NCLEX Practice Exam for Pharmacology for Anti-inflammatory and Antineoplastic Medications

EXPLANATION

✔Correct answer:

To prevent the occurrence of steroid withdrawal syndrome. Tapering oral corticosteroids is essential to prevent steroid withdrawal syndrome, a condition that occurs when corticosteroids are stopped abruptly after prolonged use. Long-term corticosteroid therapy suppresses the hypothalamic-pituitary-adrenal (HPA) axis, reducing the body's ability to produce endogenous cortisol. If the medication is discontinued suddenly, the body may not be able to respond adequately to physiological stress, potentially leading to adrenal insufficiency, which can be life-threatening.

Gradual tapering allows the HPA axis to recover and resume normal cortisol production. Symptoms of steroid withdrawal syndrome may include fatigue, weakness, hypotension, nausea, vomiting, joint pain, and even cardiovascular collapse in severe cases.

Imagine you’ve been using crutches for months because of a leg injury. Your leg muscles have weakened over time. If you suddenly toss the crutches, you’ll fall. But if you slowly rely on them less, your leg has time to regain strength. The body’s cortisol production works the same way — tapering gives it time to "exercise" and restart.

Nurses must educate patients thoroughly on the importance of tapering and monitor for signs of withdrawal or adrenal insufficiency.

• Teach the patient never to stop corticosteroids abruptly, especially after long-term use.
• Emphasize adherence to the tapering schedule provided by the healthcare provider.
• Monitor for signs and symptoms of adrenal insufficiency such as fatigue, dizziness, and low blood pressure.
• Encourage patients to report any unusual symptoms during the tapering period.
• Collaborate with the healthcare provider to adjust the tapering schedule if signs of withdrawal occur.

✘Incorrect answer options:

To achieve and maintain optimal serum medication levels. While maintaining therapeutic levels is important during active treatment, tapering is not aimed at stabilizing drug levels but rather at allowing physiological hormone regulation to resume.

To ensure the medication's reliability and consistent effectiveness. Corticosteroids are already effective when used correctly; tapering is not related to improving reliability but to preventing adverse effects of abrupt cessation.

To promote patient compliance with the prescribed regimen. Although patient education and clear tapering instructions may support compliance, this is not the primary reason for tapering. The physiological need to prevent withdrawal is the main concern.

EXPLANATION

✔Correct answer:

Risk for infection related to immunosuppression. In a patient undergoing chemotherapy, the priority nursing diagnosis is Risk for infection due to the profound immunosuppressive effects of cytotoxic agents. Chemotherapy targets rapidly dividing cells, which include bone marrow progenitor cells, leading to neutropenia—a dangerously low white blood cell (WBC) count, especially neutrophils, which are the body’s first line of defense against infection.

Neutropenic patients are at high risk for life-threatening infections, often with subtle or absent typical signs (e.g., no pus formation, minimal fever). Preventing infection is therefore critical to patient safety and survival, making it the most immediate and potentially fatal complication, and thus it takes precedence in the nursing care plan.

If a castle is under attack and its guards (white blood cells) are gone, the first priority is rebuilding the defense to prevent invasion — even before fixing the furniture inside. Similarly, infection prevention is top priority in immunocompromised patients.

Nurses must implement aggressive infection prevention strategies in patients receiving chemotherapy.

• Place the patient on neutropenic precautions: hand hygiene, private room, no fresh flowers or raw foods, and restricted visitors as needed.
• Monitor absolute neutrophil count (ANC) and WBC trends closely.
• Assess for early, subtle signs of infection (e.g., low-grade fever, chills, malaise).
• Educate the patient to avoid crowds and report any signs of illness promptly.
• Collaborate with the provider for potential prophylactic antimicrobials or colony-stimulating factors (e.g., filgrastim).

✘Incorrect answer options:

Disturbed body image related to alopecia. This is a valid psychosocial concern, but it is not immediately life-threatening. While emotional support is essential, physiological needs take precedence according to Maslow’s hierarchy.

Imbalanced nutrition: less than body requirements. Malnutrition can compromise healing and energy levels, but infection risk is more acutely dangerous in the chemotherapy setting and takes priority.

Fatigue related to treatment side effects. Fatigue is a common side effect of chemotherapy but is a lower-priority diagnosis compared to the life-threatening risk of infection.

EXPLANATION

✔Correct answer:

Risk for injury related to prolonged bleeding time, inhibition of platelet aggregation, and increased risk of gastrointestinal bleeding. When nonsteroidal anti-inflammatory drugs (NSAIDs) are combined with anticoagulants (such as warfarin or heparin), the risk of bleeding increases significantly. NSAIDs inhibit the enzyme cyclooxygenase (COX), which reduces prostaglandin production. This results in decreased gastric mucosal protection and inhibition of platelet aggregation, leading to an increased risk of gastrointestinal (GI) bleeding. Concurrently, anticoagulants prolong clotting time by interfering with the coagulation cascade.

The combination of these two classes of drugs places patients at high risk for:

• Prolonged bleeding time
• GI mucosal injury and ulceration
• Serious bleeding events (e.g., GI bleed, hematemesis, melena)

Thus, a "Risk for Injury" nursing diagnosis is appropriate, specifically addressing the mechanisms of bleeding and GI vulnerability associated with both drug classes.

Think of the stomach lining as a soft carpet. NSAIDs wear the carpet down, making it thin and prone to tearing. Meanwhile, anticoagulants remove the vacuum’s “off switch,” so if the carpet tears, it keeps unraveling (bleeding) without stopping. Together, they create a perfect storm for injury.

Nurses must monitor for signs of bleeding and ensure the patient understands the risks associated with this drug combination.

• Monitor for overt signs of GI bleeding: hematemesis, melena, abdominal pain.
• Assess for occult blood in stools using guaiac testing as indicated.
• Monitor laboratory values such as PT/INR, aPTT, hemoglobin, and hematocrit.
• Educate the patient to report unusual bruising, prolonged bleeding, or black/tarry stools immediately.
• Collaborate with the healthcare provider regarding gastroprotective agents (e.g., PPIs) to reduce GI risk.

✘Incorrect answer options:

Potential for injury related to gastrointestinal toxicity and a decrease in bleeding time. This is incorrect because NSAIDs and anticoagulants actually increase bleeding time. The statement "decrease in bleeding time" is physiologically inaccurate.

Altered protection related to gastrointestinal bleeding and increased platelet aggregation. NSAIDs inhibit platelet aggregation, not increase it. This option misrepresents the pharmacological action of NSAIDs.

Risk for injury related to thrombocytosis and prolonged prothrombin time. Thrombocytosis (an increase in platelet count) is not a typical effect of NSAIDs or anticoagulants. In fact, these drugs impair platelet function or reduce clotting capability, not increase platelets.

