NCLEX: A Simple Guide To Pharmacology

Terms you’ll need to understand:
Adverse reactions
Agonist
Allergic response
Antagonists
Buccal
Contraindications
Enteral administration
Enteric coating
FDA
Intradermal
Intramuscular
Nursing implication
Oral
Peak drug level
Pharmacodynamics
Pharmacokinetics
Pharmacotherapeutics
Side effects
Spansules
Subcutaneous
Synergistic
Toxicity
Trough drug level

Nursing skills you’ll need to master:

1. Making drug calculations
2. Administering oral medication
3. Administering parenteral medication
4. Administering suppositories
5. Interpreting normal lab values
    

Pharmacology
The graduate nurse is frequently responsible for instructing the client and the client’s family regarding the safe administration of medications. The study of pharmacology is constantly changing as new drugs are constantly being approved for public use by the Food and Drug Administration (FDA). The recent test plan approved by the National Council Licensure Exam devotes 13%–19% of the
Physiological Integrity section to pharmacology. This guide contains useful information to help you by looking at the classification and generic name of drugs. If you can remember the drug classification, frequently you can understand why the drug was ordered, as well as nursing implications including assessing the client for side effects.

Three Areas of Pharmacology
It is important to note that the study of pharmacology includes three areas:
- Pharmacokinetics—This is the study of how drugs are absorbed, dis- tributed, metabolized, and excreted by the body. Elderly clients and clients with renal or liver disease frequently have difficulty metabolizing and excreting medications. These clients can develop drug toxicity more easily than those with no renal or liver impairment.
- Pharmacodynamics—This is the study of how drugs are used by the body. Pharmacodynamics of oral hypoglycemics explain how the blood glucose is reduced by stimulating the pancreatic beta cells to produce more insulin, by also making insulin receptor sites more sensitive to insulin, and by increasing the number of insulin receptor cells. These drugs are effective only if the client’s pancreas is producing some insulin.
- Pharmacotherapeutics—This is the study of how the client responds to the drug. A client might experience side effects such as gastrointestinal symptoms to a number of medications, including antibiotics. Side effects may cause discomfort but are usually not severe enough to warrant discontinuation of the medication. Demerol (meperidine HCl) is a narcotic analgesic that can cause nausea and vomiting. To prevent these side effects, the physician frequently orders an antiemetic called Phenergan (promethazine) to be given with Demerol. These drugs have a synergistic effect that provides pain relief while preventing the discomfort of side effects.

Adverse effects of medications result in symptoms so severe that it is necessary to reduce the dosage or discontinue the medication completely.
Antituberculars and anticonvulsants are two categories of medications that can have adverse effects on the liver. The nurse should carefully assess the client for signs of jaundice that indicate drug-related hepatitis, in which case the medication will be discontinued.

How Nurses Work with Pharmacology
Nurses are expected to utilize their knowledge of pharmacology to
- Recognize common uses, side effects, and adverse effects of the client’s medication
- Challenge medication errors
- Meet the client’s learning needs

Generally, the medication the nurse is expected to administer depends on the area of practice and the assigned client. However, the following medication classifications are commonly prescribed medications for adult clients within a medical/surgical setting:
- Anti-infectives—Used for the treatment of infections.
- Antihypertensives—These lower blood pressure and increase blood flow to the myocardium.
- Antidiarrheals—Decrease gastric motility and reduce water content in bowel.
- Diuretics—Decrease water and sodium from the loop of Henle (loop diuretics) or inhibit antidiuretic hormone potassium sparing diuretics.
- Antacids—Reduce hydrochloric acid in the stomach. A common side effect of calcium- and aluminum-based antacids is constipation. (Magnesium-based antacids frequently cause diarrhea.)
- Antipyretics—Reduce fever.
- Antihistamines—Block the release of histamine in allergic reactions. Common side effects of antihistamines are dry mouth, drowsiness, and sedation.
- Bronchodilators—Dilate large air passages and are commonly pre- scribed for clients with asthma and chronic obstructive lung disease.
- Laxatives—Promote the passage of stool. Types of laxatives include stool softeners, cathartics, fiber, lubricants, and stimulants.
- Anticoagulants—Prevent clot formation by decreasing vitamin K + lev- els and blocking the clotting chain or by preventing platelet aggregation.
- Antianemics—Increase factors necessary for red blood cell production. Antianemics include B12, iron, and Epogen (erythropoetin).
- Narcotics/analgesics—Relieve moderate to severe pain. Medications in this category include opioids (morphine and codeine), synthetic opioids (meperidine), and NSAIDs (ketorolac).
- Anticonvulsants—Used for the management of seizure disorder and the treatment of bipolar disorder. Medications used as anticonvulsants include benzodiazepines, phenobarbital, and phenytoin.
- Anticholenergics—Cause the mucous membranes to become dry; therefore, oral secretions are decreased. Anticholinergics such as atropine are often administered preoperatively.
- Mydriatics—Dilate the pupils. Mydriatics are used in the treatment of clients with cataracts.
- Miotics—These constrict the pupils. Miotics such as pilocarpine HCl are used in the treatment of clients with glaucoma.

