Tehrani Labs · Nursing Pharmacology

NUR 334 Exam 4 — Master Study Guide

Your complete 3-day roadmap to 95%+ on the pharmacology exam covering Fluids & Electrolytes, GI, Nutrition, Reproductive Pharmacology, and Med Math.
📚 3 Modules 🎯 75 Learning Objectives 💊 40+ Medications 🧮 5 Med Math Types

Your 3-Day Battle Plan to 95%+

The exam covers three big areas: Module 7 (Fluid & Electrolytes — 20 items), Module 8 (GI, Nutrition, & Reproductive — 50 items), and Med Math (5 items). That's 75 parent items you must master. Follow this plan and you'll walk in with confidence.

⏱️ Budget 4–6 focused hours per day. Use the Pomodoro technique: 50 min study, 10 min break. Sleep and hydration are non-negotiable.

Day 1 · Foundation

Fluids, Electrolytes & Med Math

  • Read the Fluids & Electrolytes tab in full 90 min
  • Memorize the IV fluid tonicity chart 30 min
  • Master Med Math — all 4 formulas 60 min
  • Complete 20 practice math problems 45 min
  • Review electrolyte imbalances (K⁺, Na⁺) 45 min
  • End-of-day quiz section 30 min
Day 2 · GI Deep Dive

GI Meds & Nutrition

  • PPIs, H2 blockers, antacids, sucralfate 60 min
  • Laxatives (psyllium), stool softeners, methylnaltrexone 45 min
  • Antiemetics (ondansetron), misoprostol, bismuth 45 min
  • TPN & Enteral feedings 45 min
  • Vitamin A, folic acid, sulfasalazine, IBD 45 min
  • Quick review + flashcards 30 min
Day 3 · Reproductive + Final Review

Hormones, OB, and Full Review

  • Estrogen, estradiol, HRT, contraceptives 60 min
  • Progestins: medroxyprogesterone, norethindrone 45 min
  • Male: testosterone, finasteride, sildenafil 45 min
  • OB: oxytocin, magnesium sulfate, tocolytics, terbutaline 45 min
  • Full practice quiz — all sections 60 min
  • Cheat sheet review before bed 30 min

Progress Tracker

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🏆 The 5 Golden Rules to Ace This Exam

  1. Know the "why" — Rationale beats memorization. If you understand the mechanism, distractors fall away.
  2. Master the tonicity chart — Isotonic, hypotonic, hypertonic. This alone unlocks 8+ items.
  3. Estrogen = Clots — Any estrogen product (estradiol, conjugated, contraceptives) → DVT, PE, stroke risk. Smoking multiplies it.
  4. Read carefully for QUESTION vs QUESTION MOST — "which should the nurse question" = which is inappropriate/unsafe.
  5. Med Math: slow is smooth, smooth is fast — Write the formula, plug in, double-check units, then compute.

Module 7 — Fluids, Electrolytes & Acid-Base

🔥 High-yield reality check: This module alone = 20 exam items. If you own IV fluid tonicity, potassium, and sodium — you own the module.

The IV Fluid Tonicity Master Chart (MEMORIZE)

TypeExamplesFluid MovementWhen to UseMonitor For
Isotonic 0.9% NS (Normal Saline)
Lactated Ringer's (LR)
D5W (in the bag)		 No net shift — stays in vascular space Blood loss, vomiting/diarrhea, dehydration, hypovolemic shock, surgical fluid loss Fluid overload — listen to lungs! (crackles = pulmonary edema)
Hypotonic 0.45% NS (½ NS)
0.225% NS
D5W (once metabolized)		 Shifts OUT of vessel INTO cells (hydrates cells) Hypernatremia, cellular dehydration, DKA (after initial NS), SIADH-like states Cerebral edema, ↓BP, worsening intracranial pressure. Never in head injury.
Hypertonic 3% NaCl
5% NaCl
D5NS, D5LR, D10W
D5 ½NS		 Pulls fluid OUT of cells INTO vascular space Severe hyponatremia, cerebral edema/↑ICP, brain swelling Fluid overload, pulmonary edema, phlebitis. Give via central line, slow, monitor neuro q1–2h.
Colloid Albumin
Dextran 40
Hetastarch		 Large proteins pull fluid INTO vascular space (stays there) Hypovolemic shock, burns, hypoalbuminemia, cirrhosis with ascites, trauma with blood loss Fluid overload → pulmonary edema (tachycardia, dyspnea, cough, frothy sputum), allergic reaction
Crystalloid Isotonic, hypo, & hypertonic saline/dextrose Contain electrolytes/small molecules mimicking ECF Hydration, resuscitation, electrolyte correction Depends on tonicity
Mnemonic — Tonicity
"Hyper Hydrates the Highway, Hypo Hydrates the House"
  • Hypertonic = pulls fluid into the "highway" (vascular)
  • Hypotonic = pushes fluid into the "house" (cells)
  • Isotonic = stays put, just refills the tank
💧 Isotonic Solutions — Fluid Replacement Powerhouse
Objective: Recognize when isotonic fluids are indicated and what to assess before/during infusion.

Prime indications: Blood loss, GI fluid loss (vomiting/diarrhea), dehydration, hypovolemic shock, post-surgical fluid replacement, maintenance hydration.

