101 Must-Know NCLEX Medications Cheat Sheet

Studying for the NCLEX can feel like juggling IV pumps, dosage calculations, and pathophysiology charts all at once. One minute you’re mastering pharmacokinetics, the next you’re asked about a side-effect you saw only once in lecture. That’s where this “101 Must-Know NCLEX Medications” Cheat Sheet steps in as your pocket-sized lifesaver.

Inside, every drug is neatly sorted by category—cardiac to psych, antibiotics to anticoagulants—so you can spot patterns fast. For each med you’ll find the generic and a familiar brand name, its drug class, how it works in plain English, the nursing “pearls” exam writers love to test, and bolded high-alert warnings you can’t afford to miss. Think of it as a quick-reference map that turns endless pharmacology terrain into a road trip with clear signposts. If you have enjoyed this, check out our other nursing cheat sheets here!

Antihypertensive Medications

1. Lisinopril

Generic & Brand Name	Lisinopril (Prinivil)
Drug Class	ACE inhibitor (antihypertensive)
Mechanism of Action	Inhibits angiotensin-converting enzyme, blocking Ang I → Ang II; results in vasodilation and decreased aldosterone secretion.
Key Nursing Considerations	Assess blood pressure, renal function, and potassium for early signs of complications. Lisinopril lowers blood pressure by blocking angiotensin II production. Persistent cough warrants assessment. A dry, nagging cough may occur and often leads to discontinuation—inform patients to report this side effect. Angioedema requires immediate action. Monitor for facial or airway swelling; this is a medical emergency, and the drug should be stopped right away.
Critical Alerts	Black Box: Contraindicated in pregnancy. Lisinopril poses a significant risk of fetal injury or death; discontinue as soon as pregnancy is detected.

2. Losartan

Generic & Brand Name	Losartan (Cozaar)
Drug Class	ARB (antihypertensive)
Mechanism of Action	Blocks angiotensin II receptors, preventing vasoconstriction and aldosterone effects.
Key Nursing Considerations	Blood pressure control without the cough. Losartan is an angiotensin II receptor blocker that lowers blood pressure while avoiding the dry cough often associated with ACE inhibitors. Monitor serum potassium and renal function. Potassium and kidneys require close watch due to the risk of hyperkalemia and potential kidney effects. Instruct patients to rise slowly from sitting or lying positions. Postural changes demand patient caution to reduce the risk of dizziness and orthostatic hypotension.
Critical Alerts	Black Box: Discontinue immediately if pregnancy is confirmed. Losartan is contraindicated during pregnancy due to the risk of fetal toxicity and developmental harm.

3. Metoprolol

Generic & Brand Name	Metoprolol (Lopressor)
Drug Class	Beta-1 blocker (selective)
Mechanism of Action	Blocks β1-adrenergic receptors in the heart, reducing heart rate, contractility, and O2 demand.
Key Nursing Considerations	Hold for Low Apical Pulse. Check apical heart rate before administration; withhold if below 60 bpm. May Mask Hypoglycemia Symptoms. Can conceal tachycardia in diabetic patients; monitor closely. Use Cautiously in Asthma. Though β1-selective, high doses may affect β2 receptors and worsen bronchospasm. Avoid Abrupt Discontinuation. Sudden withdrawal may cause rebound hypertension or angina.
Critical Alerts	High Alert: Use with caution in heart failure. Though indicated in some cases, monitor for signs of worsening heart failure such as dyspnea, weight gain, or peripheral edema.

4. Amlodipine

Generic & Brand Name	Amlodipine (Norvasc)
Drug Class	Calcium channel blocker (dihydropyridine)
Mechanism of Action	Inhibits Ca2+ influx into vascular smooth muscle, causing arterial vasodilation and decreased BP.
Key Nursing Considerations	Edema is a common effect, not a fluid overload. Monitor for peripheral edema, particularly in the lower extremities, and differentiate from signs of heart failure. Slow transitions reduce risk. Educate patients to rise slowly from bed or chairs to prevent dizziness from orthostatic hypotension. Heart rate remains essentially unchanged. Unlike non-dihydropyridine agents, amlodipine typically does not significantly affect pulse rate, but monitor for hypotension. Advise regular dental care and good oral hygiene. Gingival hyperplasia may occur with long-term use.
Critical Alerts	Caution: Use with caution in patients with severe aortic stenosis. Amlodipine may worsen symptoms due to reduced preload tolerance in fixed-output cardiac conditions.

5. Diltiazem

Generic & Brand Name	Diltiazem (Cardizem)
Drug Class	Calcium channel blocker (non-dihydropyridine)
Mechanism of Action	Blocks Ca2+ channels in myocardium and nodal tissue, slowing AV node conduction and decreasing cardiac workload.
Key Nursing Considerations	Monitor for bradycardia and conduction blocks. Regularly assess heart rate and rhythm; hold the dose and notify the physician if significant bradycardia or AV block is present. Balance blood pressure and heart function. Monitor for hypotension and signs of worsening heart failure, especially in patients with reduced ejection fraction. Titrate dosage based on cardiac response. IV administration requires continuous ECG monitoring; oral dosing may require gradual adjustment to maintain therapeutic effect. Educate on postural safety and adherence. Instruct patients to rise slowly and not to abruptly stop the medication due to the risk of rebound hypertension or tachyarrhythmias.
Critical Alerts	Caution: Use with caution in heart block or sick sinus syndrome. Diltiazem can worsen AV block or sinus node dysfunction, particularly without a functioning pacemaker.

6. Clonidine

Generic & Brand Name	Clonidine (Catapres)
Drug Class	Central α2-agonist (antihypertensive)
Mechanism of Action	Stimulates α2-adrenergic receptors in the brain, reducing sympathetic outflow; lowers peripheral vascular resistance and HR.
Key Nursing Considerations	Assess for sedation and dry mouth. Monitor for CNS depression, fatigue, and anticholinergic effects such as dry mouth, which are common but tolerable with continued use. Monitor for orthostatic hypotension. Advise patients to change positions slowly and report dizziness or lightheadedness that may indicate a drop in blood pressure. Evaluate renal function with long-term use. Since the kidneys partially excrete clonidine, renal labs should be monitored in patients with impaired function. Support adherence to the dosing schedule. Emphasize the importance of taking clonidine at the same time daily and not missing doses due to the risk of rebound hypertension.
Critical Alerts	High Alert: Avoid abrupt discontinuation. Sudden withdrawal may result in severe rebound hypertensive crisis, agitation, and headache; taper the dose gradually under supervision.

7. Nitroprusside

Generic & Brand Name	Nitroprusside (Nipride)
Drug Class	Vasodilator (antihypertensive emergency)
Mechanism of Action	Releases nitric oxide to directly dilate arteries and veins, rapidly reducing BP and preload/afterload.
Key Nursing Considerations	Monitor blood pressure continuously. Because hypertension has an immediate onset and short half-life, arterial line monitoring is used in critical care settings to prevent excessive hypotension. Assess for signs of cyanide toxicity. Prolonged or high-dose infusions may lead to cyanide or thiocyanate accumulation, especially in renal or hepatic impairment. Protect from light during administration. Nitroprusside is light-sensitive and must be shielded to prevent degradation and loss of potency. Titrate dose carefully based on response. Adjust infusion rates slowly and precisely to maintain safe hemodynamic control and prevent rebound effects.
Critical Alerts	High Alert: Discontinue immediately if cyanide toxicity is suspected. Symptoms include altered mental status, metabolic acidosis, or cardiovascular instability; administer sodium thiosulfate as the antidote if indicated.

Antiarrhytmics Medications

8. Digoxin

Generic & Brand Name	Digoxin (Lanoxin)
Drug Class	Cardiac glycoside (inotrope)
Mechanism of Action	Inhibits Na⁺/K⁺-ATPase, increasing intracellular Ca²⁺ in cardiac cells; ↑ contractility (positive inotrope) and ↓ AV node conduction (negative chronotrope).
Key Nursing Considerations	Check apical pulse before administration. Continually assess for bradycardia; hold the dose and notify the provider if the heart rate is below established parameters, commonly less than 60 bpm in adults. Monitor serum digoxin levels and electrolytes. The therapeutic range is typically 0.5 to 2.0 ng per mL; closely monitor potassium, magnesium, and calcium, as imbalances increase toxicity risk. Evaluate for early signs of toxicity. Nausea, vomiting, visual disturbances such as halos or blurred vision, and confusion are early indicators and warrant prompt evaluation. Adjust dose cautiously in renal impairment. Digoxin is primarily excreted by the kidneys; dose reduction and frequent monitoring are essential in patients with decreased renal function.
Critical Alerts	High Alert: Stop immediately if signs of digoxin toxicity appear. Toxicity can lead to life-threatening arrhythmias; notify the provider, hold further doses, and prepare for antidote administration such as digoxin immune Fab.

9. Amiodarone

Generic & Brand Name	Amiodarone (Cordarone)
Drug Class	Class III antiarrhythmic
Mechanism of Action	Prolongs cardiac repolarization by blocking K⁺ channels (also has class I, II, IV effects); stabilizes arrhythmias (used for AFib, VT/VF).
Key Nursing Considerations	Monitor ECG and thyroid, liver, and pulmonary function. Regularly assess for QT prolongation, thyroid imbalance, elevated liver enzymes, and signs of pulmonary toxicity during therapy. Assess for visual disturbances and skin changes. Report symptoms such as blurred vision, corneal deposits, photosensitivity, or blue-gray skin discoloration, which may appear with long-term use. Review medication interactions closely. Amiodarone has a long half-life and inhibits many CYP450 enzymes, increasing the effects and toxicity risks of several concurrent drugs, including digoxin and warfarin. Use the loading dose with caution and monitor closely. Loading regimens are often necessary to achieve therapeutic levels quickly but require cardiac monitoring and frequent assessment.
Critical Alerts	Stop if signs of pulmonary toxicity develop. Nonproductive cough, dyspnea, or pulmonary infiltrates require immediate evaluation and potential discontinuation to prevent irreversible lung damage. Caution in thyroid dysfunction. Amiodarone contains iodine and may cause either hypo- or hyperthyroidism; thyroid function must be monitored periodically throughout treatment.

10. Adenosine

Generic & Brand Name	Adenosine (Adenocard)
Drug Class	Antiarrhythmic (nucleoside)
Mechanism of Action	Slows AV node conduction dramatically, interrupting re-entrant SVT pathways to restore normal sinus rhythm.
Key Nursing Considerations	Administer as a rapid IV push with saline flush. Due to its ultra-short half-life, adenosine must be given quickly through a large-bore IV with immediate saline flush to confirm effectiveness. Monitor ECG continuously during administration. A brief period of asystole or bradycardia is expected, and the therapeutic effect is confirmed before normal rhythm resumes. Prepare the patient for transient symptoms. Educate patients that facial flushing, chest pressure, lightheadedness, or a sense of impending doom may occur but usually resolves within seconds. Avoid in patients with AV block or sick sinus syndrome. Adenosine is contraindicated in those without a pacemaker due to its direct effect on AV node conduction.
Critical Alerts	High Alert: Use with caution in reactive airway disease. Adenosine can cause bronchospasm and is contraindicated in patients with severe asthma or chronic obstructive pulmonary disease. Contraindicated in 2ⁿᵈ/3ʳᵈ degree heart block. Adenosine is contraindicated because it slows conduction through the AV node, which is already impaired in these blocks.

