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The Diuretics
overall goal for use
reduction of fluid volume
benefits of reduced fluid volumes:
- reduced workload of the heart (blood volume is reduced)
- increased cardiac output
- decreased peripheral edema
- decreased pulmonary congestion
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The Diuretics
What general conditions are diuretics used for ??
- heart failure
- cirrhosis/liver disease
- renal diseaes/failure
- hypertension (one class of diuretics used as a primary treatment; others are secondary)
- pulmonary edema
WHY???
Because for ALL of these conditons excess fluid is a problem !!
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What does too much fluid volume really do ??
- increased circulating plasma volume
- increased peripheral vascular resistance
- increased cardiac workload
- decreased cardiac output
- decreased blood flowto kidneys
- decreased renal output which further results in increased fluid !!
- 1. fluid "backs up" to pulmonary system and crackles happen !!
- 2. fluid escapes to tissues i.e., peripheral edema happens !!
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hypertension notes
important to assess or:
can happen to a pt if bp is not controlled
- d daily weight
- i I&O
- u urine output
- r response of blood pressure
- e electrolytes
- t take pulses
- i ischemic episodes (TIA)
- c complications: the 4 C's
- CAD coronary artery disease
- CRF chronic renal failure
- CHF congestive heart failure
- CVA cerebral vascular accident
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Lab tests related to diuretics
- potassium 3.5-5.0
- sodium 135-145
- chloride 96-106
- calcium 9.0-10.5
- magnesium 1.3-2.1
- phosphorus 3.0-4.5
renal function specific:
minumum urine output per hour (adult) 30 ml/hour - pediatrics 1-2 mL/kg/hour
- serum creatinine: 0.5-1.2 (gender related differences)
- BUN 10-20 mg/dL
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Thiazide Diuretics
purpose
- work in distal convoluted tubule to:
- prevent reabsorption of water
- promote diuresis when renal function is not impaired
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Thiazide Diuretics
prototype
administration
hydrochlothiazide (HydroDIURIL)
administration: oral or I.V.
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Thiazide Diuretics
Watch out !!
- pregnancy category B
- use with caution in view of impaired renal function as it just may not work
-
Thiazide Diuretics
adverse reactions
- common: hypotenstion
- common: electrolyte imbalance
- common: hyperglycemia (amt of sugar is more concentrated)
- common: photosensitivity of skin
- common: GI upset
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Thiazide diuretics
DDI
- digoxin (cardiac sensitive to potassium balance - hypokalemia)
- antihypertensives (lowers blood pressure - so double whammy)
- lithium (narrow theraputic window - dependent on fluid, water, sodium balance)
- NSAIDs (like ibuprofen, NSAIDs = need more because of diuretics - because NSAIDs blunt affects)
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Thiazide Diuretics
know what shows the drugs are working or not working
- decreased blood pressure
- decreased edema
- increased urine output
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"High ceiling" Loop Diuretics
purpose
- block reabsorption of sodium and chloride in the ascending loop of Henle to:
- prevent reabsorption of water
- cause extensive diuresis
- because the "loops" increase renal blood flow, they are useful in renally compromised patients
- you often see the "loops" used for edema in Med-Surg applications
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"High ceiling" Loop Diuretics
extra notes
- potassium-wasting diuretic
- diuresis is quite extensive within 5 minutes
- increased renal blood flow- good if have renal problems
- increase dose - increase effects
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"High ceiling" Loop Diuretics
prototype
administration
furosemide (Lasix)
Bumetanide (Bumex)
- oral or I.V.
- (give slowly by I.V. to avoid ototoxicity)
- give over 3-5 minutes
- caution: sulfa drug sensitivity
if fluid is in 3rd spaced tissues - then lasix will be slower to work
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"High Ceiling" Loop Diuretics
watch out!!
- pregnancy category C
- use with caution in view of diabetes (it increases blood sugar)
- use with caution in view of gout (may result in hyper uricemia)
- Watch out !!