Assessment before/after bolus: Auscultate lung sounds — this is the #1 answer. Rapid infusion can cause pulmonary edema.

Assessment BEFORE isotonic bolus: Breath sounds & respiratory effort (detect fluid overload risk). Also check IV site patency.
Red flag during infusion: Crackles auscultated in lung bases = fluid overload → slow the rate & notify provider.

Safety checks before IV push medication with isotonic maintenance:

  • Verify the 6 rights of medication administration
  • Ask about allergies
  • Verify IV compatibility with the maintenance solution
  • Assess IV site for patency & signs of infiltration
  • Confirm dose, rate, and order
🩸 Hypertonic Solutions — Pull Fluid Out of Cells
Objective: Identify hypertonic solutions, indications (cerebral edema, severe hyponatremia), and critical monitoring priorities.

Classic hypertonic solutions:

  • 3% Sodium Chloride — the exam favorite
  • 5% NaCl
  • D5NS (5% dextrose in 0.9% NS)
  • D5LR
  • D10W
Cerebral edema / ↑ICP: Hang 3% hypertonic saline — draws fluid out of brain cells into vessels, reducing swelling. Assess neuro & pupillary response frequently. Ideally give via central line.
Severe hyponatremia (Na⁺ < 120): 3% NaCl is best. But correct slowly — monitor sodium q 2 hours. Rapid correction = central pontine myelinolysis (brain damage).
PRIORITY during hypertonic infusion: Assess for signs of fluid volume overload — crackles in the lungs. Also monitor for hypernatremia, phlebitis, ↑BP.

Dextran 40 (colloid, acts hypertonic-like): Watch closely for fluid overload — tachycardia, dyspnea, cough, frothy sputum, edema.

💦 Hypotonic Solutions — Hydrate the Cells
Objective: Identify who needs hypotonic fluids and who must never receive them.

Examples: 0.45% NaCl (½ NS), 0.225% NaCl, D5W (in the body after dextrose is metabolized)

Best for: Clients with hypernatremia (sodium > 145) or cellular dehydration. Example: Na⁺ 155 mEq/L → hang 0.45% NaCl.
NEVER give hypotonic fluids to: Head injury / ↑ICP (worsens cerebral edema), burn patients, third-spacing, or hypotensive patients.
🧪 Crystalloid Solutions — The Basics
Definition: Fluid replacement drugs that contain electrolytes and other substances that closely mimic the body's extracellular fluid.

Crystalloids include isotonic, hypotonic, and hypertonic solutions. They move freely between intravascular and interstitial spaces (as opposed to colloids, which stay in vessels).

Common uses: Hydration, fluid resuscitation, correcting electrolyte imbalances.

🧫 Colloid Solutions — When Blood Volume Is the Problem
Objective: Recognize appropriate indications for colloid therapy and the #1 complication.

Examples: Albumin, Dextran 40, Hetastarch, blood products.

Mechanism: Large molecules (like albumin) increase oncotic pressure inside vessels, pulling fluid IN and keeping it there.

Best used for:
  • Hypovolemic shock (especially trauma with acute blood loss)
  • Hypoalbuminemia + ascites (cirrhosis)
  • Burns with plasma loss
#1 Complication of colloids (e.g., Dextran 40): Fluid Overload → tachycardia, dyspnea, cough, frothy sputum, pulmonary edema. Priority nursing action = monitor for fluid overload.
⚗️ Acid-Base Imbalances — Sodium Bicarb Pitfalls
Scenario: Client with acidosis is given sodium bicarbonate. A few hours later: slowing respirations, irritability, muscle twitching, confusion.
Answer: Metabolic alkalosis — sodium bicarb overshot and raised the pH too much.
ImbalanceKey SignsCompensation
Metabolic acidosisWeakness, confusion, Kussmaul respirations (deep, rapid), ↓pH, ↓HCO3Lungs blow off CO₂ (fast, deep breathing)
Metabolic alkalosisSlow shallow breathing, irritability, muscle twitching, ↑pH, ↑HCO3Lungs retain CO₂ (slow breathing)
Respiratory acidosisHypoventilation, confusion, ↑CO₂, ↓pHKidneys retain HCO3
Respiratory alkalosisHyperventilation, tingling, anxiety, ↓CO₂, ↑pHKidneys excrete HCO3
ROME Mnemonic
Respiratory Opposite (pH & CO2 opposite directions) · Metabolic Equal (pH & HCO3 same direction)
⚡ Electrolyte Imbalances — Potassium (K⁺) is Life or Death
Hyperkalemia (K⁺ > 5.0) — LIFE THREATENING

Immediate treatment: IV insulin + IV dextrose shifts K⁺ into cells rapidly. Add calcium gluconate to stabilize the heart. Kayexalate (polystyrene sulfonate) is slower. If severe & renal failure → emergency hemodialysis.