Vasopressors, Inotropes, and Emergency Meds

11. Atropine

Generic & Brand Name	Atropine (Atropen)
Drug Class	Anticholinergic (muscarinic antagonist)
Mechanism of Action	Blocks acetylcholine at parasympathetic sites (e.g., SA & AV nodes), resulting in increased heart rate and decreased secretions.
Key Nursing Considerations	Used as an antidote in cholinergic crisis (organophosphate poisoning). Atropine treats cholinergic crisis by blocking muscarinic receptors, reversing bradycardia and respiratory symptoms. Assess heart rate and rhythm before and after dosing. Continuous ECG monitoring is essential to evaluate the therapeutic effect and detect arrhythmias. Monitor for anticholinergic side effects. Systemic cholinergic blockade may cause dry mouth, blurred vision, urinary retention, and constipation. Educate on heat intolerance and hydration. Atropine can inhibit sweating and increase the risk of hyperthermia, especially in hot environments; advise adequate fluid intake. Use cautiously in elderly patients. Older adults are more sensitive to CNS effects such as confusion, agitation, or hallucinations; monitor closely.
Critical Alerts	Caution: Contraindicated in glaucoma. It may trigger acute angle-closure by increasing intraocular pressure. Recognize the signs of anticholinergic toxicity. In overdose, atropine can produce a classic toxidrome including hyperthermia, dry mucosa, flushed skin, delirium, and mydriasis. Have physostigmine available for severe overdose. This cholinesterase inhibitor is the antidote to reverse life-threatening central and peripheral anticholinergic effects.

12. Epinephrine

Generic & Brand Name	Epinephrine (Adrenalin)
Drug Class	Adrenergic agonist (catecholamine)
Mechanism of Action	Stimulates α1 (vasoconstriction → ↑BP), β1 (↑HR/contractility), and β2 (bronchodilation) receptors.
Key Nursing Considerations	Use in cardiac arrest and anaphylaxis. Administer promptly in life-threatening conditions such as cardiac arrest, severe allergic reactions, or airway obstruction due to anaphylaxis. Monitor for tachycardia and hypertension. Continuous monitoring is necessary during IV or IM administration due to potent cardiovascular effects, including increased myocardial oxygen demand. Teach proper use of auto-injectors. Educate patients prescribed epinephrine for anaphylaxis on correct storage, injection technique, and the importance of seeking immediate medical care after use. Evaluate for tremors and anxiety post-administration. CNS stimulation may cause nervousness, restlessness, or headache, typically resolved without intervention. Infiltration requires immediate intervention. If extravasation occurs, promptly infiltrate the area with phentolamine to reverse local vasoconstriction and minimize tissue damage.
Critical Alerts	High Alert: Use caution in patients with cardiac disease. Epinephrine can precipitate arrhythmias, angina, or myocardial infarction; monitor closely in individuals with preexisting cardiovascular conditions.

13. Norepinephrine

Generic & Brand Name	Norepinephrine (Levophed)
Drug Class	Adrenergic agonist (vasopressor)
Mechanism of Action	Primarily stimulates α1 receptors (intense vasoconstriction) and some β1 (↑heart contractility), leading to increased vascular resistance and BP.
Key Nursing Considerations	First-line vasopressor for septic shock. Norepinephrine causes vasoconstriction and elevation of blood pressure in shock and severe hypotension. Titrate infusion based on hemodynamic response. Continuous blood pressure, heart rate, and urine output monitoring is needed to guide dose adjustments and assess organ perfusion. Monitor extremities for signs of ischemia. Prolonged vasoconstriction may lessen blood flow to limbs and digits; assess for pallor, coldness, or mottling. Support fluid resuscitation before vasopressor use. Check for adequate intravascular volume, as norepinephrine may be ineffective or harmful in hypovolemic states.
Critical Alerts	High Alert: Infiltration can cause severe tissue necrosis. If extravasation occurs, administer phentolamine subcutaneously around the site to reverse local vasoconstriction.

14. Dopamine

Generic & Brand Name	Dopamine (Intropin)
Drug Class	Adrenergic agonist/inotrope
Mechanism of Action	Dose-dependent receptor effects: low→dopaminergic (renal perfusion), mid→β1 (↑HR/contractility), high→α1 (vasoconstriction).
Key Nursing Considerations	Monitor cardiac rhythm and hemodynamic parameters. Continuous ECG and vital signs monitoring are required to detect arrhythmias and guide titration based on blood pressure and urine output. Verify for proper fluid volume before initiating therapy. Hypovolemia should be corrected before dopamine infusion to prevent ineffective perfusion and worsening hypotension. Use central access when possible. Administer dopamine via a central line to reduce the risk of peripheral extravasation and tissue damage. Adjust dosage gradually and observe for tachyarrhythmias. High doses may cause excessive vasoconstriction and increased cardiac workload; titrate slowly and assess for chest pain or palpitations.
Critical Alerts	High Alert: Treat extravasation promptly with phentolamine. Peripheral infiltration may cause necrosis due to intense vasoconstriction and must be addressed immediately with antidote infiltration.

Antianginal/Vasodilators

15. Nitroglycerin

Generic & Brand Name	Nitroglycerin (Nitrostat)
Drug Class	Nitrate (antianginal)
Mechanism of Action	Converts to nitric oxide in vascular smooth muscle -> venodilation (↓preload) and coronary artery dilation; at higher doses, also dilates arterioles (↓afterload).
Key Nursing Considerations	Assess blood pressure before and during therapy. Monitor closely for hypotension, especially during IV infusion or when titrating transdermal or sublingual forms. Evaluate for headache and flushing. Vasodilation often causes transient headache, dizziness, or facial flushing; reassure patients and adjust dose if needed. Check nitrate-free intervals for tolerance prevention. For transdermal or oral long-acting forms, schedule drug-free periods daily to reduce the risk of nitrate tolerance. Teach proper administration for angina relief. Instruct patients using sublingual tablets to sit or lie down during use, place under the tongue, and call emergency services if chest pain persists after one dose.
Critical Alerts	High Alert: Do not use with phosphodiesterase inhibitors. Concomitant use with drugs like sildenafil can cause severe hypotension and is contraindicated. Watch for profound hypotension with rapid administration. Administer IV nitroglycerin slowly and titrate carefully; abrupt drops in blood pressure may compromise perfusion and lead to syncope or shock.

Antilipemics

16. Atorvastatin

Generic & Brand Name	Atorvastatin (Lipitor)
Drug Class	Statin (antihyperlipidemic)
Mechanism of Action	Inhibits HMG-CoA reductase, the enzyme for cholesterol synthesis in liver – lowers LDL and total cholesterol; modestly raises HDL, lowers triglycerides.
Key Nursing Considerations	Monitor liver enzymes during therapy. Check AST and ALT at baseline and periodically, as hepatotoxicity may occur during statin use. Assess for muscle pain and weakness. Myopathy and rhabdomyolysis are rare but serious adverse effects; report unexplained muscle symptoms promptly. Reinforce adherence to timing and lifestyle changes. Take once daily, preferably in the evening, and emphasize the importance of diet and exercise in combination with medication. Avoid grapefruit and excessive alcohol intake. Grapefruit inhibits CYP3A4 metabolism, increasing statin levels and toxicity risk; alcohol may exacerbate liver effects.
Critical Alerts	Caution: Discontinue if rhabdomyolysis is suspected. Signs include severe muscle pain, dark urine, and elevated creatine kinase; notify the physician and stop therapy immediately.

Diuretics

17. Furosemide

Generic & Brand Name	Furosemide (Lasix)
Drug Class	Loop diuretic
Mechanism of Action	Inhibits Na⁺/K⁺/2Cl⁻ cotransporter in the ascending loop of Henle, causing major diuresis (excretion of Na⁺, K⁺, Cl⁻, water).
Key Nursing Considerations	Monitor electrolytes and renal function. Frequent potassium, sodium, magnesium, and creatinine assessment is important to prevent electrolyte imbalances and nephrotoxicity. Assess for signs of volume depletion. Monitor for hypotension, dizziness, dry mucous membranes, and decreased urine output, particularly in high doses or elderly patients. Administer early in the day. Give in the morning to minimize nocturia and improve adherence to therapy. Evaluate for hearing changes during IV use. High-dose or rapid IV administration may cause ototoxicity; assess for tinnitus or hearing loss and infuse slowly. Encourage potassium-rich foods or supplements. Hypokalemia is a common side effect and may require dietary counseling or potassium replacement.
Critical Alerts	Caution: Watch for severe hypokalemia or dehydration. Life-threatening arrhythmias and acute kidney injury can result from excessive diuresis or electrolyte loss; intervene promptly and notify the physician.

18. Spironolactone

Generic & Brand Name	Spironolactone (Aldactone)
Drug Class	Potassium-sparing diuretic
Mechanism of Action	Antagonizes aldosterone in distal nephron, causing excretion of Na⁺/water and retention of K⁺.
Key Nursing Considerations	Monitor serum potassium and renal function. Regularly assess for hyperkalemia and rising creatinine, particularly in patients with impaired renal function or those on ACE inhibitors or ARBs. Assess for endocrine-related side effects. Due to its anti-androgenic effects, gynecomastia, menstrual irregularities, and impotence may occur. Teach dietary precautions with potassium intake. Advise patients to avoid potassium-rich foods and salt substitutes to reduce the risk of hyperkalemia. Administer consistently with or without food. Reinforce adherence to the dosing schedule and educate on signs of electrolyte imbalance, such as muscle weakness or palpitations.
Critical Alerts	Caution: Discontinue if life-threatening hyperkalemia develops. Immediate intervention is required if potassium exceeds safe limits or if ECG changes indicate cardiac instability.

19. Hydrochlorothiazide

Generic & Brand Name	Hydrochlorothiazide (Microzide)
Drug Class	Thiazide diuretic
Mechanism of Action	Inhibits NaCl reabsorption in the distal convoluted tubule, promoting moderate diuresis and reducing blood volume/BP.
Key Nursing Considerations	Monitor electrolytes and glucose levels. Regularly assess for hypokalemia, hyponatremia, and elevated blood glucose, especially in patients with diabetes or on digoxin. Check blood pressure and signs of dehydration. Evaluate for orthostatic hypotension, dizziness, and dry mucous membranes, which may indicate excessive fluid loss. Administer in the morning to prevent nocturia. Giving the dose early helps maintain adherence while decreasing the risk of sleep disturbance due to frequent urination. Encourage potassium-rich foods. Dietary potassium may help counteract potassium loss and reduce the risk of muscle cramps or arrhythmias.
Critical Alerts	Caution: Use caution in patients with sulfa allergy. Hydrochlorothiazide may trigger hypersensitivity reactions in individuals with known sulfonamide allergies. Discontinue if severe electrolyte imbalance occurs. Life-threatening complications can arise from profound hypokalemia or hyponatremia and require prompt correction.