EXPLANATION

✔Correct answer:

The injury occurred more than 8 hours prior to arrival. Methylprednisolone has historically been used in the early management of acute spinal cord injuries (SCI) for its anti-inflammatory and neuroprotective effects. However, its use is time-sensitive and generally considered only within the first 8 hours after injury. Studies, particularly the National Acute Spinal Cord Injury Studies (NASCIS), showed potential benefits if administered within 8 hours, but no benefit—and even increased risk—when given after 8 hours.

Administering high-dose corticosteroids after this window can increase the risk of complications such as infection, gastrointestinal bleeding, hyperglycemia, and delayed wound healing, without improving neurological outcomes. Therefore, after 8 hours, the treatment is contraindicated in most clinical settings.

Think of methylprednisolone like using a fire extinguisher during a small kitchen fire. If you act fast (within 8 hours), you might contain the damage. But if the fire has already spread through the house (past 8 hours), spraying a fire extinguisher won’t help — and may just cause a bigger mess.

Nurses must recognize the critical timing of interventions in spinal cord injuries and coordinate rapidly with the interdisciplinary team.

• Verify the exact time of injury as part of the initial assessment.
• Communicate promptly with the provider to determine eligibility for methylprednisolone therapy.
• Monitor for side effects of corticosteroids, especially in high doses (e.g., hyperglycemia, infection).
• Educate the patient and family that this treatment is controversial and time-sensitive.
• Collaborate with the healthcare team to consider other supportive interventions when the patient presents outside the treatment window.

✘Incorrect answer options:

The injury is located at a high cervical level. The level of spinal cord injury does not contraindicate methylprednisolone use. In fact, higher-level injuries (e.g., C1–C4) may be even more critical due to potential respiratory compromise, but the decision is still based on time since injury.

The injury occurred less than 4 hours prior to arrival. This is actually within the therapeutic window, and methylprednisolone may be considered in accordance with institutional guidelines.

The injury occurred less than 8 hours prior to arrival. This falls within the appropriate timeframe for initiating treatment, assuming no contraindications such as active infection or severe comorbidities exist.

EXPLANATION

✔Correct answer:

Chloroquine. Chloroquine (and its derivative hydroxychloroquine) is an antimalarial agent frequently used in the management of autoimmune diseases such as systemic lupus erythematosus (SLE) and rheumatoid arthritis (RA). While generally well tolerated, one of the most serious adverse effects of chloroquine is retinal toxicity, which can lead to irreversible vision loss if not detected early.

This drug accumulates in retinal pigment cells and can cause bull's-eye maculopathy, a condition that may be asymptomatic until damage is advanced. Because retinal changes are often not reversible, patients on long-term therapy must undergo baseline and annual ophthalmologic exams, including visual field testing and retinal imaging (e.g., optical coherence tomography or fundus autofluorescence).

Taking chloroquine without eye exams is like driving with foggy headlights—you might not notice the damage until it's too late to fix it. Routine checks help catch problems before permanent damage is done.

Nurses must prioritize preventive education and early detection when managing patients on chloroquine therapy.

• Ensure patients receive a baseline eye exam before starting therapy.
• Reinforce the importance of annual follow-up exams, especially after 5 years of use or if high-risk (older age, renal impairment).
• Educate patients to report any visual changes such as blurred vision, difficulty focusing, or halos around lights.
• Review dosage—retinal toxicity is more common with doses >5 mg/kg/day of hydroxychloroquine equivalent.
• Collaborate with the healthcare provider to consider alternative medications if retinal changes are detected.

✘Incorrect answer options:

Colchicine. Used primarily for gout and familial Mediterranean fever, colchicine’s side effects include GI upset and bone marrow suppression, but not ocular toxicity. Routine eye exams are not required.

Penicillamine. Used for Wilson’s disease and severe RA, penicillamine may cause dermatologic and hematologic side effects, but not eye damage necessitating routine eye exams.

Gold compounds. Gold therapy (e.g., auranofin) may cause dermatitis, stomatitis, and nephrotoxicity, but ocular toxicity is not a common adverse effect requiring routine eye monitoring.

EXPLANATION

✔Correct answer:

Acetylsalicylic acid. Acetylsalicylic acid (ASA), commonly known as aspirin, is the only NSAID routinely used for its antiplatelet properties. Aspirin works by irreversibly inhibiting cyclooxygenase-1 (COX-1) in platelets, which blocks the formation of thromboxane A₂, a potent promoter of platelet aggregation. This permanent inhibition lasts for the lifespan of the platelet (7–10 days), making aspirin uniquely effective in reducing the risk of thrombotic cardiovascular events such as myocardial infarction (MI), stroke, and thrombosis in patients with coronary artery disease (CAD).

Unlike other NSAIDs, which may temporarily inhibit platelet function, aspirin’s irreversible antiplatelet action is what sets it apart and supports its routine use in cardiovascular prophylaxis at low doses (e.g., 81–325 mg daily).

Think of aspirin like a lock on a door that gets permanently jammed—it stops the platelet’s “stickiness” for good. Other NSAIDs are like temporary latches—they only stop the platelets from sticking for a short while, and then everything goes back to normal.

Nurses must understand the cardioprotective role of aspirin and monitor for associated risks, especially bleeding.

• Verify that aspirin is being used in appropriate low doses for antiplatelet therapy.
• Educate patients not to stop aspirin therapy without consulting their provider, especially after cardiac events.
• Monitor for signs of bleeding, such as bruising, blood in stool or urine, and prolonged bleeding from cuts.
• Ensure patients are not taking duplicate NSAIDs or medications that increase bleeding risk (e.g., warfarin, clopidogrel) without medical oversight.
• Encourage patients to report symptoms of GI discomfort or signs of ulceration, as aspirin can irritate the gastric lining.

✘Incorrect answer options:

Ibuprofen. While ibuprofen has temporary, reversible antiplatelet effects, it is not used therapeutically for antiplatelet purposes and may actually interfere with aspirin's action if taken concurrently.

Ketorolac. This is a potent NSAID used primarily for short-term management of moderate to severe pain, especially postoperative. It carries a high risk of GI bleeding and has no antiplatelet use in cardiac care.

Naproxen. Although some studies have explored naproxen’s cardiovascular effects, it does not offer the irreversible platelet inhibition that aspirin does and is not recommended for antiplatelet therapy in CAD.