- this class of diuretic dumps potassium
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"High Ceiling" Loop Diuretics
adverse reactions
- common: hypotension
- common: electrolyte imbalance
- hypokalemia
- hyponatremia
- hypochloremia
- hypocalcemia
- hypomagnesemia
- common: hyperglycemia
- Ototoxicity (transient deafness =rare)
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"High Ceiling" Loop Diuretics
DDI
- digoxin
- antihypertensives
- lithium
- NSAIDs
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"High Ceiling" Loop Diuretics
know what shows the drug is working or not working
- decreased peripheral edema or pulmonary congestion
- weight loss
- decreased blood pressure
- increased urine output
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Potassium Sparing
purpose
- block the action of aldosterone
- +keeps potassium and gets rid of sodium and water
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Potassium Sparing
prototype
administration
spironolactone (aldactone)
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Potassium Sparing
extra note
if can not keep potassium levels up - may be on Lasix and alittle bit of aldactone to keep potassium
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Potassium Sparing
watch out
- this class of diuretics keeps potassium
- Do not administer if K+ is >5.0 mEq/L
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Potassium Sparing
adverse reactions
- common: hyperkalemia
- common: endocrine effects (gynecomastia/impotence/irregualar menstural cycles)
triamterene may turn urine blue
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Potassium Sparing
DDI
- Ace inhibitors (may increase K+ levels)
- concurrent use of potassium supplements (may increase K+ levels)
- lithium (because of fluid balance problem)
also: other drugs that increase potassium = like Ace inhibitors
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Potassium Sparing
know what shows the drugs are working or not working
- decreased blood pressure (if used as antihypertensive)
- decreased edema
- potassium levels WNL
- (watch for hyperkalemia on cardiogram= T wave will peak)
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Potassium Sparing
know what to teach
- diet=) avoid potassium
- do not eat bananas, strawberry, avocado
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Osmotic Diuretics
purpose
increase blood osmolality to create diuresis
attracts fluids from other compartments (third-spaced, cerebral, intraocular)
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Osmotic Diuretics
prototype
mannitol (Osmitrol) - I.V. bolus in an ampule
Isosorbide (Ismotic)-used for glaucoma
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Osmotic Diuretics
administration
- I.V. - most effective given as bolus
- note: manitol requires use of filter needle to draw up or filter in IV tubing
- note: Isosorbie & glycerin have oral formulations
used for cerebral edema
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Osmotic Diuretics
watch out
extreme caution needed when administering to cardiac patients (mannitol may increase edema and cardiac workload)
do not use in patient with total renal failure
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Osmotic Diuretics
adverse reactions
- headache
- nausea
- vomiting
- dizziness
- rash
- blurred vision
- thrombophlebitis
- fluid/electrolye disorders
- dehydration
- thirst
- urticaris
- hypotenstion
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Osmotic Diuretics
DDI
from Epocrates.com
- lithium
- MAOIs
- organic nitrates
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Osmotic Diuretics
know what shows the drugs are working or not working
- decreased intracranial pressure
- decreased intraocular pressure
- normal renal function
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Osmotic Diuretics
know what to monitor
- cerebral edema=)
- mental status changes
- coma ??
- intracranial pressure decreased
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A client is to take furosemide daily. Teaching instructions should include:
good sources of potassium include avocados and strawberries
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A client taking which of the following would be at risk for ototoxicity ??
spironolactone
furosemide
hydrochlorthiazide
mannitol
furosemide
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A client is to receive mannitol,IV push bolus. Which of the following would be of concern if noted after the mannitol is administered ??
distended neck veins
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Anti-anemia: Iron
purpose
provide iron needed for RBC formation and oxygen transport
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Anti-anemia: Iron
prototype
- Ferrous sulfate (Feosol)
- Iron Dextran (NFeD)
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Anti-anemia: Iron
administration
ORAL (except for INFeD which is given IM/IV)
- Watch out !!