Hematopoietic Agents

20. Epoetin alfa

Generic & Brand Name	Epoetin alfa (Epogen)
Drug Class	Erythropoiesis-stimulant
Mechanism of Action	Synthetic erythropoietin hormone that stimulates RBC production in bone marrow.
Key Nursing Considerations	Monitor hemoglobin and hematocrit regularly. Titrate dose based on response and avoid exceeding target hemoglobin levels to reduce cardiovascular risk. Assess for hypertension during therapy. Epoetin alfa may elevate blood pressure, particularly in patients with chronic kidney disease; monitor closely and manage accordingly. Evaluate for signs of thromboembolic events. Increased hematocrit may raise the risk of clotting, especially in patients with cancer or a history of vascular disease. Administer via subcutaneous or IV route. Follow the institution protocol for route and dosing schedule; do not shake the vial as it may denature the protein.
Critical Alerts	Black Box: Hold if hemoglobin rises too rapidly or exceeds 11 g per dL. Rapid correction can increase the risk of stroke, myocardial infarction, and death, particularly in patients with renal failure.

21. Ferrous Sulfate

Generic & Brand Name	Ferrous Sulfate (Feosol, Slow FE)
Drug Class	Iron Supplement (Hematopoietic Agent)
Mechanism of Action	Replenishes iron stores necessary for the synthesis of hemoglobin, thereby supporting adequate oxygen transport by red blood cells and correcting iron deficiency anemia.
Key Nursing Considerations	Administer on an empty stomach for best absorption. Give 1 hour before or 2 hours after meals, but may give with food to minimize gastrointestinal upset if necessary. Monitor for gastrointestinal side effects. Nausea, constipation, and dark stools are common and may affect adherence; encourage hydration and fiber intake. Avoid coadministration with calcium, antacids, or certain antibiotics. These can impair iron absorption; space dosing appropriately to enhance efficacy. Reinforce proper administration technique. Advise patients to take tablets with a full glass of water and avoid crushing or chewing extended-release forms.
Critical Alerts	High warning: Iron overdose is potentially fatal in children. Store ferrous sulfate out of reach and educate caregivers on the importance of proper storage and immediate intervention if accidental ingestion occurs. Monitor for signs of iron overload with long-term use. Excessive supplementation may lead to hemosiderosis; assess ferritin and transferrin saturation in patients on chronic therapy.

Anticoagulants

22. Rivaroxaban

Generic & Brand Name	Rivaroxaban (Xarelto)
Drug Class	Factor Xa Inhibitor / Anticoagulant (Hematologic Agent)
Mechanism of Action	Selectively inhibits Factor Xa, a key enzyme in the coagulation cascade. By inhibiting Factor Xa, it significantly reduces thrombin generation, thereby decreasing the likelihood of clot formation. It is commonly used for preventing deep vein thrombosis (DVT), pulmonary embolism (PE), and managing thromboembolic risks in patients with atrial fibrillation.
Key Nursing Considerations	Monitor for signs of bleeding. Assess for bruising, hematuria, melena, or prolonged bleeding; educate patients to report any unusual bleeding immediately. Avoid abrupt discontinuation. Sudden stoppage increases the risk of thromboembolic events; taper only under provider guidance or when switching to another anticoagulant. Use cautiously with other anticoagulants or antiplatelets. Concomitant use increases bleeding risk; review all medications for interactions. Renal function affects dosing. Adjust dose in renal impairment and monitor kidney function regularly in elderly or high-risk populations.
Critical Alerts	Patients must avoid abrupt cessation without provider consultation. Premature discontinuation of rivaroxaban significantly increases the risk of thrombotic events, including stroke and myocardial infarction. Currently, there is no specific reversal agent; thus, extreme caution in dosing and monitoring is critical.

23. Warfarin

Generic & Brand Name	Warfarin (Coumadin)
Drug Class	Vitamin K antagonist (oral anticoagulant)
Mechanism of Action	Inhibits vitamin K-dependent clotting factor synthesis (factors II, VII, IX, X) in the liver.
Key Nursing Considerations	Monitor INR regularly to guide dosing. Maintain INR within the target range (typically 2 to 3) to balance the risk of bleeding and clotting. Assess for signs of bleeding and educate on precautions. Watch for bruising, gum bleeding, hematuria, and melena; instruct patients to use soft toothbrushes and avoid activities that increase injury risk. Maintain consistent dietary vitamin K intake. Sudden increases or decreases in vitamin K from green leafy vegetables can alter drug effectiveness. Review for drug and herbal interactions. Many medications and supplements, including antibiotics and NSAIDs, can increase bleeding risk or alter INR.
Critical Alerts	Black Box: Discontinue immediately in the presence of signs of serious bleeding or INR above the therapeutic range. Reverse anticoagulation with vitamin K or prothrombin complex concentrate as clinically indicated. High Alert: Contraindicated in pregnancy. Warfarin crosses the placenta and can cause fetal bleeding and malformations; use an alternative anticoagulant during pregnancy.

24. Heparin

Generic & Brand Name	Heparin (unfractionated)
Drug Class	Anticoagulant (IV/SQ)
Mechanism of Action	Activates antithrombin III, which inactivates thrombin and factor Xa, thereby preventing fibrin formation.
Key Nursing Considerations	Monitor aPTT to maintain the therapeutic range. Adjust dose based on activated partial thromboplastin time and institutional protocols to confirm adequate anticoagulation without excessive bleeding. Assess for signs of bleeding. Monitor for hematuria, melena, hematomas, or oozing at IV sites, and instruct patients to report unusual bruising or bleeding. Use cautiously with invasive procedures. Temporarily discontinue before surgery or procedures that carry bleeding risk; restart as directed based on risk assessment. Rotate subcutaneous injection sites. For prophylactic dosing, administer in the abdomen away from scars or bruises, and avoid massaging to prevent hematoma formation.
Critical Alerts	High Alert: Monitor for heparin-induced thrombocytopenia. Abrupt platelet drop may indicate HIT, a severe immune-mediated reaction; discontinue heparin and initiate alternative anticoagulation if suspected. Have protamine sulfate available for overdose. Protamine is the reversal agent for heparin and should be administered immediately in cases of severe bleeding or overdose.

25. Enoxaparin

Generic & Brand Name	Enoxaparin (Lovenox)
Drug Class	Low molecular weight heparin
Mechanism of Action	Enhances antithrombin activity to inactivate factor Xa (more selective action than heparin).
Key Nursing Considerations	Administer via deep subcutaneous injection. Alternate injection sites and avoid massaging to prevent local irritation or hematoma formation. Monitor for signs of bleeding. Assess for bruising, hematuria, and GI bleeding and notify the physician if any bleeding occurs, especially in patients with renal impairment or on other anticoagulants. Evaluate platelet counts during therapy. Enoxaparin may rarely cause heparin-induced thrombocytopenia; monitor CBC and discontinue if the platelet count drops significantly. Educate on self-administration and timing. Instruct patients on proper injection technique and importance of consistent timing for dosing. Adjust the dose for renal impairment. Decreased clearance in patients with reduced renal function increases bleeding risk; modify the dose accordingly.
Critical Alerts	High Alert: Do not use interchangeably with unfractionated heparin. Enoxaparin has a different pharmacokinetic profile and dosing regimen and should not be substituted without proper evaluation. Avoid use in patients undergoing spinal or epidural procedures. Concurrent anticoagulation increases the risk of spinal hematoma, which may lead to paralysis; follow strict timing guidelines. Antidote: Protamine partially reverses effect if needed.

Antiplatelets (Inhibit Platelet Aggregation)

26. Clopidogrel

Generic & Brand Name	Clopidogrel (Plavix)
Drug Class	Antiplatelet (ADP receptor blocker)
Mechanism of Action	Irreversibly inhibits P2Y12 ADP receptors on platelets, preventing activation of GP IIb/IIIa and thus reducing platelet aggregation.
Key Nursing Considerations	Monitor for signs of bleeding. Observe for bruising, epistaxis, hematuria, or gastrointestinal bleeding, especially in patients receiving anticoagulants or NSAIDs. Assess baseline platelet function and CBC. Regular monitoring helps detect thrombocytopenia or potential bone marrow suppression during prolonged use. Educate on avoiding injury and OTC medications. Advise patients to use caution with razors and contact sports and to consult providers before using aspirin or NSAIDs. Discontinue before surgery if advised. Clopidogrel increases surgical bleeding risk and should be held per provider guidance, typically 5 to 7 days preoperatively.
Critical Alerts	Caution: Do not use in active bleeding or peptic ulcer disease. Clopidogrel is contraindicated in patients at high risk for hemorrhage. Do not use in active bleeding or peptic ulcer disease. Clopidogrel is contraindicated in patients at high risk for hemorrhage. Watch for thrombotic thrombocytopenic purpura. Report any signs of neurologic changes, fever, renal dysfunction, or unexplained bruising, as TTP is a rare but life-threatening complication.

27. Aspirin

Generic & Brand Name	Aspirin (ASA)
Drug Class	NSAID / Antiplatelet (salicylate)
Mechanism of Action	At low doses (81–325 mg), irreversibly inhibits COX-1 in platelets, blocking thromboxane A₂ formation and thus platelet aggregation. Also analgesic & antipyretic (via COX-2 inhibition).
Key Nursing Considerations	Monitor for gastrointestinal irritation and bleeding. Assess for dyspepsia, melena, or hematemesis, particularly in elderly patients or those with a history of ulcers. Administer with food or an enteric-coated formulation. These strategies help reduce gastric mucosal irritation and improve patient tolerance. Avoid concurrent use with other NSAIDs or anticoagulants. Combination therapy increases the risk of serious bleeding and should be managed carefully. Educate on daily low-dose use for cardiovascular protection. Instruct patients to take aspirin as prescribed and not to discontinue abruptly without provider guidance.
Critical Alerts	Caution: Do not give to children or adolescents with viral illness. Aspirin is contraindicated due to the risk of Reye syndrome, a rare but life-threatening condition affecting the liver and brain. Hold prior to surgery as ordered. Aspirin increases bleeding risk and is typically withheld for 5 to 7 days before invasive procedures unless directed otherwise.

Thrombolytic / Fibrinolytic Agent (Clot Buster)

28. Alteplase

Generic & Brand Name	Alteplase (tPA)
Drug Class	Thrombolytic (fibrinolytic)
Mechanism of Action	Enzyme that converts plasminogen to plasmin, which dissolves fibrin clots (“clot buster”).
Key Nursing Considerations	Strictly adhere to time-sensitive protocols. Administer within the approved therapeutic window for best outcomes, typically within 3 to 4.5 hours of stroke symptom onset. Monitor closely for bleeding during and after infusion. Frequent neurologic checks and assessment for signs of intracranial or internal bleeding are essential, especially in stroke or post-MI care. Assess the recent history of surgery or trauma. Alteplase is contraindicated in patients with recent invasive procedures, active internal bleeding, or uncontrolled hypertension due to high hemorrhagic risk. Verify that all invasive procedures are completed before administration. To reduce bleeding complications, avoid catheter insertions, venipunctures, or injections during and for several hours after the infusion.
Critical Alerts	High Alert: Do not administer to patients with active bleeding or a history of hemorrhagic stroke. Alteplase significantly increases the risk of life-threatening bleeding, particularly in high-risk individuals. Discontinue infusion immediately if signs of serious bleeding occur. Initiate emergency supportive measures and notify the provider without delay.