ScenarioValueAnticipated Action
K⁺ 6.5 mEq/L (no renal failure)HyperkalemiaIV insulin + IV dextrose (fastest shift)
K⁺ 7.0 + acute kidney injuryCritical + AKIEmergency hemodialysis
K⁺ 5.9 mild elevationMild hyperkalemiaIV dextrose + insulin
Sodium 143 + K⁺ 6.5Hyperkalemia isolatedAnticipate polystyrene sulfonate (Kayexalate)
Hyperkalemia — MEDICATIONS TO QUESTION: 0.9% Normal Saline (contains sodium that can shift K⁺ out of cells and worsen levels). Also question Lactated Ringer's (contains K⁺) and any IV KCl.
Hypokalemia treatment: IV Potassium Chloride (KCl) — never IV push! Always dilute, use pump, watch site closely for infiltration/burning.
💉 Electrolyte Replacement — Potassium Chloride (KCl) Safety
🚨 KCl DEATH TRAP — memorize this:
  • NEVER IV push potassium chloride — causes cardiac arrest.
  • Always dilute and infuse via pump at safe rate (usually ≤10 mEq/hr peripheral, ≤20 mEq/hr central).
  • Question KCl in acute renal failure — kidneys can't excrete K⁺.
  • Question KCl if client's ECG shows abnormal conduction (prolonged PR, wide QRS).
Priority nursing action during KCl infusion: Monitor IV site for burning and infiltration q30 min. K⁺ is irritating to veins — infiltration = tissue damage. Also continuous cardiac monitoring in CKD clients.

3% NaCl for severe hyponatremia (Na⁺ 114): Monitor sodium level q 2 hours during infusion. Correction should be gradual over several days to prevent central pontine myelinolysis.

🌊 Fluid Overload — Dextran and Colloid Complication
Classic scenario: Client on Dextran 40 begins experiencing tachycardia, dyspnea, cough, edema, or frothy sputum → Fluid Overload / Pulmonary Edema.

Colloids draw water into vascular space. When too much or too fast, the vasculature overflows → lungs fill → respiratory distress. Priority: notify provider, slow/stop infusion, elevate HOB, prepare for diuretic (furosemide).

🥗 Low-Sodium Diet Teaching

OK on a low-sodium diet:

  • Broiled chicken (lean, unprocessed protein)
  • Fresh fruits (apple with peanut butter)
  • Grilled salmon, steamed broccoli
  • Fresh vegetables, oatmeal with fresh berries
  • Plain baked potato

AVOID (high sodium):

  • Pickled vegetables, sausage, deli meats, ham
  • Canned soups, frozen dinners
  • Cheese pizza, turkey sandwich with pickles
  • Ham and cheese sandwich (major offender!)

Quick Check — Fluid & Electrolytes

Q: A client is admitted with brain swelling. Which IV fluid does the nurse anticipate?

0.45% Sodium Chloride
Lactated Ringer's
3% Hypertonic Saline
0.9% Normal Saline

Module 8 — GI Medications & Nutrition

This section covers the largest chunk of your exam. Focus on mechanism and teaching points — most questions test understanding, not memorization.
💊 Proton Pump Inhibitors (PPIs) — Omeprazole & friends 3 items
Mechanism: PPIs inhibit the H⁺/K⁺-ATPase (proton pump) enzyme in gastric parietal cells → decrease gastric acid production.

Uses: GERD, peptic ulcer disease, Zollinger-Ellison syndrome, H. pylori (in triple therapy).

Healing timeframes:
  • Gastric ulcer: 4–8 weeks
  • Esophagus (GERD): 4–8 weeks
  • Zollinger-Ellison: long-term/months
Long-term risks (KNOW THESE):
  • Increased fracture risk (↓ calcium absorption → osteoporosis)
  • Vitamin B12 deficiency (long-term use)
  • Increased C. diff infection risk
  • Hypomagnesemia

Distinguish: PPIs ≠ H2 blockers ≠ antacids ≠ sucralfate. PPIs = inhibit enzyme that makes acid. H2 blockers = block histamine receptors. Antacids = neutralize existing acid. Sucralfate = coats the ulcer.

💊 H2 Receptor Antagonists — Famotidine, Ranitidine 2 items
Mechanism: Block histamine H2 receptors on parietal cells → decrease acid secretion.
Client teaching wins:
  • ✅ Avoid taking with alcohol
  • ✅ Take 30 min before eating
  • ✅ Continue even if symptoms improve
  • ✅ Take at bedtime to prevent nighttime reflux
  • ✅ Report jaundice or unusual drowsiness
Statement indicating NEED FOR MORE TEACHING:
  • ❌ "I'll take my antacid and H2 blocker at the same time" — antacids interfere with H2 absorption. Space them 1–2 hours apart.
  • ❌ "I can use herbal remedies without asking my provider."

Signs treatment is working: Relief of heartburn, decreased indigestion frequency, no acid-related pain.

💊 Antacids — Over-the-Counter Relief 1 item

Key teaching:

  • Antacids temporarily neutralize stomach acid — do NOT reduce production.
  • Take AFTER meals — but NOT at the same time as other medications (they interfere with absorption). Space by 1–2 hours.
  • Do NOT take with milk (milk stimulates acid production).
  • Antacids alone won't heal peptic ulcer disease — client may need PPI or H2 blocker.
💊 Sucralfate — The Ulcer "Coating" 2 items
Mechanism: Binds selectively to proteins at the ulcer site in acidic environment → forms a protective barrier over the ulcer. Does NOT alter acid secretion.
Take on an EMPTY stomach — 1 hour BEFORE meals. Do not take with antacids or food (interferes with binding). Minimally absorbed → local action, few systemic effects.