- Giving with antacids/milk/"cyclines" decreases effect
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Anti-anemia: Iron
adverse effects
- GI upset but taking with food can decrease effectiveness
- take with orange juice 1 hr before or 2 hrs after
- give between meals - hard to avoid calcium in diet
- will bind with calcium/tetrocycline decrease effect
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Anti-anemia: Vitamin B12
purpose
convert folic acid from inactive to active form (all cells need folic acid for DNA production)
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Anti-anemia: Vitamin B12
prototype
administration
Cyanocobalamin (Crysamine)
oral, nasal, SQ/IM
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Anti-anemia: Vitamin B12
watch out
sensitivity to cobalt - radiation from cancer
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Anti-anemia: Vitamin B12
adverse reactions
- uncommon
- hypokalemia can occur as a result of increased RBC production, rash/itching; anaphylaxis possible but rare
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Anti-anemia: Folic Acid
purpose
provide necessary ingredient for DNA production and erythropoiesis (RBC, WBC, platelets)
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Anti-anemia: Folic Acid
prototype
folic acid (folacin, folvite)
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Anti-anemia: Folic Acid
administration
oral
note: absorbed better in pill form as opposed to in food
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Anti-anemia: Folic Acid
watch out
- DDI: sulfas and methotrexate decrease folate levels
- (may be put on folic acid supplement)
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Anti-anemia: Folic Acid
adverse reactions
flushing, allergic response if given IV
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Why do we worry about hyperkalemia ??
Key facts about hyperkalemia
- most dangerous of the electrolyte disorders
- commonly accompanies metabolic acidosis
- several common underlying mechanisms can result in too much K+
- best clinical indicators:
- serum potassium levels
- electrocardiogram tracings
- serum potassium levels exceeding 7 mEg/L:
- possible serious cardiac arrhythmias/heart block leading to cardiac arrest
good thing we have Kayexalate to treat it!!
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Kayexalate
purpose
to promote potassium excretion
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Kayexalate
prototype
sodium polystyrene sulfonate (Kayexalate)
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Kayexalate
administration
oral or rectal
in pill form - comes in huge pill - can they swallow it ??
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Kayexalate
watch out
use with caution in patients who cannot tolerate shifts in sodium and pts who receive digoxin or K+ sparing diuretics
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Kayexalate
adverse reactions
common: electrolyte imbalance: you can send the K+ too low
sodium excess possible
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Kayexalate
DDI
- calcium or magnesium antacids or laxatives may reduce drug effect (oral form)
- patients on digoxin and potassium-sparing diuretics require frequent K+ monitoring
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Potassium Supplements
purpose
to treat hypokalemia (K+ level <3.5 mEq/L)
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Potassium Supplements
prototype
potassium chloride (K-Dur)
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Potassium Supplements
administration
- oral (powder to mix in water common)
- In at least 4 ounces liquid, do not crush ER tabs
- IV: rapid IV infusion can result in fatal hyperkalemia
- no more tha 40 mEq per liter IV solution
- no more than 10 mEq/hour rate
- really tears up veins - watch for phlebitis
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Potassium Supplements
watch out
- do not use with K+ sparing diuretics
- do not use when there is severe renal disase or hypoaldosteronism
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Potassium Supplements
adverse reactions
- common: GI distress - oral
- GI ulceration - oral
- hyperkalemia - IV
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Potassium Supplements
DDI
- spironolactone (and other potassium sparers)
- ACE inhibitors due to risk for hyperkalemia
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Magnesium levels
hyper
depressed deep tendon reflex
treatment: calcium gluconate
- give this because we have caused this
- we have caused this in treating something else
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Magnesium Supplements
purpose
replacement or prevention of hypomagnesemia
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Magnesium Supplements
prototype
magnesium sulfate
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Magnesium Supplements
administration
- oral - used to prevent low magnesium
- IV - used when magnesium levels are already low and in OB applications (to treat preterm labor)
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Magnesium Supplements
watch out
- pregnancy risk B
- caution used in view of renal/cardiac disease (a "no no" if AV block is present)
- cautious use in view of rectal bleeding, nausea/vomiting, abdominal pain
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Magnesium Supplements
adverse reactions
common: hypermagnesemia: monitor for deep tendon reflexes
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Magnesium Supplements
DDI
decreased absorption of tetracyclines
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Sodium Bicarbonate
purpose
an alkalinizer to correct metabolic acidosis (acidosis = <7.35)
-
Sodium Bicarbonate
prototype
sodium bicarbonate (aka "bicarb")
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Sodium Bicarbonate
administration
- oral - as an antacid