Respiratory & Allergy Medications

29. Albuterol

Generic & Brand Name	Albuterol (Ventolin)
Drug Class	Short-acting β2-agonist (SABA)
Mechanism of Action	Stimulates β2-adrenergic receptors in bronchial smooth muscle → bronchodilation (relaxes airways).
Key Nursing Considerations	Monitor respiratory rate, effort, and breath sounds. Assess effectiveness after administration and document improvements in wheezing, oxygenation, and respiratory distress. Instruct on proper inhaler or nebulizer technique. Teach the patient how to use the device correctly for maximum drug delivery and therapeutic benefit. Assess for common side effects such as tremors, palpitations, and tachycardia. These are dose-related and may be more pronounced with frequent or high-dose use. Use before corticosteroids in dual therapy. Administer bronchodilator first to open airways and improve the delivery of inhaled steroids.
Critical Alerts	Caution: Do not exceed the prescribed frequency. Overuse of albuterol can lead to decreased effectiveness, paradoxical bronchospasm, and increased cardiovascular side effects. Use caution in patients with cardiac disorders. Albuterol may exacerbate arrhythmias or angina, particularly in those with underlying heart disease.

30. Ipratropium

Generic & Brand Name	Ipratropium (Atrovent)
Drug Class	Inhaled anticholinergic (bronchodilator)
Mechanism of Action	Blocks acetylcholine (muscarinic) receptors in airways, preventing bronchoconstriction and reducing secretions.
Key Nursing Considerations	Monitor for dry mouth and throat irritation. These are common side effects due to reduced secretions and may affect adherence; offer sips of water or sugar-free candy. Instruct on proper inhalation technique. Instruct the patient not to swallow the medication and to rinse the mouth after use to avoid a bitter taste and irritation. Avoid use in patients with narrow-angle glaucoma or urinary retention. Anticholinergic effects may exacerbate these conditions and require physician evaluation before use. Use regularly for maintenance, not rescue. Ipratropium has a slower onset than beta-agonists and is intended for routine symptom control rather than acute relief. Assess for allergy to soy/peanuts. Old formulations had soy lecithin (new versions typically do not).
Critical Alerts	Caution: Do not mix with other inhaled medications unless prescribed. Combining without guidance may alter efficacy or increase side effects, particularly with other anticholinergics. Discontinue if signs of hypersensitivity occur. Rare but severe reactions may include rash, angioedema, or bronchospasm; report symptoms immediately.

31. Fluticasone

Generic & Brand Name	Fluticasone (Flovent)
Drug Class	Inhaled corticosteroid (ICS)
Mechanism of Action	Potent anti-inflammatory effect in airways: reduces airway swelling and mucus production by inhibiting inflammatory cells/mediators.
Key Nursing Considerations	Monitor for signs of oral thrush. Instruct patients to rinse the mouth after each use to prevent fungal infection and maintain oral hygiene. Assess respiratory status regularly. Evaluate for reduced wheezing, improved peak flow, and decreased need for rescue inhalers as effectiveness indicators. Educate on consistent daily use. Fluticasone is for long-term control, not acute bronchospasm; adherence is key for preventing exacerbations. Use with a spacer if prescribed. Spacers improve medication delivery to the lungs and reduce oropharyngeal deposition.
Critical Alerts	Caution: Do not use during an acute asthma attack. Fluticasone has a delayed onset and should never replace short-acting bronchodilators in emergencies. Watch for signs of adrenal suppression with high doses. Symptoms include fatigue, hypotension, and weakness; long-term high-dose use requires gradual tapering under medical supervision.

32. Montelukast

Generic & Brand Name	Montelukast (Singulair)
Drug Class	Leukotriene receptor antagonist
Mechanism of Action	Blocks leukotriene receptors in the airway, preventing leukotriene-induced inflammation and bronchoconstriction.
Key Nursing Considerations	Assess for neuropsychiatric effects. Monitor for mood changes, agitation, sleep disturbances, or suicidal thoughts and report immediately. Administer daily in the evening. Evening dosing aligns with typical nighttime worsening of asthma symptoms and enhances adherence in long-term use. Educate patients on maintenance use. Montelukast is not a rescue medication and should not be used for acute bronchospasm or asthma attacks. Monitor respiratory symptoms and allergy control. Evaluate for decreased nighttime symptoms, fewer exacerbations, and improved symptom management.
Critical Alerts	High-Alert Flag: Discontinue if neuropsychiatric symptoms emerge. Rare but serious behavioral side effects can occur; report any unusual mental status changes to the provider immediately.

33. Diphenhydramine

Generic & Brand Name	Diphenhydramine (Benadryl)
Drug Class	Antihistamine (1st generation H1-blocker)
Mechanism of Action	Blocks H1 histamine receptors centrally and peripherally, reducing allergic symptoms (sneezing, itching, hives); also has significant anticholinergic activity.
Key Nursing Considerations	Monitor for sedation and drowsiness. This medication crosses the blood-brain barrier, often causing CNS depression; advise patients to avoid driving or operating machinery. Assess for anticholinergic side effects. Dry mouth, urinary retention, constipation, and blurred vision are common, especially in older adults. Use cautiously in elderly patients. Diphenhydramine increases fall risk due to sedation and anticholinergic effects; consider alternative agents in geriatric care. Educate on the appropriate use for insomnia or motion sickness. When used as a sleep aid or for nausea, administer 30–60 minutes before bedtime or travel.
Critical Alerts	Caution:  Sedation can be significant due to the risk of falls in the elderly. Not advised for routine use in older adults due to anticholinergic effects (confusion, urinary retention). Do not use in neonates or young infants. Due to heightened sensitivity and risk of severe respiratory side effects, it is contraindicated in children under 6 months of age. Avoid in acute asthma attacks. Diphenhydramine can thicken bronchial secretions, worsening airway obstruction during active bronchospasm.

34. Theophylline

Generic & Brand Name	Theophylline (Theo-24)
Drug Class	Methylxanthine bronchodilator
Mechanism of Action	Relaxes bronchial smooth muscle (likely by phosphodiesterase inhibition → increased cAMP) and stimulates CNS and cardiac muscle (related to caffeine).
Key Nursing Considerations	Monitor serum theophylline levels closely. It has a narrow therapeutic range (typically 10–20 mcg per mL), and toxicity can occur rapidly with small dose increases. Assess for early signs of toxicity. Symptoms such as nausea, vomiting, restlessness, insomnia, or tachycardia may indicate elevated drug levels. Avoid concurrent use with CYP450 inhibitors. Medications like ciprofloxacin, cimetidine, and erythromycin can increase theophylline levels and the risk of toxicity. Educate patients to avoid caffeine. Additional methylxanthine intake from coffee, tea, or energy drinks can potentiate central nervous system stimulation and cardiac effects.
Critical Alerts	High Alert: Discontinue immediately if signs of severe toxicity occur. Seizures, arrhythmias, or hypotension warrant urgent medical evaluation and possible antidotal treatment with activated charcoal or supportive care. Use cautiously in cardiac and hepatic impairment. Reduced clearance increases toxicity risk; dose adjustments and close monitoring are required.

Antidiabetics/Insulin

35. Insulin Lispro

Generic & Brand Name	Insulin Lispro (Humalog)
Drug Class	Rapid-acting insulin
Mechanism of Action	Insulin analog with altered amino acids allowing quick absorption. Onset ~15 min, peak ~1 hr, duration 3–4 hr. Facilitates the uptake of glucose into cells (muscle, fat) and storage as glycogen.
Key Nursing Considerations	Administer within 15 minutes of meals. Timed administration promotes insulin availability, matching glucose absorption to prevent post-meal spikes. Rotate injection sites to prevent lipodystrophy. Repeated use of the same site can cause tissue changes impair insulin absorption and effectiveness. Monitor for signs of hypoglycemia. Shakiness, sweating, confusion, and tachycardia require immediate treatment with fast-acting glucose. Teach patients on timing and blood glucose monitoring. Proper administration and frequent self-monitoring help maintain target glucose levels and reduce complications.
Critical Alerts	High Alert: Do not delay administration after dosing. Due to the rapid onset of action, delayed meals following insulin lispro can cause severe hypoglycemia.

36. Insulin Regular

Generic & Brand Name	Insulin Regular (Humulin R)
Drug Class	Short-acting insulin
Mechanism of Action	Human insulin with onset ~30 min, peak 2–3 hr, duration 5–8 hr. Lowers blood glucose by promoting cellular uptake of glucose and potassium (and glycogen storage).
Key Nursing Considerations	Draw regular insulin into the syringe first, then NPH. When mixing insulin (clear first before cloudy). Administer 30 minutes before meals. This timing aligns peak insulin action with postprandial glucose rise to minimize hyperglycemia. Monitor blood glucose before and after meals. Frequent checks are necessary to evaluate insulin effectiveness and prevent hypo- or hyperglycemia. Assess for hypoglycemic symptoms. Early signs include sweating, tremors, confusion, and dizziness; provide rapid-acting glucose as needed. Instruct patients on site rotation. Changing injection locations prevents lipohypertrophy and maintains consistent absorption rates.
Critical Alerts	High Alert: There is a very high risk of harm if there is a dosing error. Verify the units (U-100 vs. U-500 formulation). Hypoglycemia can occur if insulin peaks without sufficient food intake. Do not mix with long-acting insulins unless specified. Improper mixing may alter absorption timing and lead to glycemic instability.

37. Insulin NPH (Humulin N)

Generic & Brand Name	Insulin NPH (Humulin N)
Drug Class	Intermediate-acting insulin
Mechanism of Action	Insulin with protamine and zinc added—cloudy suspension. Insulin NPH is an intermediate-acting insulin with an onset in 1 to 2 hours, a peak at 4 to 12 hours, and a duration up to 18 hours. It is used to maintain baseline insulin coverage.
Key Nursing Considerations	Administer approximately the same time daily. Consistent timing supports stable basal insulin levels and helps prevent fluctuations in blood sugar. Roll the vial gently before drawing up. NPH is a suspension and requires uniform mixing to allow accurate dosing. Monitor for delayed hypoglycemia. Due to its peak action, hypoglycemic episodes may occur several hours after administration, especially if meals are skipped. Teach patients on proper storage and injection site rotation. Keep refrigerated if unopened, and rotate injection sites to avoid lipodystrophy.
Critical Alerts	High Alert: Avoid mixing with glargine or detemir. These long-acting insulins are incompatible with NPH and may alter pharmacokinetics and efficacy. Do not use during acute hypoglycemia. Administering insulin when glucose is already low may cause severe hypoglycemia, requiring immediate intervention.