Correct teaching statement: "This will help my ulcer by coating it and reducing irritation."

💊 Misoprostol — Prostaglandin Analog 1 item
Mechanism: Synthetic prostaglandin — inhibits gastric acid production AND stimulates mucus + bicarbonate. Protects the stomach lining from NSAID-induced ulcers and helps in H. pylori therapy.
⚠️ Contraindicated in pregnancy — causes uterine contractions (used off-label for labor induction or medical abortion).
💊 Bismuth Subsalicylate (Pepto-Bismol) 1 item

Uses: Diarrhea, upset stomach — binds to and absorbs toxins.

KEY teaching points:
  • Stool may turn black — harmless, expected side effect.
  • Avoid if allergic to aspirin — contains salicylate.
  • Also may cause dark/black tongue.
💊 Stool Softeners — Docusate Sodium 1 item

Mechanism: Increases water absorption INTO the stool — makes stool softer and easier to pass. Does NOT stimulate peristalsis, does not lubricate, does not affect nutrient absorption.

💊 Psyllium Mucilloid — Bulk-Forming Laxative 3 items
First-line pharmaceutical treatment for constipation in otherwise healthy individuals. Absorbs water → bulks stool → promotes peristalsis.
Teaching points:
  • Increase fluid intake (never limit fluids!) — take with a full glass of water to avoid choking.
  • Takes 12–72 hours — not immediate relief.
  • Do NOT take at bedtime (delayed action, unpredictable).
  • Increase fiber intake through diet also.
  • Space from other meds by 1–2 hours (can reduce their absorption).
Signs it's working: Increased bowel movements; regular, soft bowel movements without straining.
💊 Methylnaltrexone — Opioid-Induced Constipation 1 item

Specific use: Opioid-induced constipation (OIC) in clients who haven't responded to conventional laxatives.

Best candidate on exam: Client on chronic/high-dose opioids (end-stage cancer, chronic pain) who has NOT had a BM despite laxatives.

NOT for: Post-op constipation from immobility, dietary constipation, suspected bowel obstruction.

💊 Ondansetron (Zofran) — Antiemetic 2 items
Best action: Give ondansetron BEFORE the chemotherapy, antibiotic, or analgesic that causes nausea — prevention beats treatment.
⚠️ Contraindication — QUESTION the order if:
  • Client has cardiac electrical abnormalities or QT prolongation on ECG — ondansetron prolongs QT → arrhythmia risk.
  • Client has known hypersensitivity/allergy to ondansetron.
💊 Sulfasalazine — For Ulcerative Colitis / RA 1 item
Question the order in:
  • Liver failure or recent hepatitis (metabolized in liver, hepatotoxic)
  • Client with sulfa allergy
Hold medication if lab shows: WBC 4,000/mm³ or lower (bone marrow suppression / leukopenia risk).
🧠 Inflammatory Bowel Disease (IBD) — Acute Exacerbation 1 item
Immediate goal in acute IBD flare: Reduce acute symptoms of active disease (pain, diarrhea, bleeding). Long-term goal = remission.
Priority interventions:
  • IV fluids and electrolytes — priority when client has dehydration signs, weight loss, fever, diarrhea.
  • Initiate bowel rest protocol — Crohn's flare with severe cramping, vomiting → first priority.
🥄 TPN (Total Parenteral Nutrition) 2 items
Administration essentials:
  • Remove TPN solution from the refrigerator 30 minutes prior to infusing (warm to room temp).
  • Change the TPN bag and tubing every 24 hours (high glucose = bacterial growth risk).
  • Give via central line only (never PEG tube, never peripheral IV due to high osmolarity).
  • Never discontinue abruptly → wean gradually to prevent hypoglycemia.
#1 monitoring priority: Blood glucose — hyperglycemia is the most frequent complication because TPN has high dextrose content. Anticipate insulin therapy if glucose 285 mg/dL.
Suspect air embolism during central-line TPN: Sudden lightheadedness + shortness of breath →
  1. Clamp the catheter
  2. Place client in Trendelenburg (left lateral) — traps air in right atrium
  3. Notify provider, give O₂
🍜 Enteral Feedings 1 item
Concerning findings — NOTIFY PROVIDER:
  • Abdominal distension + hypoactive bowel sounds (delayed emptying/ileus, aspiration risk)
  • Increased respiratory rate + labored breathing (possible aspiration)
  • Dry mucous membranes (dehydration — enteral feeds may not provide adequate free water)

Normal findings: Occasional loose stools, mild nausea with repositioning, gastric residual ≤ 15 mL (usually within limits per facility policy).

💊 Vitamin A — Fat-Soluble Vitamin 2 items

Uses: Night blindness, dermatological conditions (retinoids).

