Antibiotic

Linezolid is an antibiotic with monoamine oxidase inhibitor–type properties that is prescribed to treat vancomycin- and methicillin-resistant bacterial infections.  Selective serotonin reuptake inhibitors are contraindicated during therapy due to the increased risk of serotonin syndrome.

St. John’s wort is an herbal product commonly used by many clients to treat depression.  However, it may interact with medications used to treat depression or other mood disorders, including tricyclic antidepressants, selective serotonin and/or norepinephrine receptor inhibitors (SSRIs/SNRIs), and monoamine oxidase inhibitors (MAOIs).  Taking St. John’s wort with these medications tends to increase side effects and could potentially lead to a dangerous condition called serotonin syndrome.

Macrolide antibiotics (eg, erythromycin, azithromycin, clarithromycin) can cause QT prolongation, which can lead to life-threatening arrhythmias (eg, torsades de pointes).  They can also be hepatotoxic; therefore, the nurse should monitor liver function tests and an ECG and report significant results to the HCP.

Clients with an allergy to penicillin antibiotics (eg, amoxicillin, ampicillin) can possibly experience a cross-sensitivity reaction to cephalosporin antibiotics (eg, cefazolin, cephalexin, ceftriaxone), because the drug molecules are structurally similar.  The nurse should obtain more information about this client’s reported allergies, as reactions range from mild to severe.  In particular, the nurse must first assess the type of reaction the client had to amoxicillin

Clients prescribed metronidazole are instructed to abstain from using alcohol during, and for 3 days after, therapy, as it may cause flushing, headaches, nausea, vomiting, and abdominal cramping.  Metronidazole may cause a harmless metallic taste and darkened urine.  Clients should immediately report any new rashes, as Stevens-Johnson syndrome can occur.

Serious adverse reactions to aminoglycosides (eg, gentamicin, tobramycin, amikacin) include ototoxicity and nephrotoxicity.  Age, renal function, and drug dose affect the occurrence of these adverse reactions.  Careful dosing is especially important for older clients.  Tinnitus and vertigo are early signs of ototoxicity.  The nurse should carefully assess for changes in the client’s hearing, balance, and urinary output.

Trimethoprim-sulfamethoxazole (Bactrim) is a sulfonamide antibiotic, commonly referred to as a sulfa drug.  These antibiotics are prescribed to treat bacterial infections (eg, urinary tract infections).  Contraindications include hypersensitivity to sulfa drugs, and pregnancy or breastfeeding.

Antifungal 

Oral nystatin suspension is an antifungal medication used to treat oral thrush caused by candidal infections.  Nurses administering nystatin should assist the client in removing and soaking dentures, if present; assess the affected area frequently; educate the client to swish the medication in the mouth before swallowing; and ensure that the suspension is well shaken before dosing.

Viral Infection 

The nurse should tell the parent to discontinue the use of bismuth subsalicylate (Pepto-Bismol) as it contains a salicylate (same class as aspirin) and could possibly cause Reye syndrome.  Reye syndrome can develop in children with a recent viral illness such as varicella or influenza.  It can cause acute encephalopathy and hepatic dysfunction.  Children with viral infections should not be given aspirin or products containing salicylates.

Influenza 

Annual vaccination during influenza season is recommended for all clients age ≥6 months without life-threatening allergy to the vaccine or its ingredients.  High-risk groups include clients who have chronic conditions, those who work in health care settings or as caretakers, those age 6-23 months or ≥65, and pregnant clients.

Live attenuated intranasal vaccine

Indications

• Healthy individuals age 2-49 

Contraindications

• Age <2 or ≥50
• Immunosuppressed patients (eg, HIV with CD4⁺ cell count <200/mm³) & close contacts
• Chronic cardiovascular, pulmonary, neurologic, neuromuscular, or metabolic (eg, diabetes, renal insufficiency) diseases
• History of Guillain-Barré syndrome following previous influenza immunization
• Pregnant women
• Children/adolescents receiving long-term aspirin therapy
• Severe allergy to vaccine or its components 

Inactivated vaccine

Indications

• Individuals age ≥6 months

Contraindications

• Severe allergy to vaccine or its components. 

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).

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 

Rheumatoid Arthritis and Psoriasis

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.

Crohn Disease

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.

Anaphylaxis

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.

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.

NCLEX TIPS 

Pediatric liquid medications are often dispensed with a measuring device designed to administer the exact dose prescribed.  The following calibrated devices may be included: dropper, oral syringe , plastic measuring cup, or measuring spoon.