EXPLANATION

✔Correct answer:

“If the pills have a vinegar-like smell, I understand they should be discarded.” This response reflects a clear understanding of the proper use and storage of acetylsalicylic acid (ASA or aspirin). A vinegar-like odor is a key indicator that aspirin has chemically decomposed into acetic acid and salicylic acid, rendering it ineffective and potentially harmful. Patients must be educated to recognize this sign of degradation and dispose of the medication properly if this occurs.

This statement demonstrates the patient’s awareness of medication safety, a critical part of medication education and adherence.

Think of aspirin like milk — when it goes bad, it smells sour. If your aspirin smells like vinegar, it’s "spoiled" and no longer safe or effective — just like sour milk shouldn’t be consumed.

Nurses should ensure patients are well-informed about proper administration, storage, and signs of deterioration for common medications like aspirin.

• Instruct patients to store aspirin in a cool, dry place and to check expiration dates regularly.
• Educate patients that aspirin with a strong vinegar odor should be discarded, as it indicates breakdown.
• Teach patients to take aspirin with food or a full glass of water to reduce gastrointestinal irritation.
• Advise against altering dosage forms (e.g., crushing enteric-coated tablets) unless directed by a provider.
• Review the signs of aspirin toxicity (e.g., tinnitus, dizziness, nausea) and when to report them.

✘Incorrect answer options:

“I can crush the pills before swallowing them to make them easier to take.” Many aspirin tablets, especially enteric-coated ones, are designed to bypass the stomach and dissolve in the intestines to minimize GI irritation. Crushing them negates this protective effect and increases the risk of gastric bleeding.

“I should take the pills with antacids to prevent stomach upset.” While antacids may reduce GI discomfort, they can interfere with aspirin absorption, especially with enteric-coated formulations. Taking aspirin with food or a full glass of water is safer and more effective.

“Taking the pills on an empty stomach will help with faster absorption.” While this may be true for some medications, aspirin is best taken with food to reduce GI irritation and the risk of ulcers or bleeding.

EXPLANATION

✔Correct answer:

Immunosuppression leading to increased infection risk. Among the listed options, immunosuppression has the most profound impact on a chemotherapy patient's condition. Chemotherapeutic agents target rapidly dividing cells, which include not only cancer cells but also healthy cells in the bone marrow responsible for producing white blood cells (particularly neutrophils). This leads to neutropenia, drastically compromising the patient’s immune defenses.

This immunosuppressed state places patients at high risk for opportunistic infections, sepsis, and other complications that can quickly become life-threatening. The body's ability to fight even minor infections becomes impaired, and what would be a simple cold or skin lesion in a healthy individual can rapidly progress to systemic illness in these patients.

Think of the immune system as the body’s security team. If chemotherapy wipes out most of the team (white blood cells), the building (the body) becomes vulnerable to even the smallest intruders (bacteria, viruses). Without guards, an infection can spread unchecked, causing serious damage.

Nurses play a crucial role in infection prevention, early recognition, and prompt intervention. Below are essential care strategies:

• Implement neutropenic precautions such as hand hygiene, use of personal protective equipment (PPE), and limiting visitors with infections.
• Monitor for signs of infection—fever, chills, increased heart rate, or subtle changes in mental status.
• Administer colony-stimulating factors (e.g., filgrastim) as prescribed to promote white blood cell production.
• Educate the patient and family about food safety, avoiding raw or undercooked foods, and personal hygiene practices.
• Coordinate with the healthcare team to adjust chemotherapy dosing if neutropenia becomes severe.

✘Incorrect answer options:

Alopecia resulting from chemotherapy. While hair loss can be psychologically distressing and impact self-image, it does not directly contribute to physical debilitation or pose a health risk. It is a cosmetic side effect that does not impair physiological functioning.

Nausea and vomiting after treatment sessions. These symptoms are common side effects that can lead to dehydration, electrolyte imbalance, or poor nutritional intake, but they are usually manageable with antiemetic medications and supportive care. While distressing, they are less likely than immunosuppression to lead to severe complications like sepsis.

Changes in taste and appetite. Altered taste (dysgeusia) and appetite can lead to nutritional deficiencies and weight loss over time, which may weaken the patient. However, these are gradual effects and typically do not pose an acute, life-threatening risk compared to the effects of immunosuppression.

EXPLANATION

✔Correct answer:

“Practice effective contraception while on this medication.”  Mycophenolate mofetil (CellCept) is a potent immunosuppressive medication used to prevent organ rejection in transplant recipients. It works by inhibiting inosine monophosphate dehydrogenase, which is essential for the proliferation of T and B lymphocytes. While effective, it is associated with a high risk of teratogenicity and miscarriage, making contraceptive counseling a top priority for women of childbearing potential.

Patients must be instructed to use effective contraception during treatment and for at least six weeks after discontinuing the medication. In many cases, two forms of birth control are recommended concurrently to prevent pregnancy due to the serious risk of congenital malformations and fetal loss.

Taking mycophenolate during pregnancy is like building a house on a cracked foundation — the structure (fetus) may not form correctly. That’s why it’s vital to prevent pregnancy until it’s safe to stop the medication.

Nurses must provide comprehensive medication education and reinforce reproductive safety precautions for transplant patients.

• Educate patients on the teratogenic risks associated with mycophenolate and the importance of contraception.
• Ensure pregnancy testing is completed prior to starting therapy and as recommended during treatment.
• Advise the use of two reliable forms of contraception, especially in women of reproductive age.
• Document patient understanding and informed consent if applicable, per institutional protocol.
• Coordinate with the healthcare provider for referral to OB/GYN or family planning services as needed.

✘Incorrect answer options:

“Always take this medication with food to enhance absorption.”  Mycophenolate may be taken with or without food, and food may actually reduce GI side effects, but it does not enhance absorption. While this may help tolerate the medication better, it’s not the most critical discharge instruction.

“Avoid concurrent use of corticosteroid medications.”  This is incorrect. Mycophenolate is often used in combination with corticosteroids as part of a multidrug immunosuppressive regimen following transplantation.

“Closely monitor yourself for any adverse effects.”  While general monitoring is important, this answer is too vague and lacks the urgency and specificity required for this high-risk medication. The risk of pregnancy complications is far more critical in this context.

EXPLANATION

✔Correct answer:

A client with stable renal function post-transplant requiring long-term immune suppression. Azathioprine (Imuran) is an immunosuppressive agent commonly used as part of a long-term maintenance regimen to prevent organ rejection in transplant recipients. Its primary function is to suppress T and B lymphocyte proliferation by inhibiting purine synthesis, thus reducing the immune system’s ability to attack the transplanted organ.

Azathioprine is most effective in maintaining graft tolerance in clients with stable renal function following transplantation. It is not fast-acting enough for treating acute rejection, nor is it appropriate for non-immune-related post-transplant complications like infection. Its role is to provide chronic immune suppression to help the patient avoid chronic or late acute rejection over time.