Time-Released Drugs
The following abbreviations indicate to the nurse that the drug is timereleased. These preparations should not be crushed or opened:
- Dur = Duration
- SR = Sustained release
- CR = Continuous release
- SA = Sustained action
- Contin = Continuous
- LA = Long acting

Tampering with the preparation of medication alters the absorption of the medication. Enteric-coated tablets and caplets are those coated with a thick shell that prevents the medication from being absorbed in the upper GI tract, allowing the medication to be absorbed more slowly. Spansules are capsules containing time-released beads that are released slowly. The physician should be notified to obtain an alternative preparation if the client is unable to swallow a time-released preparation.

Administering Medications
When preparing to administer medications, the nurse must identify the client by reviewing the physician’s order. She must also administer the medication by the right route. Many medications are supplied in various preparations. The physician orders the method of administration. The choice of medication administration is dependent on several factors, including the desired blood level, the client’s ability to swallow, and the disease or disorder being treated. The nurse must be able to figure dosage calculations accurately to prevent medication errors in dosage. A 30-minute range is allowed either before or after the designated time.

The Seven Rights of Administering Medication
The nurse is expected to use the seven rights when administering medications to the client. These include five rights of drug administration, plus two from the Patient’s Bill of Rights.
The Patient’s Bill of Rights was enacted to protect the client’s well-being, both mentally and physically. The client has the right to refuse treatment that may include medications. The nurse must document any treatment provided to the client. Documentation of care given must be made promptly to prevent forgetting any details and to ensure that another nurse does not duplicate medication administration.

The seven rights are
- Right client—Identification of the client must be done by asking the client to state his name and checking the identification band.
- Right route—The physician orders the prescribed route of administra- tion.
- Right drug—Checking both the generic and trade names with the physician’s order ensures that the right drug is administered. If the client’s diagnosis does not match the drug category prescribed, the nurse should further investigate the ordered medication.
- Right amount—The nurse is expected to know common dosages for both adults and children.
- Right time—The nurse can administer the medication either 30 min- utes before the assigned time or 30 minutes after.
- Right documentation (from the Patient’s Bill of Rights and legality issues in nursing)—This right is different from the others in that it must be done to prevent duplicating drug administration.
- Right to refuse treatment (from the Patient’s Bill of Rights)—The client has the right to refuse medication or treatment. He also has the right to refuse to donate organs.

Understanding and Identifying the Various Drugs
It is important to know that drugs generally have several names. The following list explains these different names for you:
- Chemical name—This is often a number or letter designation that tells you the chemical makeup of the agent. This name is of little value to the nurse in practice.
- Generic name—This is the name given by the company that developed the drug, and it remains the same even after the patent is released and other companies are allowed to market the medication.
- Trade name—This is the name given to the drug by the originating company. This name may change after the patent is released.

It is much safer for the nurse to remember the generic name rather than the trade name because the trade name will probably change.
On the NCLEX® exam, both the generic and trade names of medications might be included for clarification.

Approximately 80% of the time generic drugs in the same category have common syllables. If you can identify the commonality within the generic names, you can more easily learn the needed information for the NCLEX®.
Let’s look at some commonly given categories of drugs and see whether we can recognize the commonalities in the names. As you will see, each drug has a common part in its name. This is a trick we want to point out that will help you to quickly identify a particular drug by the common part of the name for that drug category. Let’s jump in with the angiotensin-converting agents drug category to see how this works.

