Pharmacology Quiz: High Alert Medications

A 45-year-old patient with ARDS has been sedated with a propofol infusion at a high dose (65 mcg/kg/min) for over 48 hours. The nurse observes new-onset bradycardia, severe metabolic acidosis on the ABG, and the patient's serum is noted to be lipemic. The patient's creatine kinase (CK) level is markedly elevated.

This constellation of findings is most characteristic of which high-alert medication complication?

A patient is receiving a titrated infusion of sodium nitroprusside for a hypertensive emergency. After 48 hours of infusion, the patient becomes confused, tachycardic, and develops a metabolic acidosis with an elevated anion gap. The patient has known chronic kidney disease.

The nurse should suspect toxicity from which metabolite of this high-alert medication?

A patient is being treated for diabetic ketoacidosis (DKA) with a continuous IV infusion of regular insulin. Initial labs showed a glucose of 650 mg/dL and a serum potassium of 5.8 mEq/L. After four hours of treatment with insulin and IV fluids, the glucose is now 280 mg/dL, and the anion gap is improving.

At this stage of treatment, the nurse should prioritize monitoring for which electrolyte imbalance?

A patient is being transitioned from a therapeutic heparin infusion to oral warfarin. Today's lab results are: aPTT 75 seconds (therapeutic) and INR 1.6 (goal 2.0-3.0). The provider's orders are to continue both medications at their current doses.

What is the primary pharmacodynamic rationale for overlapping heparin and warfarin therapy for at least five days?

An 80-year-old patient with atrial fibrillation has been on stable warfarin therapy for two years, with a target INR of 2.0-3.0. The patient is admitted for pneumonia and started on sulfamethoxazole-trimethoprim. On admission, the INR was 2.5. Four days later, the INR is 7.8, and the nurse notes new ecchymosis on the patient's arms.

What is the most likely cause of the patient's supratherapeutic INR?

A patient in the intensive care unit weighs 80 kg and is hypotensive despite fluid resuscitation. The physician orders a norepinephrine infusion to begin at 0.05 mcg/kg/min. The standard pharmacy concentration is norepinephrine 4 mg in 250 mL of D5W.

At what rate in mL/hr should the nurse program the infusion pump?

A 90-kg patient is diagnosed with a pulmonary embolism. The treatment protocol includes an IV heparin bolus of 80 units/kg followed by a continuous infusion started at 18 units/kg/hr. The pharmacy supplies a standard heparin solution of 25,000 units in 250 mL of 0.9% NaCl.

To start the continuous infusion as ordered, the nurse should set the infusion pump to what rate in mL/hr?

An 82-year-old patient with type 2 diabetes and an estimated creatinine clearance of 35 mL/min is admitted with profound hypoglycemia (blood glucose 42 mg/dL) after taking their prescribed glyburide. The patient is treated with IV dextrose and the hypoglycemia resolves, but it recurs 6 hours later.

What is the most likely reason for the recurrent and prolonged hypoglycemia in this patient?

A 55-year-old patient has been receiving a continuous intravenous heparin infusion for a deep vein thrombosis for five days. The patient's baseline platelet count was 250,000/mm³. The nurse reviews the morning labs and notes the platelet count is now 90,000/mm³. The patient has no signs of active bleeding.

Which action is the highest priority for the nurse to take?

A patient with a serum potassium of 2.6 mEq/L is receiving potassium chloride 20 mEq in 100 mL 0.9% NaCl via a peripheral IV in the forearm, prescribed to infuse over 2 hours. Thirty minutes into the infusion, the patient reports severe burning pain at the IV site, which appears erythematous and swollen proximal to the catheter.

What is the nurse's most appropriate initial action?

A cachectic, opioid-naive 78-year-old patient with cancer pain is prescribed a fentanyl 25 mcg/hr transdermal patch. The patient's spouse calls the clinic 24 hours after applying the first patch, stating the patient is extremely sleepy and difficult to arouse. The spouse also mentions the patient had a fever of 101.5°F (38.6°C) overnight.

Which factor most likely contributed to the patient's acute opioid toxicity?

A patient at 32 weeks gestation is receiving an IV infusion of magnesium sulfate for pre-term labor. The nurse's assessment reveals the following: respiratory rate 10 breaths/min, absent patellar reflexes, and a complaint of feeling flushed and hot.

Which finding is the most definitive indicator of magnesium toxicity that requires the nurse to stop the infusion immediately?

A patient is undergoing a colonoscopy with moderate sedation using IV midazolam. Ten minutes after the last dose, the nurse observes that the patient's respiratory rate has decreased from 16 to 8 breaths per minute, and the end-tidal CO2 (ETCO2) has risen from 38 mmHg to 55 mmHg. Oxygen saturation remains 93% on supplemental oxygen.

Which parameter provides the earliest and most sensitive indication of midazolam-induced respiratory depression?

A patient with acute decompensated heart failure is receiving a dobutamine infusion at 5 mcg/kg/min. The nurse notes the patient's heart rate has increased from 90 to 130 bpm and the cardiac monitor shows multifocal premature ventricular contractions (PVCs). The patient's blood pressure remains stable.

What is the most appropriate initial nursing action?

A 55-year-old patient has been receiving a continuous intravenous heparin infusion for a deep vein thrombosis for five days. The patient's baseline platelet count was 250,000/mm³. The nurse reviews the morning labs and notes the platelet count is now 90,000/mm³. The patient has no signs of active bleeding.

Which action is the highest priority for the nurse to take?

A 65-year-old patient with end-stage COPD and a history of sleep apnea is receiving morphine via a patient-controlled analgesia (PCA) pump following abdominal surgery. The nurse finds the patient difficult to arouse, with a respiratory rate of 7 breaths/minute and an SpO2 of 86% on room air.

After attempting to stimulate the patient, which action should the nurse perform immediately?

A 45-year-old patient with ARDS has been sedated with a propofol infusion at a high dose (65 mcg/kg/min) for over 48 hours. The nurse observes new-onset bradycardia, severe metabolic acidosis on the ABG, and the patient's serum is noted to be lipemic. The patient's creatine kinase (CK) level is markedly elevated.

This constellation of findings is most characteristic of which high-alert medication complication?

A 72-year-old patient has been taking oral amiodarone 200 mg daily for 18 months to manage atrial fibrillation. During a routine follow-up, the nurse notes the patient has developed a new, persistent, non-productive cough and is more short of breath when walking.

These new symptoms should prompt a priority evaluation for which known, serious adverse effect of long-term amiodarone therapy?

A patient taking dabigatran for non-valvular atrial fibrillation presents to the emergency department after a significant head injury. The patient is lethargic. The provider is considering administration of the reversal agent, idarucizumab.

Which piece of information is most critical for the team to obtain to guide the decision-making process for reversal?

A cachectic, opioid-naive 78-year-old patient with cancer pain is prescribed a fentanyl 25 mcg/hr transdermal patch. The patient's spouse calls the clinic 24 hours after applying the first patch, stating the patient is extremely sleepy and difficult to arouse. The spouse also mentions the patient had a fever of 101.5°F (38.6°C) overnight.

Which factor most likely contributed to the patient's acute opioid toxicity?