Think of azathioprine as a long-term security system that keeps low-level threats from getting into your house (the transplanted kidney). It’s not meant to stop a break-in that’s already happening (acute rejection) but to prevent one in the future.

Nursing management focuses on monitoring for side effects, preventing infection, and promoting adherence to the immunosuppressive regimen.

• Monitor CBC regularly for bone marrow suppression (e.g., leukopenia, thrombocytopenia).
• Educate the client about signs of infection and the importance of avoiding exposure to pathogens.
• Emphasize strict adherence to immunosuppressive therapy to maintain graft survival.
• Monitor renal function tests (BUN, creatinine) to assess ongoing graft stability.
• Evaluate for signs of hepatotoxicity or pancreatitis, rare but serious side effects of azathioprine.

✘Incorrect answer options:

A client who recently experienced acute kidney rejection and requires immediate immune suppression. Azathioprine is not appropriate for treating acute rejection episodes. These are usually managed with high-dose corticosteroids or biologic agents like antithymocyte globulin due to their rapid and potent immunosuppressive effects.

A client with end-stage renal disease awaiting kidney transplant surgery. Immunosuppressive therapy is generally not started until after transplantation, when there is an actual risk of immune-mediated graft rejection.

A client with a urinary tract infection after transplant needing antibiotic therapy. Azathioprine is not an antimicrobial and is not indicated for treating infections. In fact, its immunosuppressive effect may increase the risk of infections, requiring careful management during infectious episodes.

EXPLANATION

✔Correct answer:

Complete blood count (CBC). Azathioprine (Imuran) is an immunosuppressive agent that inhibits purine synthesis, leading to suppression of the bone marrow, which can result in leukopenia, anemia, and thrombocytopenia. Therefore, the most critical laboratory test to monitor for potential adverse effects of azathioprine is the Complete Blood Count (CBC).

Bone marrow suppression is a serious and dose-dependent side effect of azathioprine. By monitoring the CBC, particularly white blood cell (WBC) counts, hemoglobin, and platelet levels, nurses and providers can detect early signs of myelosuppression and prevent life-threatening complications such as infection, bleeding, and fatigue due to anemia.

Think of the bone marrow as a factory producing the body’s protective gear—white blood cells, red blood cells, and platelets. Azathioprine slows down this factory. The CBC is the factory’s dashboard—it tells you if production is dangerously low.

Nurses must monitor laboratory data routinely and assess for clinical signs of hematologic compromise.

• Assess baseline CBC before starting azathioprine therapy and monitor it regularly during treatment.
• Report significant drops in WBCs, hemoglobin, or platelet counts to the healthcare provider promptly.
• Educate the patient to report signs of infection (fever, sore throat), bleeding (bruising, petechiae), or fatigue.
• Hold or adjust the dose based on CBC findings in collaboration with the healthcare team.
• Ensure proper infection control measures are in place due to immunosuppression.

✘Incorrect answer options:

Blood urea nitrogen (BUN). BUN is important for monitoring renal function, which may be relevant for transplant patients, but it is not the primary test for azathioprine toxicity. Azathioprine is more associated with bone marrow suppression than nephrotoxicity.

Electrolyte levels. While electrolytes are essential for overall health, they are not directly affected by azathioprine and are not prioritized for monitoring its adverse effects.

Erythrocyte sedimentation rate (ESR). ESR is a nonspecific marker of inflammation, often used to monitor autoimmune diseases or infections. It does not reflect the adverse effects of azathioprine and is not a priority in this context.

EXPLANATION

✔Correct answer:

It suppresses T-cell response to antigens. Cyclosporine is a cornerstone immunosuppressive agent used in organ transplantation to prevent graft rejection. Its primary mechanism of action is the selective inhibition of T-lymphocyte activation. Specifically, cyclosporine binds to the cytoplasmic protein cyclophilin, which inhibits calcineurin, an enzyme crucial for activating T-cell transcription of interleukin-2 (IL-2) and other cytokines. IL-2 is essential for T-cell proliferation and activation, which are the major drivers of cell-mediated immune responses that can result in graft rejection.

By suppressing the T-cell response to antigens, cyclosporine significantly reduces the immune system's ability to recognize and attack the transplanted organ, promoting graft survival.

Imagine T-cells as soldiers ready to attack anything unfamiliar (like a transplanted organ). Cyclosporine acts like a radio signal jammer, preventing those soldiers from receiving the order to launch an attack.

Nurses are instrumental in patient education and monitoring for side effects associated with immunosuppressive therapy like cyclosporine.

• Emphasize strict adherence to the medication regimen to prevent rejection episodes.
• Monitor renal function closely, as nephrotoxicity is a major adverse effect of cyclosporine.
• Educate the patient about the risk of infection due to immune suppression and the importance of hand hygiene and avoiding crowds.
• Instruct patients not to consume grapefruit juice, which can increase cyclosporine levels and toxicity risk.
• Monitor cyclosporine trough levels as ordered to ensure therapeutic dosing and avoid toxicity.

✘Incorrect answer options:

It strengthens the body's defense against foreign antigens. This is incorrect. Cyclosporine weakens the immune response, particularly the T-cell-mediated response, to prevent organ rejection — it does not enhance immune defense.

It inhibits B-cell immunoglobulin production. Cyclosporine has a minimal effect on B-cell function or antibody production. Its primary immunosuppressive action is T-cell inhibition.

It stimulates the production of T lymphocytes. This is the opposite of cyclosporine’s action. It suppresses the activation and proliferation of T lymphocytes, not stimulate them.

EXPLANATION

✔Correct answer:

To slow down the progression of joint damage. The primary therapeutic goal of antirheumatic medications, particularly disease-modifying antirheumatic drugs (DMARDs), in the management of rheumatoid arthritis (RA) is to slow or halt the progression of joint damage and preserve joint function. RA is a chronic, systemic autoimmune disease characterized by persistent synovial inflammation, which can lead to cartilage degradation, bone erosion, and permanent joint deformity if left untreated.

DMARDs—such as methotrexate, leflunomide, and biologic agents like etanercept or adalimumab—target various components of the immune system to reduce immune-mediated joint destruction. While these medications may also reduce inflammation, their main therapeutic advantage lies in modifying the disease course, not just treating symptoms.

Think of rheumatoid arthritis as rust slowly eating away at machinery (joints). Antirheumatic drugs aren’t just oiling the machine (like NSAIDs do); they actually stop the rust from spreading, helping the machinery last longer.

Nurses must educate patients on long-term goals, medication adherence, and routine monitoring while on DMARDs.