Angiotensin-Converting Enzyme Agents
This category of drugs is utilized to treat both primary and secondary hypertension. These drugs work by converting angioterisin I to angioterisin II.
They effect the sympathetic vasomotor center lowering the blood pressure, pulse rate, and cardiac output.
Notice that all the generic names include the syllable pril. When you see these letters, you will know that they are angiotensin-converting agents.

Angiotensin-Converting Agents


When working with angiotensin-converting agents, it is important to know the potential side effects. The following list details the possible side effects/adverse reactions with this drug category:
- Hypotension
- Tachycardia
- Headache
- Nausea/vomiting
- Respiratory symptoms

The following items are nursing considerations to know when working with this drug type:
- Monitor vital signs regularly.
- Monitor the white blood cell count.
- Monitor the electrolyte levels.

Beta Adrenergic Blockers
Beta adrenergic blockers are drugs that help lower blood pressure, lower pulse rate, and lower cardiac output. They are also used to treat migraine headaches and other vascular headaches. Certain preparations of the beta blockers are used to treat glaucoma and prevent myocardial infarctions.
These drugs act by blocking the sympathetic vasomotor response.
Notice the syllable olol. When you see this syllable, you will know that these drugs are beta-blockers.

Beta Adrenergic Blockers


The potential side effects/adverse reactions of beta adrenergic blockers are listed here:
- Orthostatic hypotension
- Bradycardia
- Nausea/vomiting
- Diarrhea
- Congestive heart failure
- Blood dyscrasias

The following list gives you some nursing considerations for working with clients using beta adrenergic blockers:
- Monitor the client for changes in lab values (protein, BUN, creatinine) that indicate nephrotic syndrome.
- Monitor the client’s blood pressure, heart rate, and rhythm.
- Monitor the client for signs of edema.
- Teach the client to
- Rise slowly
- Report bradycardia, dizziness, confusion, depression, or fever
- Taper off the medication

Anti-Infectives (Aminoglycosides)
Anti-infective drugs are bactericidals and bacteriostatics. They interfere with the protein synthesis of the bacteria, causing the bacteria to die. They are active against most aerobic gram-negative bacteria and against some of the gram-organisms.
Notice that these all end in cin, and many of them end in mycin. So, when you see either of these syllables, you know these are anti-infectives.

Anti-infective Drugs


The following list highlights some possible side effects/adverse reactions from the use of anti-infectives (aminoglycosides):
- Ototoxicity
- Nephrotoxicity
- Seizures
- Blood dyscrasias
- Hypotension
- Rash

The following items are nursing considerations you need to be aware of when working with clients using anti-infectives (aminoglycosides):
- Obtain a history of allergies.
- Monitor intake and output.
- Monitor vital signs during infusion.
- Maintain a patent IV site.
- Monitor for therapeutic levels.
- Monitor for signs of nephrotoxicity.
- Monitor for signs of ototoxicity.
- Teach the client to report any changes in urinary elimination.
- Monitor peak and trough levels.
Tests on peak and trough levels are done to obtain a blood level and determine the dosage needed for the client. They should be done 30–60 minutes after the third or fourth IV dose or 60 minutes after the third or fourth IM dose. Trough levels should be drawn 30 minutes before the next dose. The client should be taught to report any change in renal function or in hearing because this category can be toxic to the kidneys and the auditory nerve.
These drugs are frequently used to treat super-infections such as methicillinresistant staphylelococcus aureus (MRSA). Clients with MRSA exhibit the following symptoms: fever, malaise, redness, pain, swelling, perineal itching, diarrhea, stomatitis, and cough.

Benzodiazepines
(Anticonvulsants/Sedative/Antianxiety)
These drugs are used for their antianxiety effects. They relax skeletal muscles, sedate, and are used as anticonvulsants.
Notice that all these contain the syllable pam.

Not all the benzodiazepines contain pam; some of them contain pate and lam, as in aprazolam (Xanax). However, they all contain azo or aze.