38. Insulin Glargine

Generic & Brand Name	Insulin Glargine (Lantus)
Drug Class	Long-acting insulin
Mechanism of Action	Insulin analog formulated for 24-hour basal release. No pronounced peak; steady slow release. Duration ~24 hr.
Key Nursing Considerations	Administer once daily at the same time. Consistent timing maintains stable plasma insulin levels and reduces glycemic variability. Do not mix with other insulins. Mixing alters its formulation and time-release properties, leading to unpredictable effects. Teach patients to recognize and manage hypoglycemia. Though rare due to the absence of a peak, hypoglycemia can still occur, especially with skipped meals or increased activity. Rotate injection sites regularly. Proper technique and site rotation reduce the risk of lipohypertrophy and promote consistent absorption.
Critical Alerts	High Alert: High risk if confused with other insulins – verify product name (Lantus vs Humalog, etc.). Overdose causes prolonged hypoglycemia (difficult to manage due to long duration).

39. Metformin

Generic & Brand Name	Metformin (Glucophage)
Drug Class	Biguanide (oral antidiabetic)
Mechanism of Action	Decreases hepatic gluconeogenesis (glucose production) and increases insulin sensitivity in muscles; also mildly reduces GI glucose absorption.
Key Nursing Considerations	First-Line Agent for Type 2 Diabetes. Commonly prescribed as initial therapy due to efficacy, safety, and low hypoglycemia risk. Administer With Meals. Reduces gastrointestinal side effects such as nausea and diarrhea, which are typically transient. No Hypoglycemia Risk Alone. Does not stimulate insulin secretion; may promote mild weight loss. Temporarily Discontinue for IV Contrast. Hold before and for 48 hours after contrast imaging to reduce risk of lactic acidosis. Assess Renal Function Regularly. Contraindicated in significant renal impairment; monitor GFR to prevent drug accumulation. Monitor for Lactic Acidosis Symptoms. Educate patients to report signs like malaise, hyperventilation, or drowsiness. Limit Alcohol Intake. Excessive alcohol can increase the risk of lactic acidosis when combined with this medication.
Critical Alerts	Black Box Warning. Discontinue if lactic acidosis is suspected. Symptoms include malaise, myalgias, respiratory distress, and somnolence, requiring immediate evaluation. Use with caution in hepatic or renal impairment. These conditions elevate the risk of drug accumulation and metabolic complications.

40. Glipizide

Generic & Brand Name	Glipizide (Glucotrol)
Drug Class	Sulfonylurea (oral hypoglycemic)
Mechanism of Action	Stimulates pancreatic beta cells to release insulin (also increases insulin sensitivity somewhat).
Key Nursing Considerations	Administer before meals. Best taken 30 minutes prior to meals, once or twice daily for maximum absorption. Monitor for signs of hypoglycemia. Symptoms such as shakiness, diaphoresis, and confusion require immediate treatment with fast-acting carbohydrates. Avoid use in patients with sulfa allergy. Hypersensitivity reactions may occur due to structural similarity with sulfonamide antibiotics. Assess renal and hepatic function periodically. Impaired metabolism or clearance can increase the risk of prolonged hypoglycemia. Teach the patient about alcohol interaction. Alcohol can potentiate hypoglycemic effects or cause disulfiram-like reactions with sulfonylureas.
Critical Alerts	Do not use in type 1 diabetes or during diabetic ketoacidosis. Ineffective in patients without endogenous insulin production and may delay appropriate emergency treatment. Recommend medical identification. Patients should wear a medical ID indicating sulfonylurea use due to risk of severe hypoglycemia. Increased risk of hypoglycemia in elderly or malnourished patients. Initiate at lower doses and monitor closely to prevent severe hypoglycemic episodes.

41. Glucagon

Generic & Brand Name	Glucagon (GlucaGen)
Drug Class	Hyperglycemic agent (pancreatic hormone)
Mechanism of Action	Reverse severe hypoglycemia by promoting hepatic glucose release. Glucagon is a hyperglycemic agent that increases blood glucose by stimulating glycogenolysis and gluconeogenesis in the liver.
Key Nursing Considerations	Administer intramuscularly or subcutaneously during hypoglycemic emergencies. It is used when oral or IV glucose is not feasible, especially in unconscious patients. Turn the patient on their side post-injection. Nausea and vomiting are common; this position helps prevent aspiration during recovery. Teach the significant others/caregivers how to properly use the emergency kit. Timely administration by trained individuals can be life-saving in out-of-hospital settings. Reinforce the need for follow-up carbohydrate intake. Once alerted, the patient should consume oral carbohydrates to restore glycogen stores and prevent recurrence.
Critical Alerts	Caution: Do not use in pheochromocytoma or insulinoma. Glucagon can precipitate excessive catecholamine or insulin release, leading to hypertensive crisis or hypoglycemia rebound. Monitor for allergic reactions or anaphylaxis. Though rare, hypersensitivity can occur and requires prompt intervention.

Thyroid & Hormonal Agents

42. Levothyroxine

Generic & Brand Name	Levothyroxine (Synthroid)
Drug Class	Thyroid hormone (T4 replacement)
Mechanism of Action	Synthetic form of thyroxine (T4), which is converted to active T3 in the body; restores normal thyroid levels (increases metabolic rate).
Key Nursing Considerations	Administer on an empty stomach, 30 to 60 minutes before breakfast. Proper timing maximizes absorption and promotes consistent therapeutic effect. Monitor TSH and free T4 levels regularly. Laboratory monitoring is needed for dose titration and assessing treatment efficacy. Teach patients to avoid iron, calcium, and antacids near dosing. These substances interfere with absorption and may reduce drug effectiveness. Observe for signs of overdose or undertreatment. Symptoms such as palpitations, anxiety, or weight loss suggest overreplacement, while fatigue and cold intolerance indicate underdosing.
Critical Alerts	Caution: Excess doses cause atrial fibrillation or osteoporosis over time. In acute overdose, thyrotoxicosis symptoms can be life-threatening (treat supportively – no specific antidote). Advise consistent adherence. Skipping doses can lead to myxedema coma in severe cases. Do not use for weight loss in euthyroid patients. High doses may cause life-threatening cardiac effects and are not indicated for obesity management.

43. Propylthiouracil (PTU)

Generic & Brand Name	Propylthiouracil (PTU)
Drug Class	Thionamide (antithyroid)
Mechanism of Action	Suppress thyroid hormone synthesis in hyperthyroidism. Propylthiouracil inhibits thyroid peroxidase, reducing the production of T3 and T4, and also blocks peripheral conversion of T4 to T3.
Key Nursing Considerations	Administer at consistent times each day. Regular dosing maintains therapeutic hormone suppression and stabilizes thyroid function. Monitor thyroid function tests and liver enzymes regularly. Long-term use requires close observation for efficacy and hepatic safety. Instruct patients to report signs of infection. PTU may cause agranulocytosis, presenting with fever or sore throat and requiring immediate evaluation. Avoid abrupt discontinuation. Sudden withdrawal can cause a rebound hyperthyroid state and may precipitate thyroid storm.
Critical Alerts	Black Box: Risk of severe liver injury and acute liver failure. Monitor liver function closely, especially in the first six months of therapy, and discontinue if hepatic dysfunction develops. Contraindicated in early pregnancy unless no alternative is available. PTU crosses the placenta and is associated with fetal hepatotoxicity; use only when benefits outweigh risks.

44. Desmopressin (DDAVP)

Generic & Brand Name	Desmopressin (DDAVP)
Drug Class	Antidiuretic hormone analog
Mechanism of Action	Synthetic analog of ADH (vasopressin) enhances water reabsorption in kidneys (collecting ducts) and concentrates urine; it also raises plasma Factor VIII/von Willebrand factor.
Key Nursing Considerations	Administer orally, intranasally, or parenterally as prescribed. The route depends on the indication and patient condition, with intranasal preferred for enuresis and parenteral for acute DI. Monitor serum sodium and fluid status closely. Desmopressin can cause water retention and dilutional hyponatremia, especially in the elderly or those with excessive fluid intake. Advice on fluid restriction. Patients should avoid excessive fluid intake to reduce the risk of hyponatremia and associated complications. Assess for headache, nausea, and behavioral changes. These may indicate hyponatremia or water intoxication and require prompt intervention.
Critical Alerts	High Alert: Risk of hyponatremia and seizures due to water intoxication. Monitor serum electrolytes and educate patients and significant others to recognize early signs of water retention or neurologic changes. Use cautiously in patients with cardiovascular disease or hypertension. Fluid shifts may exacerbate volume overload and lead to cardiac complications.

Corticosteroids

45. Prednisone

Generic & Brand Name	Prednisone (Deltasone)
Drug Class	Glucocorticoid (systemic corticosteroid)
Mechanism of Action	Suppresses inflammation and the immune response by binding to glucocorticoid receptors, altering gene expression (↓ cytokines, prostaglandins, etc.). Also increases gluconeogenesis and protein/fat metabolism.
Key Nursing Considerations	Administer with food to reduce gastric irritation. Corticosteroids can cause gastrointestinal discomfort and increase the risk of ulcers. Taper doses gradually when discontinuing. Abrupt withdrawal may lead to adrenal insufficiency due to suppression of the hypothalamic-pituitary-adrenal axis. Monitor for hyperglycemia, fluid retention, and mood changes. Long-term use is associated with metabolic changes and psychological effects. Teach patients about infection risk. Prednisone suppresses immune function, making patients more susceptible to infections. Encourage bone health measures and regular eye exams (cataract risk) if long-term. Long-term prednisone weakens bones, so calcium, vitamin D, and weight-bearing exercise help prevent osteoporosis. It can also cause cataracts and glaucoma.
Critical Alerts	High-Alert (Caution): Prolonged high-dose use can cause adrenal suppression and Cushingoid features. Monitor for signs such as moon face, buffalo hump, and muscle wasting. Use cautiously in patients with diabetes, hypertension, or peptic ulcer disease. Steroids can exacerbate these conditions and require close monitoring.

46. Fludrocortisone

Generic & Brand Name	Fludrocortisone (Florinef)
Drug Class	Mineralocorticoid
Mechanism of Action	Synthetic aldosterone analog: promotes sodium and water reabsorption in the distal tubules and potassium excretion, helping maintain blood pressure and salt balance.
Key Nursing Considerations	Monitor blood pressure and electrolyte levels closely. The drug promotes sodium retention and potassium excretion, increasing the risk of hypertension and hypokalemia. Advise patients to report signs of fluid overload. Rapid weight gain, edema, and shortness of breath may indicate excessive sodium retention requiring dose adjustment. Administer with food to minimize gastric discomfort. Like other corticosteroids, fludrocortisone may irritate the GI tract. Encourage consistent follow-up and lab monitoring. To maintain safety, serum electrolytes, renal function, and blood pressure must be routinely assessed.
Critical Alerts	Caution: Use with caution in patients with heart failure, renal disease, or hypertension. Fluid retention may exacerbate these conditions and lead to decompensation. Abrupt discontinuation may precipitate adrenal crisis. Always taper the dose as directed and reinforce adherence to prescribed dosing.