• Emphasize the importance of starting DMARDs early to prevent irreversible joint damage.
• Monitor liver function, CBC, and renal function regularly, as many DMARDs can cause systemic side effects.
• Educate the patient that symptom relief may take several weeks; these are long-term medications, not quick fixes.
• Encourage adherence to the regimen even when symptoms improve, as disease activity may persist at a subclinical level.
• Provide teaching on infection prevention, especially when using immunosuppressive DMARDs or biologics.

✘Incorrect answer options:

To directly modify the acute inflammatory response. This is more characteristic of NSAIDs or corticosteroids, which provide symptomatic relief. DMARDs target the underlying disease process, not just acute inflammation.

To promote the elimination of autoantibodies. While some DMARDs can reduce autoantibody production, this is not their primary mechanism or therapeutic goal. The key objective is to preserve joint integrity.

To enhance the effectiveness of NSAIDs. DMARDs are not adjuncts to NSAIDs. NSAIDs may be used alongside DMARDs for symptom control, but the main role of DMARDs is disease modification, not boosting NSAID effectiveness.

EXPLANATION

✔Correct answer:

Osteoarthritis. Corticosteroids are powerful anti-inflammatory medications often used to manage autoimmune or inflammatory conditions. However, osteoarthritis (OA) is primarily a degenerative joint disease, not an inflammatory one. While corticosteroids may be used for temporary symptom relief via intra-articular injections during flare-ups, they are not a standard or primary treatment for OA. Long-term systemic corticosteroid use does not modify disease progression in OA and may carry unnecessary risks.

In contrast, corticosteroids are a mainstay treatment for autoimmune and inflammatory diseases like rheumatoid arthritis and systemic lupus erythematosus, where inflammation is a central pathological component. They may also be considered in acute spinal cord injury, though their routine use is now controversial and dependent on clinical protocols.

Think of corticosteroids as firefighters. They are most useful where there's an "inflammatory fire" (like in rheumatoid arthritis or lupus). But in osteoarthritis, there's no big fire—just wear and tear like an old machine part. Using a firefighter there wouldn’t fix the underlying issue and might even cause collateral damage.

Nurses play an essential role in patient education, monitoring therapeutic response, and minimizing side effects of corticosteroid use.

• Educate patients that corticosteroids are not typically used long-term for osteoarthritis and may have significant side effects with prolonged use.
• Monitor patients on corticosteroids for signs of immunosuppression, hyperglycemia, and osteoporosis.
• Encourage non-pharmacological strategies for OA such as physical therapy, weight management, and joint protection techniques.
• Advocate for patient safety by ensuring medication use aligns with current evidence-based guidelines.
• Collaborate with the healthcare provider for appropriate medication alternatives in OA management, such as NSAIDs or hyaluronic acid injections.

✘Incorrect answer options:

Rheumatoid arthritis. Corticosteroids are often used in RA to reduce joint inflammation and pain, especially during flare-ups or while waiting for disease-modifying antirheumatic drugs (DMARDs) to take effect. Their immunosuppressive properties help control the autoimmune process.

Systemic lupus erythematosus. This autoimmune disease frequently requires corticosteroids to suppress systemic inflammation and prevent organ damage. They are especially critical in managing flares involving the kidneys, skin, or central nervous system.

Acute spinal cord injury. Although controversial, high-dose corticosteroids (like methylprednisolone) have been used within 8 hours of acute spinal cord injury to potentially reduce inflammation and secondary neuronal injury. However, their use has declined due to risk of complications and mixed evidence. Nonetheless, corticosteroids are still considered in some clinical settings depending on institutional protocols.

EXPLANATION

✔Correct answer:

“I understand the importance of taking it at the same time each day and being mindful of the fat content in my meals.”  Cyclosporine is a critical immunosuppressive agent used in transplant patients to prevent organ rejection. Its effectiveness and safety depend heavily on maintaining consistent blood levels, which is why patients must take it at the same time each day. Additionally, food — especially high-fat meals — can alter cyclosporine absorption, potentially affecting drug levels. Therefore, consistency in food intake (especially fat content) around dosing is important to minimize variability.

This statement shows the patient understands two key principles:

1. Dosing consistency (timing and food context) is vital to maintain therapeutic drug levels.
2. Food-fat interactions can influence absorption and potentially lead to subtherapeutic or toxic levels.

Think of cyclosporine like baking a cake — if the oven temperature and ingredients aren’t consistent every time, the cake won’t turn out right. Just like that, inconsistent timing or meals can throw off how the body absorbs cyclosporine.

Nurses must educate patients on the importance of medication adherence and factors that affect drug absorption and toxicity.

• Instruct patients to take cyclosporine at the same time each day to maintain stable blood levels.
• Educate patients to avoid high-fat meals around dosing unless consistently done to maintain absorption patterns.
• Monitor cyclosporine trough levels to ensure therapeutic range and minimize toxicity.
• Advise against grapefruit or grapefruit juice, which can dramatically increase cyclosporine levels.
• Emphasize not to adjust the dose without consulting the healthcare provider.

✘Incorrect answer options:

“I should mix the medicine in a Styrofoam cup.”  Cyclosporine should never be mixed or stored in Styrofoam, as it may adhere to the container, affecting the accuracy of the dose. It should be mixed in glass or hard plastic containers.

“I should take the medication on an empty stomach.” While cyclosporine can be taken on an empty stomach, what matters most is consistency—either always with food or always without. Abruptly changing intake patterns can alter absorption and affect therapeutic drug levels.

“If I vomit after taking it, I should take another dose immediately.” This is incorrect and potentially dangerous. Taking another dose may result in overdose if some of the medication was absorbed. The patient should notify the healthcare provider for guidance if vomiting occurs soon after dosing.

EXPLANATION

✔Correct answer:

Clients on long-term NSAID therapy for arthritis management. Long-term NSAID use is a well-established risk factor for gastrointestinal (GI) complications, particularly gastric ulcers, erosions, and GI bleeding. Clients with chronic conditions like osteoarthritis or rheumatoid arthritis often require prolonged and consistent NSAID therapy to manage inflammation and pain. This sustained exposure to NSAIDs suppresses prostaglandin synthesis, which in turn reduces the protective mucosal lining of the stomach and intestines, making them more vulnerable to ulceration and bleeding.

This group also tends to be older in age, which is an additional independent risk factor for NSAID-induced GI injury. Therefore, clients receiving daily, long-term NSAID therapy—especially without gastroprotective agents like proton pump inhibitors (PPIs)—are at the highest risk for GI bleeding.

Think of NSAIDs like sandpaper — if you use them once in a while, there’s minimal wear. But using them daily on the same surface (like the stomach lining) will eventually cause damage and tears — just like chronic NSAID use can wear down stomach protection and cause bleeding.