- IV - generally bolus but can be added to solution for continuous infusion (rare)
- note: IV use is generally restricted to situations where there is proven deficit on ABGs to confirm acidosis
- note: when given IV, remember - it doesn't mix with anything (i.e., numerous incompatabilities)
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Sodium Bicarbonate
watch out
- hypertenstion
- heart failure
- kidney disease
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Sodium Bicarbonate
adverse reactions
- sodium overload
- renal calculi
- metabolic alkalosis
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Sodium Bicarbonate
DDI
- corticosteroids (can result in decrease K+, increase Na+)
- increases effect of pseudophedine and quinidine
- decreases effect of lithium, salicylates (aspirin), and benzos
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Calcium Supplements
purpose
- to treat or prevent hypocalemia
- preventive use is directed toward "at risk" populations (adolescents, women who are postmenopausal, pregnant, breast feeding)
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Calcium Supplements
prototype
calcium citrate
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Calcium Supplements
administration
- oral - common
- take at a different time than glucocorticoids, tetracyclines, thyroid hormone
IV - somewhat rare, incompatibilities exist
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Calcium Supplements
watch out
use with caution in view of decreased GI function, renal disease, dehydration
-
Calcium Supplements
adverse reactions
hypercalcemia - somewhat rare, generally only a problem with IV administration
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Calcium Supplements
DDI
Many possible !! (but it is still pretty darn safe)
- glucocorticoids - decrease absorption of Ca+
- tetracyclines - decrease absorption of drug
- thyroid hormones - decrease absorption of drug
- thiazide diuretics - increased absorption of Ca+
- digoxin combined with parenteral Ca+ = severe bradycardia
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With any calcium enhancer....
- encourage clients to consume adequate amounts of dietary calcium
- What are calcium foods you would recommend??encourge client to perform weight-bearing excercises daily
- What kind of exercise would you recommend??
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SERMs:
selective estrogen receptor modulators
purpose
prevention and treatment of postmenopausal osteoporosis; also as a protection against breast cancer
-
SERMs
prototype
administration
raloxifene
oral
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SERMs
watch out
history of blood clots, cancer, stroke, elevated triglycerides, liver disease
-
SERMs
adverse reactions
- deep vein thrombosis
- pulmonary embolism
- stroke
- common: hot flashes (1 in 10 patients report)
- leg cramps (1 in 14 patients report)
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SERMs
DDI
- cholestyramine
- warfarin
- systemic estrogens
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Biphosphonates
purpose
inhibit bone resorption by decreasing number and action of osteoclasts
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Biphosphonates
prototype
alendronate sodium (Fosamax)
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Biphosphonates
administration
- oral: tablets or liquid
- tabs: may be daily or once a week
- liquid: once a week
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Biphosphonates
watch out
existing esophageal disorders (GERD) should not use
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Biphosphonates
adverse reactions
esophagitis
also a risk for hyperparathyroidism at high doses (monitor PTH levels)
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Biphosphonates
DDI
- calcium supplements
- antacids
- orange juice
- caffeine will decrease absorption so take 30 minutes before or after these products
use with salicylates = increased GI distress
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Calcitonin-Salmon
purpose
inhibits activity of osteoclasts to decrease bone absorption
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Calcitonin-Salmon
prototype
calcitonin-salmon (fortical, miacalcin)
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Calcitonin-Salmon
administration:
- intranasal (most common)
- SQ
- IM
- Note: keep nasal spray container in upright position
- must alternate nasals - bloody and runny nose
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Calcitonin-Salmon
watch out
- pregnancy category C
- cautious use in kidney patients
-
Calcitonin-Salmon
adverse reactions
- rhinitis and epistaxis (with nasal spray)
- skin rash
- injection site redness/irritation (injectable form)
- nausea
- allergic response
-
Calcitonin-Salmon
DDI
decrease in serum lithium levels
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Which of the following should a client be monitored for when receiving magnesium sulfate?
depressed deep tendon reflexes
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A client with hyperkalemia has been prescribed Kayexalate rectally. Which of the following is an appropriate nursing intervention related to this route of administration??
irrigate the colon after the Kayexalate solution has been expelled
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Which of the following is used for treatment of hypermagnesemia?
calcium gluconate
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Which precaution is necessary when administering potassium chloride IV?
select all that apply
infusion pump
rate of no more than 10 mEq/hour
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Which of the following clients should not take raloxifene (Evista)? select all that apply
- 55-year-old who had a DVT one year ago
- 38-year-old who is pregnant
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