Benzodiazepines (Anticonvulsants/Sedative/Antianxiety) Drugs


The following list gives you some possible side effects or adverse reactions from the use of this drug:
- Drowsiness
- Lethargy
- Ataxia
- Depression
- Restlessness
- Slurred speech
- Bradycardia
- Hypotension
- Diplopia
- Nystagmus
- Nausea/vomiting
- Constipation
- Incontinence
- Urinary retention
- Respiratory depression
- Rash
- Urticaria

The following are some nursing considerations to know when working with this drug type:
- Monitor respirations.
- Monitor liver function.
- Monitor kidney function.
- Monitor bone marrow function.

Phenothiazines (Antipsychotic/Antiemetic)
These drugs are used as antiemetics or major tranquilizers. They are also used to treat psychosis in those clients with schizophrenia.
If given by injections, they should be given IM Z-track because they are irritating to the tissue. If the client is allergic to one of these, he probably is allergic to all of them.
Should the client inadvertently be given one of these and an allergic reaction occur, the client should be given Benadryl (diphenhydramine hydrochloride) or Congentin
(benztropine mesylate).

All these contain the syllable zine.

Phenothiazines (Antipsychotic/Antiemetic)Drugs


The following list gives you some possible side effects or adverse reactions from the use of this drug type:
- Extrapyramidal effects
- Drowsiness
- Sedation
- Orthostatic hypotension
- Dry mouth

Glucocorticoids
These drugs are used in the treatment of conditions requiring suppression of the immune system and in Addison’s disease. These drugs cause antiinflammatory, antiallergenic, and antistress effects.They are used for replacement therapy for adrenal insufficiency (Addison’s disease); as antiinflammatory drugs in transplant clients; and to reduce cerebral edema associated with head trauma, neurosurgery, and brain tumors. They also have general anti-inflammatory effects and are used in immunosuppressant therapy.

Notice that all these contain sone or cort.

Glucocorticoids Drugs


Notice there are many trade names for this category. NCLEX® may provide you with both the trade name and the generic name.

The following list gives you some possible side effects or adverse reactions from the use of this drug type:
- Acne
- Poor wound healing
- Ecchymosis
- Bruising
- Petechiae
- Depression
- Flushing
- Sweating
- Mood changes (depression)
- Hypertension
- Osteoporosis
- Diarrhea
- Hemorrhage
These drugs cause Cushing’s Syndrome. Signs of Cushing’s Syndrome include moon face, edema, elevated blood glucose levels, purple straie, weight gain, buffalo hump, and hirsutism.

The following list gives you some nursing considerations to know when working with this drug type:
- Monitor glucose levels.
- Weigh the client daily.
- Monitor blood pressure.
- Monitor for signs of infection.

Antivirals
These drugs are used for their antiviral properties. They inhibit viral growth by inhibiting an enzyme within the virus. Herpetic lesions respond to these drugs. Clients with acquired immune deficiency syndrome (AIDS) are often treated with this category of drugs either alone or in combination with other antiviral drugs to treat viral infections. These drugs are also used to treat herpetic lesions (HSV-1, HSV-2), varicella infections (chickenpox), herpes zoster (shingles), herpes simplex (fever blisters), encephalitis, cytomegalovirus (CMV), retinitis (inflammation of the retina), and respiratory syncytial virus (RSV).
Notice that all these contain vir.

Antiviral Drugs


The following list gives some side effects that are usually associated with this drug type:
- Nausea
- Vomiting
- Diarrhea
- Oliguria
- Proteinuria
- Vaginitis
- Central nervous side effects (these are less common):
- Tremors
- Confusion
- Seizures

The following list gives you some nursing considerations to know when working with this drug type:
- Tell the client to report a rash because this can indicate an allergic reac- tion.
- Watch for signs of infection.
- Monitor creatinine levels frequently.
- Monitor liver profile.
- Monitor bowel pattern before and during treatment.

Cholesterol-Lowering Agents
The name says it all for these drugs. This drug type is used to help clients lower cholesterol and triglyceride levels and to decrease potential for cardiovascular disease complications. Notice that all these contain the syllable vastatin. It should be noted that many advertisements call these 'statin' drugs.
These drugs should not be confused with the statin drugs used for their antifungal effects. These can include nystatin (trade name Mycostatin or Nilstat).

Cholesterol-Lowering Drugs


Of all the preceding drugs, only take Lipitor at night. This category should not be taken with grapefruit juice.