Nurses play a key role in recognizing high-risk clients and ensuring preventive strategies are in place.

• Assess for signs of GI distress (e.g., abdominal pain, melena, hematemesis) in patients on chronic NSAID therapy.
• Review medication regimens to ensure gastroprotective agents are prescribed for long-term NSAID users.
• Educate patients to take NSAIDs with food or milk to reduce gastric irritation.
• Monitor lab values, such as hemoglobin and hematocrit, to detect occult bleeding.
• Collaborate with the healthcare provider to explore alternative pain management options when GI risk is high.

✘Incorrect answer options:

Clients taking NSAIDs occasionally for menstrual cramps. Short-term or intermittent NSAID use for menstrual cramps carries minimal GI risk, especially in younger, otherwise healthy individuals.

Clients using NSAIDs for intermittent tension headaches. Like the previous group, occasional NSAID use for headaches does not significantly increase GI bleeding risk unless taken excessively or combined with other risk factors (e.g., alcohol use, age, corticosteroids).

Clients with impaired kidney function currently using NSAIDs. While this group is at increased risk for nephrotoxicity, they are not the highest risk group for GI bleeding unless also on long-term NSAID therapy. The primary concern in this population is renal function deterioration, not necessarily GI complications.

EXPLANATION

✔Correct answer:

The osteoporotic effects resulting from prolonged steroid use. Long-term corticosteroid therapy is a well-established risk factor for secondary osteoporosis, which significantly increases the risk for fragility fractures, especially in the spine, ribs, and hips. Glucocorticoids decrease bone formation by inhibiting osteoblast activity and increase bone resorption by promoting osteoclast lifespan and activity. They also reduce calcium absorption from the GI tract and increase renal calcium excretion, further compromising bone integrity.

In patients with rheumatoid arthritis (RA), this risk is compounded because both the disease and its treatment (e.g., corticosteroids) can lead to reduced bone density. However, in this case, the vertebral compression fracture is most directly linked to the chronic use of steroids, rather than RA progression itself.

Think of bones like a brick wall. Steroids, over time, act like acid rain that slowly erodes the mortar between the bricks. Eventually, the wall weakens and collapses under pressure — just like bones that fracture easily when weakened by long-term steroid use.

Nurses should assess fracture risk in patients receiving long-term corticosteroids and advocate for preventive measures to protect bone health.

• Educate patients on the risk of osteoporosis with prolonged steroid therapy.
• Encourage adequate calcium and vitamin D intake or supplementation as ordered.
• Promote weight-bearing and resistance exercises when feasible to maintain bone density.
• Monitor for signs of bone loss, such as height loss or back pain, and report findings promptly.
• Collaborate with the healthcare team to consider bone-protective medications like bisphosphonates if appropriate.

✘Incorrect answer options:

An unrelated, coincidental medical condition. While possible, this choice does not address the most likely cause based on the patient’s medical history. Compression fractures in patients with RA on long-term steroids are rarely coincidental.

Progressive deterioration due to rheumatoid arthritis itself. RA can contribute to bone erosion and joint damage, particularly in small joints, but vertebral compression fractures are more commonly associated with osteoporosis from steroid use than with the disease process of RA alone.

The administration of an excessively high dose of steroids. Although high doses increase risk, the duration of therapy plays a more critical role in osteoporosis development. Even moderate doses, when taken over a long time, can result in significant bone loss.

EXPLANATION

✔Correct answer:

Single-agent therapy frequently leads to the development of resistant cell lines. The primary rationale behind combination chemotherapy is to prevent or delay the development of drug-resistant cancer cell lines. Cancer cells, like bacteria, have the potential to mutate and develop resistance to medications. When only one drug is used (monotherapy), there is a higher chance that some tumor cells will survive and adapt, rendering the therapy ineffective over time.

By using multiple drugs with different mechanisms of action, combination chemotherapy reduces the chance that cancer cells will be resistant to all the agents simultaneously. This strategy targets cancer cells at various stages of their growth cycle, disrupts multiple cellular pathways, and makes it harder for cells to survive and multiply.

Think of cancer like a fortress. Using one weapon repeatedly (a single drug) might let the enemy build defenses against it. But using a variety of tools and attacks (multiple drugs) from different directions makes it much harder for the enemy to resist and survive.

Nurses should educate and monitor patients on the implications of combination chemotherapy, as well as manage side effects and provide psychosocial support. Key actions include:

• Educate the patient about the purpose and benefits of combination therapy in reducing resistance and improving outcomes.
• Monitor for cumulative toxicities, since using multiple drugs may increase side effects.
• Encourage strict adherence to the prescribed regimen to maintain drug effectiveness and avoid resistance development.
• Coordinate with the healthcare team to assess for potential drug-drug interactions.
• Support the patient emotionally as treatment complexity and side effects may be more pronounced.

✘Incorrect answer options:

The likelihood of therapeutic success increases when two drugs are used concurrently. While this may seem true, it is not the primary rationale for combination chemotherapy. Improved success is a secondary benefit. The main goal is to avoid resistance, not just increase the likelihood of success.

Single-agent therapy necessitates higher doses for prolonged remissions. This is partially true; however, higher doses can increase toxicity. While dose intensity plays a role, resistance development remains the primary concern addressed by combination therapy.

There is a possibility of two distinct cancers being present. This is not a typical justification for combination chemotherapy. Treating two different cancers would require a different therapeutic strategy altogether. Most combination regimens are designed for a single cancer type, not multiple malignancies.

EXPLANATION

✔Correct answer:

Intravenous steroids can be administered either in diluted or undiluted form. Intravenous (IV) steroids, such as methylprednisolone or hydrocortisone, are commonly used in acute care settings to manage severe inflammation, autoimmune flare-ups, allergic reactions, or adrenal insufficiency. These medications can be administered either diluted or undiluted, depending on the specific drug formulation, dosage, rate of administration, and patient condition.

For example:

• Hydrocortisone sodium succinate (e.g., Solu-Cortef) can be given as an IV bolus (undiluted) or infused (diluted) over a prescribed period.
• Methylprednisolone sodium succinate (e.g., Solu-Medrol) may also be given as an IV push over a few minutes or diluted for infusion depending on the clinical context.

Administration should always follow the manufacturer's guidelines and institutional protocols regarding rate, dilution, and compatibility with IV fluids.

Think of IV steroids like concentrated juice — sometimes you can drink it straight (undiluted), and other times you mix it with water (diluted), depending on how strong it is and how fast you want to drink it. The key is following the recipe — or in this case, the medication guidelines.

Nurses must assess the patient’s condition and ensure safe administration of IV steroids according to best practices.

