A nurse is preparing to administer cyclosporine (Sandimmune), a calcineurin inhibitor, to a client who had a kidney transplant. Which of the following actions should the nurse take? (Select all that apply.)¹

A. Shake the oral solution vigorously before administration. This is to ensure that the drug is well mixed and evenly distributed in the solution¹². Cyclosporine is a lipophilic drug that forms a microemulsion in the oral solution, which enhances its absorption and bioavailability¹². Shaking the oral solution helps to maintain the stability and consistency of the microemulsion¹².

B. Dilute the oral solution in a glass container with milk or orange juice. This is to improve the taste and palatability of the drug, which may otherwise be bitter or unpleasant¹². Cyclosporine can be diluted with milk, chocolate milk, or orange juice, but not with grapefruit juice, which can increase its blood levels and toxicity¹². The diluted solution should be consumed immediately or refrigerated and used within 24 hours¹². A glass container should be used instead of a plastic one, which may absorb some of the drug and reduce its dose¹².

C. Administer the medication at the same time every day. This is to maintain a consistent blood level of the drug and avoid fluctuations that may affect its efficacy and safety¹². Cyclosporine has a narrow therapeutic window and requires careful monitoring and dosing adjustment to prevent organ rejection or toxicity¹². Administering the medication at regular intervals helps to achieve optimal blood concentrations and avoid peaks and troughs that may increase the risk of adverse effects or suboptimal response¹².

D. Monitor blood pressure and report hypertension to the provider. This is to detect and manage one of the most common and serious side effects of cyclosporine, which is hypertension¹². Cyclosporine can cause vasoconstriction and sodium retention, which can increase blood pressure and lead to cardiovascular complications such as stroke, heart failure, or kidney damage¹². The nurse should measure blood pressure regularly and report any elevation or signs of hypertensive crisis to the provider¹². The provider may prescribe antihypertensive drugs or adjust the dose of cyclosporine to control blood pressure¹².

E. Obtain serum drug levels periodically to verify therapeutic range. This is to ensure that the dose of cyclosporine is adequate and appropriate for the individual patient's needs and response¹². Cyclosporine has a high inter- and intra-patient variability in pharmacokinetics, which means that its absorption, distribution, metabolism, and excretion can differ significantly among different patients or even within the same patient over time¹². Factors such as age, weight, gender, genetics, diet, drug interactions, organ function, and disease state can affect cyclosporine blood levels and require dose adjustment¹². The nurse should obtain serum drug levels at specified times (usually 12 hours after the last dose) and report them to the provider, who may modify the dose based on the results¹².

The laboratory value that should be monitored periodically when taking allopurinol is serum creatinine level. Allopurinol is a drug that lowers the level of uric acid in the blood and urine by inhibiting the enzyme xanthine oxidase, which is involved in the metabolism of purines¹². Allopurinol is used to treat gouty arthritis, a condition that causes painful inflammation of the joints due to the deposition of uric acid crystals¹².

The other options are incorrect because:

- Option A is wrong because serum uric acid level is not the laboratory value that should be monitored periodically when taking allopurinol. Serum uric acid level is the amount of uric acid in the blood, which is a waste product that is produced by the breakdown of purines. Serum uric acid level is usually high in patients with gouty arthritis, which causes inflammation and pain in the joints due to the deposition of uric acid crystals . Allopurinol lowers serum uric acid level by inhibiting xanthine oxidase, which is involved in the metabolism of purines . However, serum uric acid level is not a reliable indicator of allopurinol's effectiveness or toxicity, because it does not reflect the amount of uric acid in the tissues or urine, where it can cause damage or complications . Serum uric acid level may also fluctuate due to various factors such as diet, hydration, renal function, or drug interactions . Therefore, serum uric acid level is not the laboratory value that should be monitored periodically when taking allopurinol.

- Option B is wrong because serum potassium level is not the laboratory value that should be monitored periodically when taking allopurinol. Serum potassium level is the amount of potassium in the blood, which is an electrolyte that is essential for the function of nerves, muscles, and heart. Serum potassium level is normally regulated by the kidneys, which excrete excess potassium or retain potassium when needed . Serum potassium level can be affected by various factors such as diet, hydration, acid-base balance, renal function, or drug interactions . Allopurinol does not have a direct effect on serum potassium level, but it may interact with some drugs that can alter serum potassium level, such as diuretics, angiotensin-converting enzyme inhibitors, or potassium supplements . However, these drug interactions are not specific to allopurinol and can occur with any drug that affects renal function or electrolyte balance . Therefore, serum potassium level is not the laboratory value that should be monitored periodically when taking allopurinol.

- Option D is wrong because serum calcium level is not the laboratory value that should be monitored periodically when taking allopurinol. Serum calcium level is the amount of calcium in the blood, which is a mineral that is involved in various processes such as bone formation, muscle contraction, nerve transmission, and blood clotting. Serum calcium level is normally regulated by the parathyroid glands, which secrete parathyroid hormone (PTH) to increase calcium absorption from the gut and bone resorption from the skeleton . Serum calcium level can be affected by various factors such as diet, hydration, vitamin D status, renal function, or drug interactions . Allopurinol does not have a direct effect on serum calcium level, but it may interact with some drugs that can alter serum calcium level, such as thiazide diuretics, which can increase calcium reabsorption in the kidney and cause hypercalcemia . However, these drug interactions are not specific to allopurinol and can occur with any drug that affects renal function or calcium metabolism . Therefore, serum calcium level is not the laboratory value that should be monitored periodically when taking allopurinol.