Here is a list of side effects or adverse reactions that could occur with this drug type:
- Rash
- Alopecia
- Dyspepsia
- Liver dysfunction
- Muscle weakness (myalgia)
- Headache

Rhabdomyolysis, a muscle-wasting syndrome, has been linked with the use of cholesterol-lowering agents.

The following list gives you some nursing considerations to know when working with this drug type:
- A diet low in cholesterol and fat should be included in therapy.
- Monitor cholesterol levels.
- Monitor liver profile.
- Monitor renal function.
- Monitor visual changes because opacities can occur in clients taking vas- tatins.
- Monitor for muscle pain and weakness.

Angiotensin Receptor Blockers
These drugs block vasoconstrictor and aldosterone-secreting angiotensin II.
They are used to treat primary or secondary hypertension and are an excellent choice for clients who complain of the coughing associated with ACE inhibitors. Notice that all these contain sartan.

Angiotensin Receptor Blocker Drugs


Following are some side effects associated with this drug category:
- Dizziness
- Insomnia
- Depression
- Angina pectoris
- Second-degree AV block
- Conjunctivitis
- Diarrhea
- Nausea/vomiting
- Impotence
- Muscle cramps
- Neutropenia
- Cough

The following list gives you some nursing considerations to know while working with this drug type:
- Monitor blood pressure and pulse.
- Monitor BUN.
- Monitor creatinine before beginning treatment.
- Monitor electrolytes.
- Tell the client to report edema in feet and legs daily.
- Monitor hydration status.

Cox 2 Enzyme Blockers
These drugs are used to treat osteoarthritis and rheumatoid arthritis. These drugs are considered to be nonsteroidal anti-inflammatory drugs (NSAIDs).
They relieve pain by reducing the inflammation associated with arthritis.
Notice that all these drugs contain the syllable cox.

Cox 2 Enzyme Blocker Drugs


Following are some side effects associated with this drug category:
- Fatigue
- Anxiety
- Depression
- Dizziness
- Tachycardia
- Tinnitus
- Nausea
- Gastroenteritis
- Stomatitis

Some nursing considerations associated with this drug category are
- The client should be taught to report any changes in bowel habits because this can indicate GI bleeding.
- Monitor platelet count.
- Tell the client to report bruising.

These drugs have been associated with an increased risk of heart attacks and strokes.

Histamine 2 Antagonists
These drugs are used in the treatment of gastroesophageal reflux disease
(GERD), acid reflux, and gastric ulcers. They inhibit histamine 2 (H2) release in the gastric parietal cells, therefore inhibiting gastric acids.
Notice that all these contain the syllable tidine.

Histamine 2 Antagonist Drugs


Following are some side effects associated with this drug category:
- Confusion
- Bradycardia/Tachycardia
- Diarrhea
- Psychosis
- Seizures
- Agranulocytosis
- Rash
- Alopecia
- Gynecomastia
- Galactorrhea

Following are some nursing considerations associated with this drug category:
- Gastric pH should be checked periodically.
- Monitor BUN.
- Administer with meals.
- If taking with antacids, take antacids one hour before or after taking these drugs.
- Cimetidine may be prescribed in one large dose at bedtime.
- Sucralfate decreases the effects of histamine 2 receptor blockers.

Proton Pump Inhibitors
These drugs suppress gastric secretion by inhibiting the hydrogen/potassium
ATPase enzyme system. They are used in the treatment of gastric ulcers, indigestion, and GERD.
Notice that all these drugs contain the syllable prazole and should be given prior to meals.

Proton Pump Inhibitors


Some side effects associated with this drug category are as follows:
- Headache
- Insomnia
- Diarrhea
- Flatulence
- Rash
- Hyperglycemia

Some nursing considerations associated with this drug category are as follows:
- Do not crush pantoprazole.
- May take before meals for best absorption.
- Monitor liver function.
A recently released psychiatric medication named Abilify has the generic name aripiprazole. It is not a proton pump inhibitor.

Anticoagulants
These drugs are used in the treatment of thrombolytic disease. This category prevents conversion of fibrin to prothrombin to thrombin, therefore producing anticoagulant effects. They are used to treat pulmonary emboli, myocardial infarction, deep-vein thrombosis, after coronary artery bypass surgery, and for other conditions requiring anticoagulation.
Notice that all these drugs contain the syllable parin and are heparin derivatives. The client should have a PTT checked to evaluate the bleeding time.
The antidote to these drugs is protamine sulfate.