• Check the drug reference or institutional guidelines for the appropriate route, dilution, and administration rate.
• Monitor vital signs and watch for side effects such as hypertension, hyperglycemia, or signs of infection.
• Assess IV site for patency before administering high-alert medications like corticosteroids.
• Educate the patient about potential short-term effects such as mood changes, flushing, or increased appetite.
• Coordinate with the healthcare provider if unsure about compatibility or need for dilution.

✘Incorrect answer options:

Intravenous steroids must always be diluted prior to administration. This is incorrect. Some IV steroids can be administered safely in undiluted form, especially during emergencies or when IV push is indicated. Dilution depends on the drug and context.

Intravenous steroids should only be administered via IV push. This is too restrictive. While IV push is an option, steroids can also be given via intermittent or continuous infusion depending on patient needs and drug type.

Intravenous administration of steroids is contraindicated in acutely ill patients. This is false. IV steroids are often indicated in acutely ill patients, such as those with asthma exacerbation, septic shock, adrenal crisis, or autoimmune flare-ups. They are not contraindicated, but should be used cautiously with appropriate monitoring.

EXPLANATION

✔Correct answer:

Bleeding. The platelet count of 10,000/mm³ is critically low and indicative of severe thrombocytopenia. Normal platelet levels range from 150,000 to 400,000/mm³. When platelet levels fall below 20,000/mm³, the patient is at significant risk for spontaneous bleeding, including potentially life-threatening hemorrhages (e.g., intracranial or gastrointestinal).

In this case, even though the WBC count is within normal limits and RBC count is stable, the extremely low platelet count is the most concerning finding, making the patient highly susceptible to bruising, petechiae, mucosal bleeding, and internal hemorrhage. This is a common complication of chemotherapy, which can suppress bone marrow function and lead to pancytopenia or selective cytopenias.

Platelets are like emergency road repair teams that seal cracks in the pavement (blood vessels). With so few workers (platelets), even a tiny crack can grow into a dangerous pothole — or in the body, uncontrolled bleeding.

Nurses must take precautionary and protective measures to reduce bleeding risk and ensure patient safety.

• Place the patient on bleeding precautions, including avoiding invasive procedures, IM injections, and rectal temperatures.
• Monitor for signs of bleeding: petechiae, epistaxis, hematuria, melena, and gum bleeding.
• Educate the patient to use a soft toothbrush, avoid contact sports, and shave with an electric razor.
• Prepare for platelet transfusions if ordered, especially if the patient is actively bleeding or undergoing a procedure.
• Notify the healthcare provider immediately of any signs of hemorrhage or rapid drop in platelet count.

✘Incorrect answer options:

Infection. While infection is a common concern in chemotherapy patients, the WBC count here is 5000/mm³, which falls within the normal range (4,000–10,000/mm³). Therefore, bleeding is the more immediate concern in this patient.

Angina. Angina is associated with coronary artery disease and is not directly related to thrombocytopenia or the CBC findings here. There is no indication of cardiac ischemia or anemia in this case.

None of the choices. This is incorrect. The patient’s critically low platelet count makes bleeding a very real and urgent risk, and appropriate precautions must be initiated immediately.

EXPLANATION

✔Correct answer:

Chloroquine (Aralen). Chloroquine, an antimalarial agent, is also classified as a disease-modifying antirheumatic drug (DMARD) and is effective in managing autoimmune conditions such as rheumatoid arthritis (RA), Sjögren’s syndrome, and systemic lupus erythematosus (SLE). Chloroquine and its more commonly used derivative, hydroxychloroquine (Plaquenil), exert immunomodulatory effects by altering antigen presentation and reducing inflammatory cytokine production.

Chloroquine is especially beneficial in:

• RA: for reducing joint pain and inflammation.
• SLE: for managing fatigue, skin manifestations, and preventing disease flares.
• Sjögren’s syndrome: for improving symptoms like fatigue, arthralgia, and mild systemic involvement.

Its broad-spectrum autoimmune activity makes it an ideal therapeutic agent for patients presenting with overlapping features of multiple connective tissue diseases.

Think of chloroquine like a multi-tool — it might not be the strongest tool for just one job, but it’s uniquely useful when you have multiple problems at once. It works across several autoimmune conditions without needing separate medications.

Nurses should focus on promoting medication adherence and monitoring for long-term adverse effects.

• Educate the patient that symptom improvement may take several weeks to months of therapy.
• Emphasize the importance of regular eye exams, as long-term use of chloroquine may cause retinal toxicity.
• Monitor for signs of gastrointestinal upset or skin changes, which are common side effects.
• Ensure consistent medication intake and follow-up to assess drug effectiveness and tolerance.
• Collaborate with ophthalmology and rheumatology for long-term management support.

✘Incorrect answer options:

Auranofin (Ridaura). Auranofin is a gold compound used specifically for RA and not indicated for SLE or Sjögren’s syndrome. Its scope is too narrow for overlapping autoimmune conditions.

Allopurinol (Zyloprim). Allopurinol is used to treat gout by lowering uric acid levels. It has no therapeutic role in RA, SLE, or Sjögren’s syndrome, making it an inappropriate choice.

Sulfasalazine (Azulfidine). Sulfasalazine is a DMARD primarily used in RA and inflammatory bowel diseases, but it is not effective for SLE or Sjögren’s syndrome. Its utility does not extend across all three conditions.

EXPLANATION

✔Correct answer:

A potential decrease in oxygen-carrying capacity. For a chemotherapy patient with pre-existing cardiac disease, the greatest risk for cardiac complications is a decrease in the blood's oxygen-carrying capacity, which is primarily mediated by red blood cells and hemoglobin. Chemotherapy can cause bone marrow suppression, leading to anemia, which reduces the amount of oxygen delivered to the myocardium and other tissues.

In patients with existing cardiac conditions (e.g., coronary artery disease, heart failure), a decrease in oxygen delivery can exacerbate myocardial ischemia, cause angina, arrhythmias, or worsen heart failure. This is particularly dangerous because the heart relies heavily on a constant oxygen supply to function effectively under stress.

Think of the heart as an engine that needs a steady flow of oxygen to keep running. If anemia limits that oxygen, the engine struggles, especially if it’s already damaged. Chemotherapy can cut the fuel line (oxygen), putting extra stress on an already weak engine.

For patients at risk of cardiac complications, nurses must monitor closely for anemia and signs of compromised oxygenation.

• Monitor hemoglobin and hematocrit levels regularly in chemotherapy patients.
• Assess for clinical signs of anemia: fatigue, dyspnea, tachycardia, and chest pain.
• Report significant drops in hemoglobin/hematocrit to the provider, especially in cardiac patients.
• Anticipate orders for packed red blood cell transfusions if oxygen delivery becomes critically low.
• Monitor oxygen saturation and vital signs to detect early signs of decompensation.

