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.

D. "I will report any signs of infection to my provider." Prednisone is a synthetic glucocorticoid that is used to treat rheumatoid arthritis, a chronic inflammatory autoimmune disease that affects the joints and other tissues . Prednisone reduces inflammation, pain, swelling, and stiffness by inhibiting the synthesis of inflammatory mediators and suppressing the immune system .

One of the possible side effects of prednisone is infection, which can be serious or life-threatening due to the suppression of the immune system and increased susceptibility to opportunistic pathogens such as fungi, viruses, bacteria, and parasites . The client should monitor for signs of infection such as fever, sore throat, cough, wound drainage, or urinary symptoms, and report them to the provider as soon as possible . The provider may prescribe antibiotics or antifungals to treat the infection or adjust the dose of prednisone to prevent further complications .

The other options are incorrect because:

Option A is wrong because the client should not take prednisone every other day to prevent side effects. Prednisone should be taken as prescribed by the provider, usually once or twice daily with food or milk to prevent gastrointestinal irritation . Prednisone should not be taken every other day or on an irregular schedule, because this can cause fluctuations in blood levels and increase the risk of adverse effects or suboptimal response . Prednisone should also not be stopped abruptly, because this can cause withdrawal symptoms such as fatigue, weakness, nausea, vomiting, or hypotension due to adrenal insufficiency . Prednisone should be tapered gradually under the supervision of the provider to allow the adrenal glands to resume normal cortisol production .

Option B is wrong because the client should not stop taking prednisone if they develop indigestion. Indigestion is a common side effect of prednisone that can be caused by irritation or ulceration of the gastric mucosa due to increased acid secretion and decreased mucus production . The client should not stop taking prednisone without consulting with the provider, because this can cause withdrawal symptoms or worsen their condition . The client should take prednisone with food or milk to reduce gastric irritation and report any severe or persistent indigestion to the provider . The provider may prescribe antacids, histamine-2 blockers, or proton pump inhibitors to protect the stomach lining and prevent bleeding or perforation .

Option C is wrong because the client does not need to increase their intake of foods that are high in potassium. Potassium is an electrolyte that is essential for the function of nerves, muscles, and heart. Potassium levels are normally regulated by the kidneys, which excrete excess potassium or retain potassium when needed . Prednisone does not have a significant effect on potassium levels, unlike mineralocorticoids such as aldosterone, which promote sodium reabsorption and potassium excretion in the kidney . Prednisone may interact with some drugs that can alter potassium levels, such as diuretics, angiotensin-converting enzyme inhibitors, or potassium supplements . However, these drug interactions are not specific to prednisone and can occur with any drug that affects renal function or electrolyte balance . The client should have their potassium levels monitored periodically and follow a balanced diet that meets their nutritional needs . The client should not increase their intake of foods that are high in potassium without consulting with the provider, because this can cause hyperkalemia , which can lead to cardiac arrhythmias or cardiac arrest .

The statement by the client that indicates understanding of the teaching is B. "I will report any signs of chest pain or shortness of breath to my provider." Celecoxib is a selective COX-2 inhibitor that is used to treat osteoarthritis, a degenerative joint disease that causes pain, stiffness, and reduced mobility . Celecoxib works by inhibiting the enzyme COX-2, which is involved in the synthesis of prostaglandins, thromboxanes, and prostacyclins . These are lipid-derived inflammatory mediators that regulate various physiological processes such as pain, inflammation, blood clotting, and gastric protection .

One of the possible side effects of celecoxib is cardiovascular events, such as myocardial infarction, stroke, or heart failure . Celecoxib can cause cardiovascular events by increasing the risk of thrombosis, vasoconstriction, and hypertension . Celecoxib inhibits the synthesis of prostacyclin, which is a vasodilator and antiplatelet agent that protects the endothelium and prevents thrombus formation . Celecoxib also increases the synthesis of thromboxane A2, which is a vasoconstrictor and proplatelet agent that promotes platelet aggregation and thrombus formation . Celecoxib also reduces the renal excretion of sodium and water, which can increase blood volume and blood pressure . The risk of cardiovascular events is higher in patients who have preexisting cardiovascular disease, diabetes, hypertension, hyperlipidemia, or smoking history , or who use high doses or long-term treatment of celecoxib .