Bone Health/Uric Acid Medications

47. Alendronate

Generic & Brand Name	Alendronate (Fosamax)
Drug Class	Bisphosphonate (Bone resorption inhibitor)
Mechanism of Action	Alendronate inhibits osteoclast-mediated bone resorption, thereby increasing bone mineral density. It helps slow the rate of bone loss and is primarily used in the treatment and prevention of osteoporosis in postmenopausal women and men.
Key Nursing Considerations	Administer on an empty stomach with a full glass of water. Maximum absorption occurs in the fasting state, and coadministration with food severely reduces efficacy. Keep the patient upright for at least 30 minutes after taking the medication. This prevents esophageal irritation and ulceration, a known complication with oral bisphosphonates. Advise patients about the importance of adherence. Consistent weekly or daily dosing is essential to maintaining therapeutic benefit and fracture prevention. Encourage adequate calcium and vitamin D intake. Bone health depends on sufficient nutrient levels alongside bisphosphonate therapy.
Critical Alerts	Contraindicated in patients with esophageal disorders, delayed gastric emptying, or inability to sit upright. These conditions heighten the risk of esophageal injury. Immediately report thigh or jaw pain. Monitor for signs of atypical femur fractures or osteonecrosis of the jaw, especially in long-term users or those undergoing dental surgery.

48. Allopurinol

Generic & Brand Name	Allopurinol (Zyloprim, Aloprim)
Drug Class	Xanthine Oxidase Inhibitor (Antigout agent)
Mechanism of Action	Allopurinol inhibits the enzyme xanthine oxidase, which is responsible for the conversion of hypoxanthine to uric acid. This action lowers serum and urinary uric acid levels, helping prevent gout attacks and uric acid nephropathy, especially during cancer treatment (tumor lysis syndrome).
Key Nursing Considerations	Initiate therapy after the acute attack resolution. Starting during an active flare may worsen symptoms due to rapid urate mobilization. Monitor renal function and uric acid levels regularly. Dose adjustments are necessary in renal impairment to avoid accumulation and toxicity. Encourage increased fluid intake. Adequate hydration helps prevent kidney stone formation and supports urate excretion. Teach patients to report skin rashes immediately. Hypersensitivity reactions, including Stevens-Johnson syndrome, may occur and require urgent evaluation.
Critical Alerts	Discontinue immediately if signs of serious skin or hypersensitivity reactions develop. Allopurinol carries a risk of serious hypersensitivity reactions, including Stevens-Johnson syndrome and toxic epidermal necrolysis, particularly in individuals of Asian descent with the HLA-B*5801 allele. Immediate discontinuation is required at the first sign of rash.

Gastrointestinal Medications

49. Omeprazole

Generic & Brand Name	Omeprazole (Prilosec)
Drug Class	Proton pump inhibitor (PPI)
Mechanism of Action	Irreversibly inhibits H⁺/K⁺-ATPase pump in gastric parietal cells, dramatically reducing acid secretion (both basal and stimulated).
Key Nursing Considerations	Administer before meals, preferably in the morning. Maximum effectiveness occurs when taken before food stimulates acid secretion. Monitor for magnesium deficiency and B12 levels with prolonged use. Long-term therapy may impair absorption and lead to deficiencies. Teach patients to avoid abrupt discontinuation. Stopping suddenly can cause rebound acid hypersecretion and recurrence of symptoms.
Critical Alerts	Caution: Be cautious with concurrent clopidogrel use. Omeprazole may reduce clopidogrel’s antiplatelet effect and increase risk of thrombosis. Prolonged use may increase the risk of C. difficile infection and bone fractures, especially in elderly or hospitalized patients. Use the lowest effective dose for the shortest duration necessary.

50. Famotidine

Generic & Brand Name	Famotidine (Pepcid)
Drug Class	H2 blocker (antacid)
Mechanism of Action	Blocks H2 histamine receptors on gastric parietal cells, decreasing acid secretion, especially at night.
Key Nursing Considerations	Administer with or without food as prescribed. It reduces gastric acid production and is effective at both meal and basal acid levels. Monitor renal function, especially in older adults. Famotidine is excreted renally and may accumulate, increasing the risk of CNS effects such as confusion. Assess for improvement in GI symptoms. Continued discomfort may indicate underlying complications or the need for further diagnostic evaluation. Advise patients to avoid NSAIDs and irritants. Reducing gastric irritants supports ulcer healing and prevents recurrence.
Critical Alerts	Caution: Watch for rare bradycardia/hypotension. If administered rapidly via IV, push for at least more than 2 minutes. Use with caution and adjust dosing accordingly. High-dose or prolonged use in renal impairment may increase the risk of QT prolongation and CNS side effects, particularly in the elderly.

51. Docusate

Generic & Brand Name	Docusate (Colace)
Drug Class	Stool softener (emollient laxative)
Mechanism of Action	Surfactant: Lowers surface tension of stool, allowing water and fats to penetrate and soften fecal mass.
Key Nursing Considerations	Administer with a full glass of water. Adequate hydration enhances its effectiveness in softening stools and preventing constipation. Use for prevention, not active constipation relief. It is not a stimulant laxative and is best used to maintain regularity rather than for rapid bowel evacuation. Monitor bowel patterns and consistency. Prolonged use may indicate an underlying issue or lead to dependence if misused. Advise patients to avoid straining during defecation. Especially important for patients with cardiovascular conditions, rectal surgery, or hemorrhoids.
Critical Alerts	Caution: Overuse can cause dependence on laxatives over time. Use only as needed to maintain soft stools. Do not use with mineral oil, as it may increase systemic absorption and the risk of lipid pneumonia. Due to its sodium content, use caution in patients on sodium-restricted diets.

52. Lactulose

Generic & Brand Name	Lactulose (Kristalose)
Drug Class	Osmotic laxative (disaccharide)
Mechanism of Action	Synthetic sugar not absorbed well: draws water into colon (osmotic effect) to soften stool; also acidifies colon, converting ammonia to ammonium, which is trapped and excreted (useful in hepatic encephalopathy)
Key Nursing Considerations	Titrate the dose based on the number of stools. For maximum effect, aim for 2–3 soft bowel movements daily in patients with hepatic encephalopathy. Assess for signs of electrolyte imbalance. Prolonged use or excessive dosing may cause dehydration, hypokalemia, or hypernatremia. Encourage adequate fluid intake. Hydration helps prevent dehydration and enhances therapeutic action. Monitor ammonia levels and mental status in liver patients. Improved alertness indicates effectiveness in reducing ammonia in hepatic encephalopathy.
Critical Alerts	Caution: If given rectally, watch for distention/cramping. If possible, have the patient retain the enema for 30–60 minutes for effect. Use with caution in diabetic patients due to the potential for hyperglycemia. Avoid excessive dosing to prevent diarrhea-related complications such as dehydration or electrolyte imbalance.

53. Loperamide

Generic & Brand Name	Loperamide (Imodium)
Drug Class	Antidiarrheal (opioid analog)
Mechanism of Action	Opioid agonist acting on gut mu-receptors – slows intestinal motility and increases fluid absorption by allowing more transit time. Does not cross BBB significantly (no analgesic effect).
Key Nursing Considerations	Monitor frequency and consistency of stools. Evaluate effectiveness and identify any signs of constipation or ileus. Use with caution in infectious diarrhea. Avoid in cases caused by invasive organisms or pseudomembranous colitis, as it may worsen outcomes by delaying toxin clearance. Assess for signs of dehydration. Encourage oral rehydration to prevent fluid and electrolyte imbalance in patients with ongoing diarrhea. Teach patients proper dosing and duration. Advise against exceeding recommended doses, especially in children or the elderly.
Critical Alerts	Black Box (High doses): Risk of torsades de pointes and sudden death with abuse or overdose (FDA warning). Some individuals misuse high doses to achieve opioid effects. Otherwise, at normal doses, it is not high-alert. Do not use in children under 2 years due to risk of serious cardiac events. High doses may cause QT prolongation, arrhythmias, or central nervous system depression.

54. Ondansetron

Generic & Brand Name	Ondansetron (Zofran)
Drug Class	Antiemetic (5-HT3 antagonist)
Mechanism of Action	Block serotonin receptors to control nausea. Ondansetron selectively inhibits 5-HT3 receptors in the central nervous system and gastrointestinal tract to reduce chemotherapy or postoperative-induced nausea and vomiting.
Key Nursing Considerations	Monitor for QT interval prolongation. Assess ECG in patients with cardiac history or those receiving other QT-prolonging agents. Watch for signs of serotonin syndrome. Be cautious when used with other serotonergic drugs, especially SSRIs or SNRIs. Assess bowel patterns and hydration. Constipation or diarrhea may occur; monitor for dehydration in patients with persistent GI symptoms. Administer 30 minutes before chemotherapy. For postoperative patients, follow timing protocols for maximum antiemetic effect.
Critical Alerts	Caution: Serotonin syndrome is possible if combined with other serotonergic agents. Rare, but watch if patient on SSRIs, etc..). Be aware of the potential for masking progressive ileus. If no output, treat the underlying issue rather than just blocking vomit. May cause dose-dependent QT prolongation and torsades de pointes. Avoid in patients with congenital long QT syndrome or those on high-risk QT-prolonging medications.

55. Metoclopramide

Generic & Brand Name	Metoclopramide (Reglan)
Drug Class	Prokinetic/Antiemetic
Mechanism of Action	Dopamine-2 receptor antagonist (and some 5-HT agonism) – increases GI motility (promotes gastric emptying, intestinal transit) and raises lower esophageal sphincter tone; also has antiemetic effect via CTZ dopamine blockade.
Key Nursing Considerations	Monitor for extrapyramidal symptoms. Assess for involuntary movements, especially in high doses or prolonged use. Evaluate mental status changes. Can cause drowsiness, agitation, or depression, particularly in older adults. Avoid use in bowel obstruction or perforation. GI stimulation may worsen mechanical obstruction or a perforated gut. Administer 30 minutes before meals and at bedtime. This optimizes its prokinetic effect in patients with gastroparesis.
Critical Alerts	Black Box: May cause tardive dyskinesia with long-term use. Avoid therapy beyond 12 weeks unless benefits outweigh risks; symptoms may be irreversible. High Alert: Hold the dose and inform the physician if a patient develops extrapyramidal side effects. May cause acute dystonic reactions, akathisia, and Parkinsonian symptoms, particularly in younger adults and children. Watch out for neuroleptic malignant syndrome. Rare but life-threatening; symptoms include hyperthermia, muscle rigidity, altered mental status, and autonomic instability.

