethoprim, sulfamethoxazole) share common side effects,
including:
1. Crystalluria causing kidney injury – client should drink 8 glasses of water daily to
maintain adequate urine output (eg, 1200-1500 mL/day)
2. Photosensitivity and risk for sunburn – client should avoid sun exposure and apply
sunscreen
3. Folic acid deficiency (megaloblastic anemia and stomatitis) – client should eat folate-
rich foods and take 1 mg/day folic acid supplement
4. Rarely life-threatening agranulocytosis (leukopenia) – client should be monitored for
complete blood count at the start of therapy and report fever or sore throat immediately
5. Stevens-Johnson syndrome – client should stop the medicine if rash develops
(Option 2)  Ulcerative colitis is characterized by bloody diarrhea, and the medication is taken to
reduce this effect.
(Option 3)  Urine and skin can turn an orange-yellow color but will return to normal when the
drug is discontinued.  This is an expected finding.
Educational objective:
Sulfasalazine (Azulfidine) is used for mild to moderate chronic inflammatory RA and
inflammatory bowel disease.  Important adverse effects include crystalluria with kidney injury,
yellow-orange skin and urine discoloration, folic acid deficiency, and photosensitivity.

The clinic nurse is preparing to administer an allergy immunotherapy injection to a client

recently initiated on the therapy.  Which statement by the client indicates a need for further
teaching?

Allergy immunotherapy injections (allergy shots) trigger an increase in the body's production

of specific immunoglobulins to reduce the client's allergy symptoms when exposed to specific
allergens (eg, pollen, cat dander, dust mite).  Small doses of the allergen(s) are injected
subcutaneously on a client-specific schedule.
Rarely, allergy shots may induce an immediate and potentially fatal anaphylactic reaction.  The
client must remain at the facility for 30 minutes after an injection so the nurse can monitor for
severe systemic reactions (eg, respiratory failure, tongue and throat swelling) (Option 1).
(Option 2)  For the first few months, allergy shots are typically given every week, with a dose
increase at every injection until the target maintenance dose is reached.  The maintenance dose is
then given every few weeks for 3-5 years.
(Option 3)  Although rare, the client may have a mild, systemic allergic reaction (eg, hives,
itching, facial swelling, mild asthma) up to 24 hours after an allergy shot.  The occurrence of
any systemic reaction should be reported to the health care provider as the next dose increase
may need to be delayed.
(Option 4)  It is common to have a localized reaction to an allergy shot.  The nurse should
reinforce teaching that some redness and swelling at the injection site is expected and not life-
threatening.
Educational objective:
A client receiving an allergy shot is at risk for anaphylaxis immediately after the injection, so the
client must remain at the facility and be monitored for 30 minutes after the injection.

A client with fibromyalgia refuses to take the prescribed drug duloxetine.  When the nurse asks,
why, the client responds, "Because I'm not depressed!"  What is the nurse's most
appropriate response?
Fibromyalgia (FM) results from abnormal central nervous system pain transmission and
processing.  It is characterized by chronic, bilateral musculoskeletal axial pain (above and below
the waist), multiple tender points, fatigue, and sleep/cognitive disturbances.
Duloxetine (Cymbalta) is a serotonin-norepinephrine reuptake inhibitor that has both
antidepressant and pain-relieving effects.  It is used to relieve chronic pain that interferes with
normal sleep patterns in clients with FM.  With the restoration of normal sleep patterns, fatigue
often improves as well (Option 2).  Other effective drugs to treat the chronic pain associated
with FM include pregabalin and amitriptyline (Elavil), an older tricyclic antidepressant drug.
(Option 1)  Although depression often accompanies chronic pain, duloxetine can be prescribed
specifically to treat the chronic pain associated with FM.
(Option 3)  Duloxetine is prescribed for major depressive disorder and to relieve pain associated
with diabetic neuropathy and FM.  It is not given to relieve the adverse effects of other drugs.
(Option 4)  A client has the right to refuse any drug.  However, the nurse should first explain the
purpose of the drug to the client before notifying the HCP.
Educational objective:
Medications such as duloxetine, pregabalin, and amitriptyline have neuropathic pain-relieving
effects.  They are commonly used for treating pain associated with diabetic neuropathy and FM. 
Duloxetine is particularly effective for treating both depression and pain.

A client comes to the emergency department following a bee sting.  The client has a diffuse rash,
hypotension, and throat tightness.  One injection of IM epinephrine does not improve the client's
condition.  What action should the nurse take next?

Anaphylactic shock has an acute onset, and manifestations usually develop quickly (20-30
minutes).  Circulatory failure and respiratory manifestations, including laryngeal edema (from
inflammation) and bronchoconstriction (primarily from release of histamine), can lead to
cardiac/respiratory arrest.
The management of anaphylactic shock includes:
1. Ensure patent airway, administer oxygen
2. Remove insect stinger if present
3. IM epinephrine is the drug of choice and should be given to this client.  Epinephrine
stimulates both alpha- and beta-adrenergic receptors and dilates bronchial smooth muscle
(beta 2) and provides vasoconstriction (alpha 1).  The IM route (mid anterior lateral
thigh) is better than the subcutaneous route.  Repeat dose every 5-15 minutes.
4. Place in recumbent position and elevate legs
5. Maintain blood pressure with IV fluids, volume expanders or vasopressors
6. Bronchodilator (inhaled beta agonist) such as albuterol is administered to dilate the
small airways and reverse bronchoconstriction
7. Antihistamine (diphenhydramine) is administered to modify the hypersensitivity
reaction and relieve pruritus
 8. Corticosteroids (methylprednisolone [Solu-Medrol]) are administered to decrease
airway inflammation and swelling associated with the allergic reaction
9. Anticipate cricothyrotomy or tracheostomy with severe laryngeal edema
(Option 1, 2, and 3)  These are appropriate responses that should come after a repeat dose of
epinephrine has been given.
Educational objective:
IM epinephrine is the single most important medication to be given in anaphylactic shock.  The
dose should be repeated every 5-15 minutes if symptoms are still present.  Antihistamines,
corticosteroids, and IV fluids are other supportive treatments.