🚨 TERATOGEN: High-dose Vitamin A is contraindicated in pregnancy — causes birth defects. If the lab shows positive hCG, question the prescription immediately.
Also question high-dose Vitamin A if: Elevated ALT and AST (hepatotoxic risk).
Client teaching that shows understanding:
  • ✅ "I will increase carrots, spinach, sweet potatoes" (beta-carotene)
  • ✅ "This vitamin can cause fetal harm if taken in excessive quantities while pregnant"
  • ❌ "More is better for my baby" → needs teaching (excess Vit A = teratogenic)
💊 Folic Acid — For Anemia 1 item

Prescribed for: Folate deficiency anemia — especially in clients with:

  • Alcohol abuse (alcohol impairs folate absorption)
  • Macrocytic anemia (high MCV — the classic megaloblastic anemia)
  • Pregnancy (prevent neural tube defects)

Recognition clues: Low hemoglobin + high MCV (>100 fL) + low serum folate + alcohol history = folate deficiency anemia.

Reproductive Pharmacology — Hormones

🔑 The estrogen unifying principle: All estrogen-containing meds increase clotting. That means DVT, PE, stroke, MI. Smoking multiplies this risk. Age >35 or history of migraines with aura or previous thromboembolic event = contraindication.
👩 Estrogen / Conjugated Estrogen 3 items
Used for: Menopausal symptoms, HRT.
🚨 CONTRAINDICATIONS — Client should NOT take estrogen if:
  • Previous pulmonary embolism or DVT / thromboembolic history
  • Abnormal uterine bleeding (undiagnosed)
  • History of estrogen-dependent cancer
  • Pregnancy
Increased risks with estrogen:
  • Deep vein thrombosis (DVT)
  • Pulmonary embolism
  • Stroke
  • Breast cancer (with prolonged use)
  • Gallbladder disease
Risk factors that INCREASE side effects of estrogen therapy:
  • Age 50+ (vascular aging + cumulative exposure)
  • Hypothyroidism (estrogen affects thyroid binding globulin)
  • History of migraines with aura (↑ stroke risk)
  • Smoking
👩 Estradiol — Estrogen for HRT 2 items
Client should AVOID:
  • Smoking (dramatically ↑ blood clot risk)
  • Grapefruit juice (inhibits metabolism → higher drug levels → more adverse effects)
Drug interactions: Antibiotics (especially rifampin) decrease efficacy of estradiol-containing contraceptives → unintended pregnancy risk.
Serious cardiovascular warning signs → seek immediate care:
  • Sudden shortness of breath + chest pain = possible pulmonary embolism
  • Sudden severe headache, one-sided weakness = stroke
  • Unilateral leg pain/swelling = DVT

Most serious risk of hormonal contraceptives: Hypertension → thromboembolic events (stroke, MI, DVT).

💊 Hormone Replacement Therapy (Estrogen-Progestin HRT) 2 items
Best nurse response when client asks about HRT: "There are risks as well as benefits to hormone replacement therapy and the decision is individual for each client." Balanced, patient-centered, encourages provider discussion.
Increased risks with estrogen-progestin HRT (SATA answer):
  • Myocardial infarction (MI)
  • Dementia (esp. in women over 65)
  • Venous thromboembolism (DVT/PE)
  • Stroke
  • Breast cancer
  • Endometrial hyperplasia
NOT increased: Hip fractures (HRT protects bones), colorectal cancer, cataracts, hypotension, renal failure.
💊 Oral Contraceptives (Combined) 1 item
Concerning client factors for oral contraceptive appropriateness:
  • History of epilepsy — anticonvulsants (phenytoin, carbamazepine) induce liver enzymes → ↓ contraceptive efficacy
  • Current smoker + hypothyroid — smoking ↑ CV risk
  • Currently taking antibiotics — reduces effectiveness
  • Migraines with aura, history of DVT, breast cancer
💊 Medroxyprogesterone (Depo-Provera) 2 items
QUESTION the prescription if client has:
  • History of thromboembolic disease / DVT
  • History of depression (may exacerbate — monitor carefully)
  • Suspected breast cancer, pregnancy
Question this home medication: St. John's Wort — induces CYP450 → decreases medroxyprogesterone effectiveness.
New assessment findings to report to provider: Unilateral leg pain and swelling = possible DVT — emergent.
💊 Norethindrone — Progestin-Only Contraceptive 2 items
Client teaching:
  • Take at the same time daily — critical for effectiveness (missed/late doses = pregnancy risk).
  • Do NOT crush.
  • Not during pregnancy.
Side effects to teach about:
  • Photosensitivity (sunburn/rash — wear sunscreen)
  • Acne flare-ups (especially in sensitive skin/rosacea clients)

Consequence of inconsistent dosing: Increased chance of pregnancy / contraceptive failure.

⏰ Emergency Contraception 1 item
Priority question to ask: "How long ago did you have unprotected sex?" Effectiveness depends on timing:
  • Levonorgestrel (Plan B) → most effective within 72 hours
  • Ulipristal acetate → up to 5 days

Also important: Ask about medications that decrease effectiveness — enzyme inducers (anticonvulsants, rifampin, St. John's Wort).

💊 Sildenafil (Viagra) — PDE-5 Inhibitor 1 item
🚨 CONTRAINDICATED WITH NITRATES — combining causes life-threatening hypotension.
  • Nitroglycerin
  • Isosorbide
  • All nitrates for angina

Mechanism: PDE-5 inhibitor — relaxes blood vessels; with nitrates, vasodilation is compounded → severe hypotension → potentially fatal.