The other options are incorrect because:

Option A is wrong because the client should not take celecoxib with grapefruit juice to enhance its absorption. Grapefruit juice can interact with celecoxib and increase its blood levels and toxicity . Grapefruit juice inhibits the enzyme CYP3A4, which is involved in the metabolism of celecoxib . By inhibiting CYP3A4, grapefruit juice reduces the clearance of celecoxib and increases its bioavailability and half-life . This can lead to overdose or adverse effects such as gastrointestinal bleeding, renal impairment, or liver damage . The client should avoid grapefruit juice and other foods or drinks that can affect the metabolism of celecoxib .

Option C is wrong because the client should not take celecoxib on an empty stomach to avoid nausea. Nausea is a common side effect of celecoxib that can be caused by irritation or ulceration of the gastric mucosa due to decreased mucus production and increased acid secretion . The client should not take celecoxib on an empty stomach, because this can worsen gastric irritation and increase the risk of bleeding or perforation . The client should take celecoxib with food or milk to reduce gastric irritation and report any severe or persistent nausea to the provider . The provider may prescribe antacids, histamine-2 blockers, or proton pump inhibitors to protect the stomach lining and prevent bleeding or perforation .

Option D is wrong because the client should not stop taking celecoxib if they develop a rash or itching. Rash or itching are possible signs of hypersensitivity or allergic reaction to celecoxib , which can be serious or life-threatening. The client should not stop taking celecoxib without consulting with the provider, because this can cause withdrawal symptoms or worsen their condition . The client should monitor for signs of hypersensitivity or allergic reaction such as rash, itching, hives, swelling, difficulty breathing, or anaphylaxis , and report them to the provider as soon as possible . The provider may prescribe antihistamines or corticosteroids to treat the reaction or discontinue celecoxib and switch to another drug.

Aspirin is a nonsteroidal anti-inflammatory drug (NSAID) that can irritate the stomach lining and increase the risk of ulcers. Proton pump inhibitors (PPIs) and misoprostol are medications that can help protect the stomach lining and reduce the risk of ulcers in people taking NSAIDs. PPIs work by reducing the amount of acid produced by the stomach, while misoprostol helps to replace prostaglandins, which are important for protecting the stomach lining. Giving aspirin with a PPI or misoprostol can help prevent ulcer formation in people with a history of peptic ulcer disease who need to take aspirin.³

The other options are incorrect because:

- A. Give enteric-coated or buffered aspirin to reduce gastric irritation: Enteric-coated aspirin is designed to resist dissolving and being absorbed in the stomach, so it passes into the small intestine, where it’s absorbed into the bloodstream. The goal is to prevent stomach ulcers and bleeding that can sometimes occur with aspirin use. However, research indicates that enteric-coated aspirin may not be as effective as regular aspirin at reducing blood clot risk. Also, the gastrointestinal benefit of enteric-coated aspirin is minimal to nonexistent. When it comes to rates of ulceration and bleeding, there’s no difference between enteric-coated and regular aspirin¹.

- B. Give aspirin with an antacid to neutralize gastric acid: While antacids can help reduce heartburn and upset stomach that aspirin may cause, they do not prevent the formation of ulcers. Aspirin is a nonsteroidal anti-inflammatory drug (NSAID) that can increase the risk of bleeding, including in the stomach and gastrointestinal tract (digestive tract)⁵.

- D. Give aspirin with food or milk to decrease gastric absorption: Taking aspirin with food or milk can help reduce stomach irritation caused by aspirin⁷. However, this does not prevent the formation of ulcers in people with a history of peptic ulcer disease.

Cyclosporine (Sandimmune) is a calcineurin inhibitor used to prevent organ rejection after a kidney transplant. It works by suppressing the immune system to prevent the body from attacking the transplanted organ. Before administering the medication, the nurse should check the client's blood pressure because cyclosporine can cause hypertension¹. The nurse should also obtain serum drug levels periodically to verify that the medication is within the therapeutic range. This is important because cyclosporine has a narrow therapeutic index, meaning that there is a small difference between an effective dose and a toxic dose. Monitoring drug levels can help ensure that the client is receiving an effective dose while avoiding toxicity¹.

The other options are not the best choices for the following reasons:

B. Checking the client's peripheral pulses: While it is important to monitor the client's peripheral pulses as part of routine care, it is not a priority assessment before administering cyclosporine.

C. Checking the most recent potassium level: Cyclosporine can affect electrolyte levels, including potassium, but it is not a priority assessment before administering the medication.

D. Checking the client's intake-and-output record for the last 24 hours: Monitoring the client's fluid balance is important, but it is not a priority assessment before administering cyclosporine.