Anticoagulant Drugs


Here are some side effects associated with this drug category:
- Fever
- Diarrhea
- Stomatitis
- Bleeding
- Hematuria
- Dermatitis
- Alopecia
- Pruritus

Here are some nursing considerations associated with this drug category:
- Blood studies (hematocrit and occult blood in stool) should be checked every three months.
- Monitor PTT often (therapeutic levels are 1.5–2.0 x the control).
- Monitor platelet count.
- Monitor for signs of bleeding.
- Monitor for signs of infection.

More Drug Identification Helpers
These are some of the commonly given medications that allow you to utilize the testing technique of commonalities. Looking at these similarities will help you manage the knowledge needed to pass the NCLEX® and better care for your clients.
Here are some other clues that may help you in identifying drug types:

1. - Caine = anesthetics
2. - Mab = monoclonal antibodies
3. - Ceph or cef = cephalosporins
4. - Cillin = penicillins
5. - Cycline = tetracycline
6. - Stigmine = cholinergics
7. - Phylline = bronchodilators
8. - Cal = calciums
9. - Done = opioids

Do not give tetracycline to pregnant women or small children. It stains the teeth dark and stunts the growth of small children.

Herbals
Herbals are not considered to be medications. They are not regulated by the FDA and can be obtained without a prescription. They do, however, have medicinal properties. Herbals are included on the NCLEX® in the category of pharmacology.
- Feverfew—These prevent and treat migraines, arthritis, and fever. This herbal should not be taken with coumadin, aspirin, NSAIDs, thrombolytics, or antiplatelet medications because it will prolong the bleeding time.
- Ginseng—This is used as an anti-inflammatory. It has estrogen effects, enhances the immune system, and improves mental and physical abilities. This herbal decreases the effects of anticoagulants and NSAIDs.
Use Ginseng with caution when using estrogen because clotting can occur, leading to cardiac disease. This herbal also should not be taken by clients taking corticosteroids because the combination of these two can result in extremely high levels of corticosteroids. High doses cause liver problems.
- Ginko—This improves memory and can be used to treat depression. It also improves peripheral circulation. Ginko should not be taken with
MAO inhibitors, anticoagulants, or antiplatelets. It increases the bleeding time in clients taking NSAIDs, cephalosporins, and valproic acid.
- Echinacea—This is used to treat colds, fever, and urinary tract infec- tions. This herbal may interfere with immunosuppressive agents, methotrexate, and ketoconizole.
- Kava-kava—This herb is used to treat insomnia and mild muscle aches and pains. This herbal increases the effects of central nervous system
(CNS) suppressants and decreases the effects of levodopa. It can also increase the effect of MAOIs.
- St. John’s Wort—This is used to treat mild to moderate depression.

This herbal increases adverse CNS effects when used with alcohol or antidepressant medications.
- Ma Huang—This is used to treat asthma and hay fever, for weight loss, and to increase energy levels. This herbal increases the effect of MAOIs, sympathomimetics, theophylline, and cardiac glycosides.

Drug Schedules
It is important for the nurse to be aware of the drug schedules; several questions might be asked on the NCLEX® regarding safety.
- Schedule I—Research use only (for example, LSD)
- Schedule II—Requires a written prescription. No telephone renewals are allowed (for example, narcotics, Ritalin, and phenobarbital)
- Schedule III—Requires a new prescription after six months or five refills; it can be a telephone order (for example, codeine, steroids, and antidepressants)
- Schedule IV—Requires a new prescription after six months (for exam- ple, Diazepam)
- Schedule V—Dispensed as any other prescription or without prescrip- tion if state law allows (for example, antidiarrheals and antitussives)

Pregnancy Categories for Drugs
These drug categories might also be included on the NCLEX® exam. It is important for the nurse to know which categories the pregnant client should avoid:
- Category A—No risk to fetus.
- Category B—Insufficient data to use in pregnancy.
- Category C—Benefits of medication could outweigh the risks.
- Category D—Risk to fetus exist, but the benefits of the medication could outweigh the probable risks.
- Category X—Avoid use in pregnancy or in those who may become pregnant. Potential risks to the fetus outweigh the potential benefits.