💊 Testosterone Therapy 2 items
Transdermal patch administration: Apply a new patch daily at the same time (some sources say every 2-3 days per facility; the exam key states "every day/daily" for consistent hormone levels).
Signs of EFFECTIVE testosterone therapy:
  • ✅ Increased muscle mass, energy, libido
  • ✅ Reduction in fatigue, improved mood
  • ✅ Increased hematocrit within normal limits
  • ✅ Decreased breast tumor size (in hormone-sensitive breast cancer patients)

Adverse effects (NOT signs of effectiveness): Fluid retention, amenorrhea, hair loss, acne, oily skin, gynecomastia (in men — indicates excess estrogen conversion), unexplained weight gain with edema.

💊 Finasteride — 5-alpha Reductase Inhibitor 2 items
Use: Benign prostatic hyperplasia (BPH). Blocks conversion of testosterone → dihydrotestosterone (DHT), shrinking the prostate.

Ask during medication reconciliation: "Do you wake up frequently at night to void?" (Assesses nocturia — symptom of BPH the drug treats.)

🚨 TERATOGENIC — critical questions to ask male clients on finasteride:
  • "Is there a possibility that your partner could be pregnant?" (Semen exposure = fetal harm.)
  • "Are you currently donating blood or planning to?" — Contraindicated; blood recipient could be pregnant → fetal harm.
Teaching points (SATA):
  • ✅ May experience sexual dysfunction (↓ libido, ED)
  • ✅ Do NOT donate blood while on this medication
  • ✅ May experience headaches, dizziness
  • ✅ Unsafe for women to handle (especially pregnant women)
  • ❌ Does NOT increase libido
💊 5-alpha Reductase Inhibitors — Mechanism 1 item

Correct explanation of MOA: "It promotes shrinkage of an enlarged prostate" / "Blocks the enzyme that converts testosterone to its active form (DHT)."

NOT: Relaxes bladder neck, blocks alpha-1 receptors, causes orthostatic hypotension — those describe alpha blockers (tamsulosin), not 5-ARIs.

Onset: Slow — takes months to see effects, unlike alpha blockers which work immediately.

Quick Check — Reproductive

Q: A client on sildenafil for ED is now prescribed nitroglycerin for angina. What is the nurse's priority action?

Teach the client to take sildenafil in the morning and nitro at night
Notify the provider — this combination is contraindicated
Monitor blood pressure daily and continue both
Advise the client to reduce sildenafil dose

OB / Labor & Delivery Medications

🤰 Oxytocin (Pitocin) 2 items
Two main uses:
  • Induce/augment labor (antepartum)
  • Reduce bleeding after childbirth (postpartum — promotes uterine contraction → prevents hemorrhage)
Adverse effects to know:
  • Rapid painful contractions (tetanic contractions) — hyperstimulation → fetal distress
  • Uterine rupture — life-threatening emergency
  • Water intoxication (with prolonged infusion)
Increased risk of uterine rupture with: History of multiple vaginal births (grand multiparity). Uterus may not contract effectively.
💊 Magnesium Sulfate 2 items
Off-label uses:
  • Delay preterm labor (tocolytic — relaxes uterine smooth muscle)
  • Acute asthma exacerbation (relaxes bronchial smooth muscle)
Also: Seizure prevention in preeclampsia (approved use).
🚨 Magnesium Sulfate TOXICITY / OVERDOSE — signs:
  • Flushing skin
  • Drowsiness, muscle weakness, respiratory depression
  • Absent/hypoactive deep tendon reflexes
  • Hypotension, bradycardia
  • Intense hunger, nervousness (early)
🚨 ANTIDOTE: Calcium Gluconate IV. If HR 48, DTRs absent, respirations 8 → administer calcium gluconate as prescribed.
💊 Tocolytics (Delay Preterm Labor) 1 item
Drugs classified as tocolytics (SATA):
  • ✅ Terbutaline (beta-agonist)
  • ✅ Nifedipine (calcium channel blocker)
  • ✅ Magnesium Sulfate
  • ✅ Indomethacin (prostaglandin inhibitor)
  • ✅ Ritodrine (beta-agonist)
NOT tocolytics (they contract the uterus): Oxytocin, methylergonovine, misoprostol, carboprost, estradiol.
💊 Terbutaline — Beta-Agonist Tocolytic 1 item
🚨 BLACK BOX WARNING: When used more than 48-72 hours, terbutaline carries a black box warning for fetal death.
Adverse effects — teach client to REPORT:
  • Tachycardia, chest pain, palpitations (beta-agonist stimulates heart)
  • Shortness of breath — could signal maternal pulmonary edema (serious complication)

🎯 OB Med Summary Table

DrugEffect on UterusKey Point
OxytocinContractsPostpartum hemorrhage prevention; watch for hyperstimulation
Magnesium sulfateRelaxesAntidote: Calcium gluconate
TerbutalineRelaxesBlack box: fetal death if >48-72 hrs
NifedipineRelaxesCCB tocolytic; ↓BP
IndomethacinRelaxesProstaglandin inhibitor
MisoprostolContractsAlso protects gastric mucosa
MethylergonovineContractsPostpartum hemorrhage

Med Math — 5 Guaranteed Points

Good news: Only 4 formulas cover all 5 med math items. Practice each one until it's automatic. These are the highest ROI questions on the exam.

