The nurse is caring for a client who takes methotrexate for rheumatoid arthritis and receives a prescription for adalimumab. Which instructions should the nurse provide the client?

Undergo annual eye examinations.

Have a chest x-ray prior to your first dose.

Avoid crowds and people who are sick.

Obtain routine vaccinations as scheduled.

Answer and Explanation

The Correct Answer is C

A) Undergo annual eye examinations:
While methotrexate and adalimumab can both have potential ocular side effects, such as blurred vision or eye pain, the need for annual eye examinations is more commonly associated with methotrexate therapy. Methotrexate can cause ocular toxicity, including retinopathy and optic neuropathy, which necessitates regular monitoring by an ophthalmologist. However, adalimumab is not typically associated with annual eye examinations, so this instruction is not directly relevant to the addition of adalimumab to the client’s regimen.

B) Have a chest x-ray prior to your first dose:
A chest x-ray is not routinely required before initiating adalimumab therapy. While screening for tuberculosis (TB) may be necessary in clients starting adalimumab due to its immunosuppressive effects, a chest x-ray is not always indicated for this purpose. Instead, TB screening usually involves a thorough history, physical examination, and possibly tuberculin skin testing or interferon-gamma release assays. Therefore, this instruction is not specifically related to the addition of adalimumab to the client’s treatment regimen.

C) Avoid crowds and people who are sick:
Adalimumab is a biologic disease-modifying antirheumatic drug (DMARD) that suppresses the immune system’s inflammatory response by targeting tumor necrosis factor-alpha (TNF-alpha). As a result, clients taking adalimumab are at increased risk of infections, including bacterial, viral, and fungal infections. Therefore, instructing the client to avoid crowds and individuals who are sick helps reduce the risk of exposure to infectious pathogens and minimize the likelihood of developing infections while on adalimumab therapy.

D) Obtain routine vaccinations as scheduled:
While maintaining up-to-date vaccinations is important for overall health and immunity, clients receiving biologic DMARDs like adalimumab may have a reduced response to vaccines due to immunosuppression. Therefore, it is generally recommended to administer necessary vaccinations before starting adalimumab therapy whenever possible. However, the decision to administer vaccines should be individualized, and certain live vaccines may be contraindicated while receiving adalimumab. Nonetheless, this instruction is not directly related to the addition of adalimumab to the client’s medication regimen.

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Correct Answer is A

Explanation

A) Monitor blood pressure:
This is the correct answer. Tamsulosin, like other alpha-blockers, can cause orthostatic hypotension, which is characterized by a sudden drop in blood pressure when transitioning from lying down or sitting to standing. Monitoring blood pressure, particularly when initiating therapy or adjusting the dosage, helps detect and manage hypotensive episodes. Clients should be advised to change positions slowly to minimize the risk of falls or injury.

B) Assess urine output:
While tamsulosin can affect urinary function by relaxing smooth muscle in the prostate and bladder neck, it typically does not significantly impact urine output. Therefore, monitoring urine output is not a primary intervention for assessing adverse reactions to tamsulosin.

C) Obtain daily weights:
Tamsulosin is not typically associated with significant fluid retention or changes in body weight. Daily weight measurements are more relevant for assessing fluid balance in clients receiving medications such as diuretics or those with conditions like heart failure or renal disease.

D) Perform a bladder scan:
Tamsulosin does not directly affect bladder volume or urinary retention to the extent that necessitates routine bladder scanning. Bladder scans are typically performed in clients with suspected urinary retention or those at risk for urinary retention due to conditions like BPH, but it's not a standard intervention for monitoring adverse reactions to tamsulosin.

A. Expresses that they cannot get enough air to breathe. B. Respiratory rate of 7 breaths/minute. C. Bilateral wheezing on auscultation. D. Pulse oximeter reading of 89% on room air.

Correct Answer is B

Explanation

A) Expresses that they cannot get enough air to breathe: While this statement suggests respiratory distress, it is not as objective an assessment finding as a respiratory rate of 7 breaths/minute. Objective measurements are typically more reliable indicators for initiating interventions.
B) Respiratory rate of 7 breaths/minute: A respiratory rate of 7 breaths/minute is indicative of respiratory depression, which is a potential side effect of opioid analgesics like morphine sulfate. Naloxone is an opioid antagonist used to reverse opioid-induced respiratory depression. Administering a prescribed PRN dose of naloxone is appropriate to counteract the respiratory depression and prevent further complications.
C) Bilateral wheezing on auscultation: Wheezing is more commonly associated with bronchoconstriction or airway obstruction rather than opioid-induced respiratory depression. Naloxone is not indicated for wheezing unless there is concurrent opioid-induced respiratory depression.
D) Pulse oximeter reading of 89% on room air: While a pulse oximeter reading of 89% indicates hypoxemia, it may not be solely due to opioid-induced respiratory depression. Other factors, such as hypoventilation, ventilation-perfusion (V/Q) mismatch, or lung disease, could contribute to decreased oxygen saturation. Administering naloxone solely based on pulse oximetry readings may not address the underlying cause adequately. It is essential to assess the client comprehensively, considering clinical signs and symptoms along with objective data.

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The nurse is caring for a client who takes methotrexate for rheumatoid arthritis and receives a prescription for adalimumab. Which instructions should the nurse provide the client?

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