✘Incorrect answer options:

A reduction in white blood cell count. While a low WBC count increases the risk of infection, it is not directly related to cardiac workload or function. It’s a concern, but not the greatest risk for cardiac complications.

A possible elevation in sodium levels, leading to fluid overload. Although fluid overload can worsen heart failure, this option is speculative and less directly tied to chemotherapy than anemia is. Electrolyte disturbances do matter, but a confirmed reduction in oxygen-carrying capacity is more immediately threatening to a cardiac patient.

A decrease in hematocrit levels. While this reflects anemia, it is a measurement, not a pathophysiological factor in itself. A low hematocrit contributes to reduced oxygen-carrying capacity, which is the more appropriate and encompassing answer.

EXPLANATION

✔Correct answer:

Taken with food to reduce gastric irritation. Ibuprofen is a commonly used over-the-counter nonsteroidal anti-inflammatory drug (NSAID) that can effectively relieve pain, inflammation, and fever. However, like other NSAIDs, it inhibits prostaglandin synthesis, which normally helps protect the stomach lining. Without this protective effect, the risk of gastric irritation, ulcers, and gastrointestinal (GI) bleeding increases, particularly with frequent or high-dose use.

To reduce these side effects, ibuprofen should be taken with food, milk, or a full glass of water. This helps protect the gastric mucosa by buffering the acidic nature of the drug and slowing its direct contact with the stomach lining.

Taking ibuprofen on an empty stomach is like pouring vinegar on a paper napkin — it’ll eat through it fast. But if you put a plate (food) underneath, it protects the napkin — just like food protects your stomach lining.

Nurses must reinforce safe self-medication practices with patients who regularly use NSAIDs to minimize risks and complications.

• Educate patients to always take ibuprofen with meals or snacks to reduce GI irritation.
• Assess the patient’s frequency and dosage of OTC ibuprofen use to evaluate risk for side effects.
• Advise against long-term self-medication without provider supervision, especially in older adults.
• Monitor for signs of GI distress, such as heartburn, black/tarry stools, or abdominal pain.
• Encourage patients to use the lowest effective dose for the shortest necessary duration.

✘Incorrect answer options:

Administered intravenously for faster relief. Ibuprofen is not typically administered IV outside of hospital settings. IV formulations exist but are reserved for specific indications under provider supervision. OTC ibuprofen is formulated for oral use only.

Taken together with a glass of orange juice. Orange juice is acidic and may increase gastric irritation, not reduce it. It does not provide the protective buffering effect that food or milk can offer.

Swallowed on an empty stomach for better absorption. While NSAIDs may be absorbed slightly faster on an empty stomach, this practice significantly increases the risk of GI irritation and bleeding. The benefit of absorption speed does not outweigh the potential harm.

EXPLANATION

✔Correct answer:

“Limit your intake of calcium-rich foods while taking this medication.” Probenecid (Benemid) is a uricosuric agent used primarily in the management of chronic gout. It works by inhibiting the reabsorption of uric acid in the renal tubules, thereby increasing uric acid excretion. While certain dietary considerations are important in gout management (e.g., limiting purines and alcohol), there is no specific contraindication or caution regarding calcium-rich foods while taking probenecid.

This makes the instruction to “limit calcium-rich foods” the least pertinent for this teaching plan, as calcium intake does not significantly affect uric acid excretion or drug action in this context.

Teaching someone on probenecid to limit calcium is like warning a swimmer about snow — it’s not directly related to the environment they’re in. It may matter in another setting, but not this one.

Nurses should focus on hydration, GI comfort, and hypersensitivity monitoring when educating patients on probenecid.

• Encourage increased fluid intake (2–3 liters/day) to help prevent uric acid crystal formation in the kidneys (uric acid nephrolithiasis).
• Advise the patient to take the medication with food to reduce gastrointestinal irritation.
• Teach the patient to report signs of hypersensitivity, such as rash, fever, or swelling, as probenecid can rarely cause serious allergic reactions.
• Reinforce adherence, as this medication is not used for acute attacks but for long-term uric acid level control.
• Monitor renal function regularly, especially in older adults or those with a history of renal calculi.

✘Incorrect answer options:

“Be sure to drink plenty of fluids throughout the day.” This is essential to prevent the formation of uric acid kidney stones, a known risk when uric acid excretion increases.

“Take this medication with food to reduce stomach upset.” This is important, as probenecid may cause GI distress, especially in early therapy.

“Call your provider if you develop a rash or fever.” This is critical as probenecid can cause hypersensitivity reactions, including Stevens-Johnson syndrome in rare cases.

EXPLANATION

✔Correct answer:

Chronic kidney disease. Gold compounds, such as auranofin (oral) or gold sodium thiomalate (injectable), are classified as disease-modifying antirheumatic drugs (DMARDs) used historically in the treatment of rheumatoid arthritis (RA). Although their use has declined with the advent of newer DMARDs, they may still be prescribed in select cases.

Gold compounds are contraindicated in patients with chronic kidney disease (CKD) due to their renal excretion and potential to cause nephrotoxicity. Accumulation of the drug in renal-impaired patients increases the risk of proteinuria, hematuria, nephrotic syndrome, and progressive renal damage. Therefore, patients with pre-existing renal dysfunction should not receive gold therapy.

Giving gold compounds to someone with kidney disease is like pouring more water into a clogged drain — it only worsens the overflow. The kidneys can’t eliminate the drug properly, leading to buildup and toxicity.

Nurses play a vital role in screening for contraindications and monitoring renal function before and during gold therapy.

• Review renal function tests (e.g., BUN, creatinine, GFR) before initiating therapy.
• Monitor for signs of nephrotoxicity, such as proteinuria or decreased urine output.
• Educate patients on the importance of routine urine tests during gold therapy.
• Ensure patients report early signs of kidney issues, such as swelling, fatigue, or frothy urine.
• Collaborate with the healthcare provider to explore safer alternatives in patients with renal impairment.

✘Incorrect answer options:

Rheumatoid nodules. The presence of rheumatoid nodules is a common extra-articular manifestation of RA and is not a contraindication for gold therapy. It may even indicate more severe disease, warranting aggressive DMARD use.

Morning stiffness. Morning stiffness is a hallmark symptom of RA and reflects inflammatory activity. It is a clinical indication, not a contraindication, for initiating DMARDs like gold compounds.

Joint deformities. Joint deformities indicate chronic and advanced RA but are not a contraindication to gold therapy. However, gold compounds are more effective in early stages and may have limited benefit in advanced joint damage.