Formula #1: Infusion Time (Hours)

Time (hr) = Total Volume (mL) ÷ Rate (mL/hr)

Example: 750 mL NS at 75 mL/hr → 750 ÷ 75 = 10 hours

Practice:

  • 960 mL NS at 80 mL/hr → 960 ÷ 80 = 12 hours
  • 1,300 mL LR at 100 mL/hr → 1300 ÷ 100 = 13 hours

Formula #2: Drip Rate (gtt/min from Total Volume)

Drip Rate (gtt/min) = (Volume in mL × Drop Factor) ÷ Time in minutes

Example: 500 mL over 7 hours with 15 gtt/mL tubing

Convert: 7 hr × 60 min = 420 min
(500 × 15) ÷ 420 = 7,500 ÷ 420 = 17.86 → 18 gtt/min

Practice:

  • 750 mL over 6 hr, 20 gtt/mL → (750 × 20) ÷ 360 = 42 gtt/min
  • 1000 mL over 8 hr, 10 gtt/mL → (1000 × 10) ÷ 480 = 21 gtt/min

Formula #3: IV Pump Rate (mL/hr from Bolus)

Rate (mL/hr) = Volume (mL) ÷ Time (hr)
(Convert minutes to hours first!)

Example: Ceftriaxone 1 g in 100 mL over 30 min

Convert: 30 min = 0.5 hr
100 ÷ 0.5 = 200 mL/hr

Practice:

  • Vancomycin 1.25 g in 250 mL over 90 min → 250 ÷ 1.5 = 167 mL/hr
  • Piperacillin-tazobactam 3.375 g in 150 mL over 45 min → 150 ÷ 0.75 = 200 mL/hr

Formula #4: Dose Volume Calculation

Volume (mL) = Dose Ordered (mg) ÷ Concentration (mg/mL)

Example: Olanzapine 1.25 mg IM per day; available 10 mg/mL

1.25 ÷ 10 = 0.125 mL → round to 0.1 mL

Practice:

  • Haloperidol 2.5 mg IM; available 5 mg/mL → 2.5 ÷ 5 = 0.5 mL
  • Lorazepam 1.75 mg IM; available 4 mg/mL → 1.75 ÷ 4 = 0.4375 → 0.4 mL

Formula #5: Drip Rate (gtt/min from mL/hr)

Drip Rate (gtt/min) = (Rate mL/hr × Drop Factor) ÷ 60

Example: 170 mL/hr with 10 gtt/mL tubing

(170 × 10) ÷ 60 = 1700 ÷ 60 = 28.33 → 28 gtt/min

Practice:

  • 220 mL/hr, 15 gtt/mL → (220 × 15) ÷ 60 = 55 gtt/min
  • 150 mL/hr, 10 gtt/mL → (150 × 10) ÷ 60 = 25 gtt/min

🎯 Test-Day Med Math Strategy

  1. Write out the formula on your scratch paper first — before you look at the numbers.
  2. Convert units before plugging in — minutes to hours, grams to mg, mcg to mg. This is where errors happen.
  3. Estimate the answer roughly — if the ordered dose looks tiny compared to the concentration, expect a small mL number.
  4. Read the rounding instructions — "nearest whole" vs "nearest tenth" is a common trap.
  5. Double-check with your calculator — every single time.

Full Practice Quiz — Mixed Topics

Complete every question. Read the rationale carefully. If you miss a question, revisit that section.

1. Client on TPN through central line reports lightheadedness and shortness of breath. First action?

Check the client's capillary blood glucose
Slow the infusion and notify provider
Clamp the catheter and place client in Trendelenburg position
Flush the central line with sterile saline

2. Client with GERD taking omeprazole for one year asks about long-term risks. Best response?

"Long-term use can increase risk of osteoporosis and fractures."
"This medication has no significant long-term effects."
"You may develop resistance to the medication."
"PPIs increase stomach acid production over time."

3. Client receiving continuous enteral tube feedings. Which finding should the nurse report?

Abdominal distension and hypoactive bowel sounds
Occasional loose stools
Client reports mild nausea during repositioning
Gastric residual volume of 15 mL

4. Client on estrogen therapy. Which risk factor MOST increases risk of adverse effects?

Never having been pregnant
Age 50 or history of migraines with aura
Caucasian ethnicity
Family history of osteoporosis

5. Client with brain swelling — which IV fluid is anticipated?

3% hypertonic saline
Lactated Ringer's
0.45% sodium chloride
0.9% normal saline

6. Client with K⁺ 6.5 mEq/L, normal kidneys. Anticipated intervention?

Administer IV dextrose and IV regular insulin
Administer 3% hypertonic saline
Administer IV magnesium sulfate
Encourage potassium-rich foods

7. Client on Dextran 40 develops tachycardia, dyspnea, cough. What is this?

Allergic reaction
Renal failure
Fluid overload
Liver toxicity

8. Client on IV magnesium sulfate: HR 48, DTRs absent, RR 8. Priority action?

Monitor urinary output
Assess for neuromuscular excitability
Administer calcium gluconate as prescribed
Increase the magnesium sulfate infusion rate

9. 750 mL NS is prescribed to run at 75 mL/hr. How long will it take?