56. Pancrelipase

Generic & Brand Name	Pancrelipase (Creon)
Drug Class	Pancreatic enzyme supplement
Mechanism of Action	Improves digestion with enzyme replacement. Pancrelipase contains lipase, protease, and amylase to aid digestion in patients with pancreatic insufficiency, such as cystic fibrosis or chronic pancreatitis.
Key Nursing Considerations	Administer with meals or snacks. Capsules should be taken with food to mimic regular pancreatic enzyme release and improve nutrient absorption. Monitor nutritional status and growth. Assess weight, height, and fat-soluble vitamin levels regularly to confirm adequate therapeutic response. Advise on swallowing whole. Instruct patients not to crush or chew enteric-coated forms to avoid oral mucosa irritation or enzyme inactivation. Assess for allergic reactions. Contains porcine-derived proteins, which may cause hypersensitivity in some individuals.
Critical Alerts	Caution: Avoid use in patients with pork allergies. May trigger severe allergic reactions in those sensitive to animal-derived products. Monitor for fibrosing colonopathy. High doses, especially in children with cystic fibrosis, may increase the risk of this rare but serious GI complication.

57. Sulfasalazine

Generic & Brand Name	Sulfasalazine (Azulfidine)
Drug Class	Aminosalicylate (5-ASA anti-inflammatory)
Mechanism of Action	Colon-targeted anti-inflammatory: colonic bacteria split sulfasalazine into 5-ASA (mesalamine) and sulfapyridine. 5-ASA acts locally in the colon to reduce inflammation (via COX and lipoxygenase inhibition).
Key Nursing Considerations	Assess for sulfa allergy before administration. Hypersensitivity reactions can range from mild rashes to life-threatening Stevens-Johnson syndrome. Encourage fluid intake. Adequate hydration helps prevent crystalluria and kidney stone formation. Monitor complete blood count regularly. Sulfasalazine can cause bone marrow suppression, particularly with long-term use. Educate on orange-yellow discoloration. Patients should be informed that the medication may turn urine or skin a yellow-orange color, which is harmless. Supplement with folic acid. The drug can impair folate absorption, increasing the risk of anemia in some patients.
Critical Alerts	Caution: Discontinue if signs of bone marrow suppression or severe rash appear. Early recognition of serious adverse effects like agranulocytosis or toxic epidermal necrolysis helps protect patient safety.

Antibiotics/Antimicrobials

58. Amoxicillin

Generic & Brand Name	Amoxicillin (Amoxil)
Drug Class	Penicillin (aminopenicillin)
Mechanism of Action	Target bacterial cell wall synthesis. Amoxicillin inhibits bacterial cell wall formation, leading to lysis and death; it is widely used for respiratory, urinary, and skin infections.
Key Nursing Considerations	Assess for penicillin allergy. Cross-reactivity with other beta-lactams may cause severe allergic reactions, including anaphylaxis. Administer with food if GI upset occurs. Though well absorbed orally, taking it with meals may reduce nausea and increase tolerance. Monitor for signs of superinfection. Prolonged use may lead to yeast overgrowth or C. difficile–associated diarrhea. Instruct the patient to complete the full course. Incomplete treatment may lead to antibiotic resistance and treatment failure.
Critical Alerts	Caution: Discontinue immediately if a hypersensitivity reaction occurs. Anaphylaxis or severe skin rash requires emergency intervention and permanent avoidance of penicillin-class drugs.

59. Ceftriaxone

Generic & Brand Name	Ceftriaxone (Rocephin)
Drug Class	Cephalosporin antibiotic (3rd gen)
Mechanism of Action	Target bacterial wall integrity with broad coverage. Ceftriaxone disrupts bacterial cell wall synthesis, making it effective against many gram-negative and some gram-positive organisms.
Key Nursing Considerations	Screen for penicillin allergy before administration. Although cross-reactivity is lower than with earlier cephalosporins, patients with a severe penicillin allergy may be at risk for hypersensitivity. Rotate IM injection sites and reconstitute with lidocaine if needed. IM use can be painful; lidocaine may reduce discomfort unless contraindicated. Monitor liver function tests and bilirubin levels. Ceftriaxone can cause biliary sludge and cholestasis, particularly in neonates and those with liver impairment. Avoid calcium-containing IV solutions in neonates. Concomitant use with calcium can cause life-threatening precipitates in the lungs or kidneys. Advise the patient on full course adherence. Skipping doses or stopping early increases the risk of resistance and treatment failure.
Critical Alerts	Caution: High-dose or long-term use can significantly alter gut flora. Monitor for C. difficile-associated diarrhea. Do not administer calcium-containing IV products to neonates. Risk of fatal calcium-ceftriaxone precipitation mandates strict adherence to compatibility guidelines.

60. Vancomycin

Generic & Brand Name	Vancomycin (Vancocin)
Drug Class	Glycopeptide antibiotic
Mechanism of Action	Inhibits cell wall synthesis by binding peptidoglycan precursors (D-Ala-D-Ala), preventing bacterial cell wall formation (bactericidal against Gram+ like MRSA).
Key Nursing Considerations	Monitor trough levels consistently. Trough levels guide therapeutic dosing and prevent toxicity—draw 30 minutes before the fourth dose or per institutional protocol. Assess for nephrotoxicity and ototoxicity. Monitor BUN, creatinine, and hearing, especially in older adults or those receiving concurrent nephrotoxic drugs. Administer via IV infusion over at least 60 minutes. Rapid infusion can trigger red man syndrome, a histamine-mediated reaction with flushing and hypotension. Use central lines for long-term therapy when possible. Vancomycin is a vesicant and can cause phlebitis or tissue injury with peripheral IV use. Report persistent fever or lack of clinical improvement. Treatment failure or resistant organisms may require ID consultation or regimen adjustment.
Critical Alerts	High Alert (Caution): Do not administer rapidly. Infusing faster than recommended increases the risk of red man syndrome. Closely monitor kidney function. Vancomycin-associated nephrotoxicity is dose-related and may be irreversible if unrecognized.

61. Doxycycline

Generic & Brand Name	Doxycycline (Vibramycin)
Drug Class	Tetracycline antibiotic
Mechanism of Action	Binds 30S ribosomal subunit in bacteria, preventing protein synthesis (bacteriostatic). Broad-spectrum against atypicals, tick-borne diseases, MRSA skin infections, etc.
Key Nursing Considerations	Avoid giving with dairy, antacids, or iron. These interfere with absorption and reduce drug effectiveness; administer 1–2 hours apart from such products. Protect patients from photosensitivity. Advise the use of sun protection, as doxycycline can cause heightened sensitivity to sunlight and increase the risk of severe sunburn. Monitor for gastrointestinal irritation. Take with a full glass of water and remain upright for 30 minutes to reduce esophageal irritation or ulceration. Use caution in children and pregnancy. Doxycycline can cause permanent tooth discoloration and inhibit bone growth in children under eight and the fetus. Inform on the potential for yeast infections. Disruption of normal flora may lead to candidiasis, especially with prolonged use.
Critical Alerts	Caution: Do not use in pregnancy or in children under 8. The risk of fetal harm and developmental issues makes doxycycline contraindicated in these populations unless the benefits outweigh the risks. Discontinue immediately with signs of intracranial hypertension. Headache or visual disturbances may indicate this rare but serious complication.

62. Azithromycin

Generic & Brand Name	Azithromycin (Zithromax)
Drug Class	Macrolide antibiotic
Mechanism of Action	Inhibit protein synthesis to halt bacterial growth. Azithromycin binds to the 50S ribosomal subunit, making it effective for respiratory infections, skin infections, and certain STIs including chlamydia.
Key Nursing Considerations	Administer with food if GI upset occurs. Macrolides commonly cause nausea or abdominal pain, and food can reduce these symptoms. Monitor for QT prolongation. Use caution in patients with existing arrhythmias or those on other QT-prolonging agents. Avoid coadministration with aluminum- or magnesium-containing antacids. These can interfere with azithromycin absorption and reduce efficacy. Teach patients on proper Z-Pak dosing. The standard regimen is 500 mg on day 1, followed by 250 mg daily for four days. Instruct the patient to report palpitations or dizziness. These may be signs of serious cardiac adverse effects requiring immediate evaluation.
Critical Alerts	Caution: Use with caution in hepatic impairment. Azithromycin may cause transient elevations in liver enzymes or rare hepatotoxicity, especially with prolonged use. Discontinue immediately if symptoms of arrhythmia develop. QT prolongation can precipitate torsades de pointes in high-risk patients.

63. Gentamicin

Generic & Brand Name	Gentamicin (Garamycin)
Drug Class	Aminoglycoside antibiotic
Mechanism of Action	Binds 30S ribosome, causing misreading of mRNA and halting protein synthesis (bactericidal). Excellent Gram– activity; synergy with β-lactams for some Gram+.
Key Nursing Considerations	Monitor peak and trough levels to reach the therapeutic range. Gentamicin requires serum concentration monitoring to avoid toxicity and confirm effective dosing. Assess renal function before and during therapy. This drug is nephrotoxic; monitor BUN and creatinine regularly and encourage adequate hydration. Observe for signs of ototoxicity. Tinnitus, vertigo, or hearing loss may indicate early cochlear or vestibular damage and should be reported immediately. Avoid mixing with penicillins in IV lines. Incompatibility can inactivate both drugs; administer separately using different IV sites or times. Adjust dosing in renal impairment. Gentamicin clearance is decreased in patients with kidney dysfunction, increasing the risk of toxicity. Advise the patient on adherence to topical forms. Use as prescribed for eye or ear drops and complete the course to prevent resistance or recurrence.
Critical Alerts	High Alert: Risk for irreversible hearing loss and renal damage. Prolonged high trough levels or preexisting renal impairment increase toxicity risk—discontinue if signs emerge. Neuromuscular blockade is a rare side effect. Watch if the patient is also on muscle relaxants or has neuromuscular disease.

64. Trimethoprim–Sulfamethoxazole

Generic & Brand Name	Trimethoprim–Sulfamethoxazole (Bactrim)
Drug Class	Sulfonamide combo antibiotic
Mechanism of Action	Synergistic folate antagonists: SMX inhibits folic acid synthesis (dihydropteroate synthase); TMP inhibits dihydrofolate reductase. Combined effect is bactericidal.
Key Nursing Considerations	Monitor for sulfa allergy reactions. Trimethoprim–sulfamethoxazole is contraindicated in patients with known sulfonamide hypersensitivity due to the risk of severe rash or anaphylaxis. Promote hydration to prevent crystalluria. Encourage fluid intake to lessen the risk of kidney stones and promote drug excretion. Monitor for hematologic toxicity during long-term use. Periodic CBCs are needed, as the drug can cause bone marrow suppression and anemia. Assess renal function before initiating therapy. Impaired renal function requires dose adjustment to avoid accumulation and toxicity. Stress the importance of sun protection. Photosensitivity is a common side effect—advise patients to use sunscreen and avoid prolonged sun exposure. Monitor potassium and creatinine levels. Hyperkalemia and elevated creatinine may occur, especially in patients with renal impairment or those taking ACE inhibitors or ARBs. Caution in late pregnancy and neonates. Avoid use near term or in infants under two months due to the risk of kernicterus from bilirubin displacement.
Critical Alerts	Caution: May cause Stevens-Johnson syndrome or toxic epidermal necrolysis. Discontinue immediately if rash, mucosal lesions, or systemic symptoms occur.