7.5 hours
10 hours
12 hours
15 hours

10. Male client on finasteride for BPH. Most important question to ask before surgery?

"Have you noticed changes in urinary patterns?"
"Are you experiencing sexual dysfunction?"
"Do you have a history of prostate cancer?"
"Is there a possibility your partner could be pregnant?"

11. Client with acidosis on sodium bicarb develops slowed respirations and irritability. Cause?

Metabolic alkalosis
Fluid volume overload
Hyponatremia
Hyperkalemia

12. Client with peptic ulcer on H. pylori therapy asks about misoprostol. Best explanation?

"It reduces bacterial load"
"It protects the stomach lining by increasing mucus production"
"It reduces heartburn from the infection"
"It reduces acid production directly"

13. Which IV fluid has 20 gtt/mL and needs to run 750 mL over 6 hours. Drip rate?

21 gtt/min
36 gtt/min
42 gtt/min
50 gtt/min

14. Client on norethindrone for contraception. Priority teaching?

Take at the same time daily
Crush the pill for easier swallowing
Take with food only
Take during pregnancy

15. Which client should the nurse ANTICIPATE administering methylnaltrexone?

65-year-old with end-stage lung cancer on large doses of morphine
32-year-old postpartum with hemorrhoids
28-year-old with suspected appendicitis
72-year-old newly diagnosed with gastroparesis

⚡ The Night-Before Cheat Sheet

Review this the night before AND the morning of the exam. Do not try to learn new material — reinforce what you know.

💧 IV Fluids at a Glance

SolutionTypeUse For
0.9% NaCl (NS)IsotonicDehydration, hypovolemia, blood loss
Lactated Ringer'sIsotonicFluid loss, burns, surgery
D5W (in bag)Isotonic → Hypotonic in bodyFree water; caution in ↑ICP
0.45% NaClHypotonicHypernatremia, cellular dehydration
3% NaClHypertonicSevere hyponatremia, cerebral edema
D5NS, D5LR, D10WHypertonicProvides calories + fluid
Albumin, DextranColloidHypovolemic shock, hypoalbuminemia

🚨 One-Line Red Flags

TPN

Central line only · monitor glucose · change bag q24h · never abrupt stop · warm 30 min before

Estrogen

Clots! DVT, PE, stroke, MI. Contraindicated if prior thromboembolism, abnormal bleeding, smoking + age >35

Sildenafil

NEVER with nitrates (isosorbide, nitroglycerin) → life-threatening hypotension

Finasteride

Teratogen. No blood donation. Pregnant partner risk. Avoid crushing.

PPIs long-term

Fractures, B12 deficiency, C. diff

Sucralfate

Empty stomach, 1 hr before meals, don't take with antacid

Psyllium

Plenty of fluids! Takes 12-72 hrs. Don't limit water.

Mag Sulfate toxicity

Flushing, ↓RR, ↓DTRs, ↓HR, ↓BP → antidote = calcium gluconate

Oxytocin

Postpartum: prevents hemorrhage. Adverse: rapid painful contractions, uterine rupture

Terbutaline

Black box warning: fetal death if >48-72 hrs. Report SOB, tachycardia

Ondansetron

QT prolongation risk. Question if cardiac electrical abnormality on ECG

KCl (potassium)

NEVER IV push. Watch site for burning/infiltration. Question in AKI.

Bismuth (Pepto)

Black stool = harmless. Avoid if aspirin allergy (contains salicylate).

Vitamin A

Teratogen. Question if hCG positive. Question if ↑ALT/AST.

Sulfasalazine

Question in liver failure/hepatitis. Hold if WBC ≤4000.

Methylnaltrexone

Opioid-induced constipation only (fails on other laxatives)

🔢 Med Math Formula Sheet

1. Time (hr) = Volume (mL) ÷ Rate (mL/hr) 2. gtt/min from total = (mL × drop factor) ÷ minutes 3. mL/hr from bolus = mL ÷ hours 4. Volume (mL) = Dose ÷ Concentration 5. gtt/min from mL/hr = (mL/hr × drop factor) ÷ 60

📌 5 Answers You Can Almost Always Trust

  1. Ondansetron before chemo/antibiotic/analgesic (not after)
  2. 3% NaCl for cerebral edema / severe hyponatremia
  3. Insulin + Dextrose for hyperkalemia (fastest)
  4. Calcium gluconate for magnesium toxicity
  5. Trendelenburg + clamp catheter for suspected air embolism

🌟 Day of Exam

  • Sleep 7+ hours the night before. Cramming past midnight backfires.
  • Eat breakfast — protein + complex carbs. No new caffeine dose.
  • Arrive early. Take 3 deep breaths before starting.
  • Read every question TWICE. Watch for "except," "question," "further teaching."
  • If you don't know it — use process of elimination. Eliminate two, then narrow down.
  • Trust your first instinct. Don't second-guess unless you find a fact you missed.
  • You've got this. Dr. Tehrani believes in you.