65. Ciprofloxacin

Generic & Brand Name	Ciprofloxacin (Cipro)
Drug Class	Fluoroquinolone antibiotic
Mechanism of Action	Inhibits DNA gyrase and topoisomerase IV, preventing bacterial DNA replication (bactericidal). Broad Gram– coverage; newer gen have more Gram+.
Key Nursing Considerations	Monitor for tendon inflammation or rupture. Ciprofloxacin can increase the risk of tendinopathy, especially in older adults and those on corticosteroids. Encourage hydration to prevent crystalluria. Adequate fluid intake supports renal clearance and lessens the risk of kidney stone formation. Assess for signs of peripheral neuropathy. Patients should report burning, tingling, or weakness, which may be irreversible if not addressed early. Avoid concurrent use with antacids or supplements. Calcium, magnesium, aluminum, or iron can reduce ciprofloxacin absorption—space doses by at least 2 hours. Monitor for CNS effects in older adults. May cause dizziness, confusion, or seizures, particularly in patients with renal impairment or a history of seizures. Teach children to avoid sun exposure. Photosensitivity is a potential side effect, so use sunscreen and wear protective clothing outdoors.
Critical Alerts	Black Box: May cause QT prolongation. Use caution in patients with cardiac conditions or those on other QT-prolonging drugs. Risk of disabling and potentially permanent adverse effects involving tendons, muscles, joints, nerves, and CNS. Discontinue if symptoms appear.

66. Metronidazole

Generic & Brand Name	Metronidazole (Flagyl)
Drug Class	Nitroimidazole antibiotic/antiprotozoal
Mechanism of Action	Disrupts DNA structure after reduction by anaerobes/protozoa, leading to cell death. Effective against anaerobic bacteria and certain protozoa.
Key Nursing Considerations	Assess for neurotoxicity with prolonged use. Monitor for signs of peripheral neuropathy, such as numbness or tingling, especially during extended therapy. Avoid alcohol during and after therapy. Disulfiram-like reaction may occur with alcohol consumption—teach patients to abstain for at least 48 hours after the last dose. Monitor for GI side effects. Nausea, metallic taste, and abdominal discomfort are common but typically self-limiting. Administer with food if GI upset occurs. Taking metronidazole with meals can improve tolerance and decrease nausea. Watch for signs of superinfection. Long-term or repeated use may result in fungal or bacterial overgrowth—report oral thrush or vaginal itching. Inform on potential urine discoloration. Darkening of urine is harmless and expected, but should still be explained to avoid alarm.
Critical Alerts	Caution: Carcinogenic risk. Metronidazole is carcinogenic in animal studies; avoid unnecessary long-term use. Use with caution in patients with blood dyscrasias. Rare but serious hematologic effects, such as leukopenia, may occur.

67. Isoniazid (INH)

Generic & Brand Name	Isoniazid (INH)
Drug Class	Antitubercular (antibiotic)
Mechanism of Action	Inhibits synthesis of mycolic acids in Mycobacterium tuberculosis cell walls (bactericidal to rapidly dividing TB bacilli).
Key Nursing Considerations	Monitor hepatic function throughout therapy. Isoniazid carries a risk of hepatotoxicity; assess liver enzymes regularly and watch for jaundice, fatigue, or dark urine. Administer pyridoxine (vitamin B6) supplementation. Prevent peripheral neuropathy by co-administering B6, especially in malnourished, alcoholic, or diabetic patients. Instruct on consistent daily dosing. Emphasize adherence to the prescribed duration and schedule to avoid drug resistance and treatment failure. Avoid alcohol and hepatotoxic drugs. Combining INH with alcohol or other liver-damaging medications increases the risk of severe liver injury. Teach the patient about the early signs of neuropathy. Instruct patients to report numbness, tingling, or burning in the hands or feet promptly. Assess for drug interactions. INH can interact with phenytoin, carbamazepine, and other CYP450 substrates, increasing their toxicity risk.
Critical Alerts	Black Box: Severe and sometimes fatal hepatitis. Monitor closely during the first three months, especially in patients over 35, those with preexisting liver disease, or alcohol users.

68. Rifampin

Generic & Brand Name	Rifampin (Rifadin)
Drug Class	Antitubercular antibiotic (Rifamycin)
Mechanism of Action	Inhibits DNA-dependent RNA polymerase in bacteria, suppressing RNA and protein synthesis. Bactericidal against Mycobacterium tuberculosis and others.
Key Nursing Considerations	Assess for liver toxicity throughout therapy. Rifampicin can cause hepatotoxicity; monitor liver function tests and teach patients to report signs like jaundice or dark urine. Use additional contraception if on hormonal birth control. Rifampicin is a potent CYP450 inducer and can lessen the efficacy of oral contraceptives. Inform about harmless body fluid discoloration. Urine, sweat, tears, and saliva may turn orange-red, which is expected and not harmful. Promote adherence to the complete TB regimen. Incomplete therapy can lead to drug resistance and treatment failure. Reinforce the importance of strict compliance. Avoid alcohol during treatment. Combining with alcohol heightens the risk of liver damage and worsens side effects. Monitor for flu-like symptoms. Intermittent dosing may trigger fever, chills, and muscle aches; evaluate if symptoms persist.
Critical Alerts	Black box: None officially designated, but caution is warranted due to significant hepatotoxic risk and potential for serious drug interactions.

Antifungal & Antiviral Agents

69. Fluconazole

Generic & Brand Name	Fluconazole (Diflucan)
Drug Class	Azole antifungal
Mechanism of Action	Inhibits fungal ergosterol synthesis by blocking the enzyme 14-α-demethylase (a CYP450 enzyme), damaging fungal cell membrane integrity.
Key Nursing Considerations	Monitor liver function during prolonged use. Fluconazole carries a risk of hepatotoxicity, particularly with extended treatment; check LFTs regularly and teach patients to report signs like jaundice or fatigue. Watch for QT interval prolongation. This antifungal can cause cardiac arrhythmias in susceptible patients; use caution in those with preexisting cardiac conditions or on QT-prolonging drugs. Avoid use in pregnancy unless needed. High doses, especially in the first trimester, may increase the risk of birth defects. Adjust dosage in renal impairment. Fluconazole is renally excreted; dose adjustments are necessary to prevent accumulation and toxicity. Be alert for signs of Stevens-Johnson syndrome. Though rare, fluconazole may cause severe cutaneous reactions; discontinue immediately if rash, blistering, or mucosal involvement appears.
Critical Alerts	Caution: None officially designated, but severe hepatotoxicity and serious skin reactions (including Stevens-Johnson syndrome) require close monitoring and immediate intervention if suspected.

70. Acyclovir

Generic & Brand Name	Acyclovir (Zovirax)
Drug Class	Antiviral (anti-herpes)
Mechanism of Action	Guanosine analog: after activation by viral thymidine kinase, it incorporates into viral DNA, causing chain termination; selectively inhibits herpes viral DNA polymerase.
Key Nursing Considerations	Administer acyclovir promptly at the onset of symptoms. Early use of acyclovir improves its effectiveness in controlling viral replication and lowering outbreak severity. Encourage hydration during therapy. Adequate fluid intake helps prevent crystal-induced nephropathy, a known risk with IV or high-dose oral use. Adjust dosage in renal impairment. Acyclovir is excreted renally; dose adjustments are required to avoid toxicity in patients with decreased kidney function. Monitor for signs of CNS toxicity in high-risk populations. Confusion, tremors, and hallucinations may occur, especially in elderly or renally impaired patients. Use caution with concurrent nephrotoxic drugs. Combining acyclovir with other nephrotoxic agents may increase the risk of renal damage; monitor renal function closely.
Critical Alerts	Caution: No official black box warning, but renal toxicity and neurotoxicity are critical risks requiring dose adjustment and careful monitoring, particularly in older adults and those with kidney impairment.

Psychiatric Medications

71. Fluoxetine (Prozac)

Generic & Brand Name	66. Fluoxetine (Prozac)
Drug Class	SSRI (antidepressant)
Mechanism of Action	Selectively inhibits reuptake of serotonin (5-HT) in the CNS, increasing serotonin availability in synapses.
Key Nursing Considerations	Initiate with monitoring for suicidal ideation. Fluoxetine may increase the risk of suicidal thoughts, especially in children, adolescents, and young adults during early treatment phases. Assess for serotonin syndrome in polypharmacy. Combining fluoxetine with other serotonergic agents can lead to serotonin syndrome; watch for agitation, tremor, hyperreflexia, or fever. Avoid abrupt discontinuation. Taper gradually to prevent withdrawal symptoms such as dizziness, insomnia, or flu-like effects. Administer in the morning to minimize insomnia. Fluoxetine has activating effects and may interfere with sleep if taken late in the day. Monitor for weight changes and sexual dysfunction. These are common long-term side effects that may affect adherence.
Critical Alerts	Black Box: Antidepressants increase the risk of suicidal thinking and behavior in children, adolescents, and young adults; monitor closely, especially during initial therapy and dose adjustments.

72. Amitriptyline

Generic & Brand Name	Amitriptyline (Elavil)
Drug Class	Tricyclic antidepressant (TCA)
Mechanism of Action	Inhibits reuptake of serotonin and norepinephrine in CNS; also blocks muscarinic, histamine, and α1 receptors (responsible for many side effects).
Key Nursing Considerations	Initiate with caution in patients with suicidal risk. Amitriptyline has a high lethality in overdose and should be prescribed with care, particularly in depressed individuals. Monitor for anticholinergic effects. Common side effects include dry mouth, urinary retention, constipation, and blurred vision; assess regularly, especially in older adults. Assess for orthostatic hypotension. This medication can cause dizziness or fainting upon standing, so educate patients to rise slowly. Evaluate for sedation and CNS depression. Amitriptyline is highly sedating; administer at bedtime and avoid use with alcohol or CNS depressants. Obtain a baseline ECG in older adults. Tricyclics can prolong QT interval—use caution in those with cardiac history.
Critical Alerts	High Alert (Caution): Highly lethal in overdose. As few as a 10-day supply can be fatal (due to cardiotoxicity and CNS effects). Contraindicated after recent MI or in severe heart disease. Due to arrhythmia risk. Antidepressants increase the risk of suicidal thoughts and behaviors in children, adolescents, and young adults. Monitor closely during initial treatment and with dose adjustments.

73. Phenelzine

Generic & Brand Name	Phenelzine (Nardil)
Drug Class	MAOI (antidepressant)
Mechanism of Action	Irreversibly inhibits monoamine oxidase, the enzyme that breaks down serotonin, norepinephrine, and dopamine. This increases levels of these neurotransmitters in the brain.
Key Nursing Considerations	Monitor for hypertensive crisis with tyramine intake. Phenelzine is an MAOI that can cause a sudden and dangerous rise in blood pressure if taken with tyramine-rich foods like aged cheese, cured meats, and fermented products. Assess for drug interactions before initiating therapy. This drug has a high risk of interactions with SSRIs, TCAs, decongestants, and stimulants, which may lead to serotonin syndrome or hypertensive events. Educate on washout periods between antidepressants. A gap of at least 14 days is required when switching to or from other serotonergic agents to avoid severe adverse effects. Observe for CNS stimulation or orthostatic hypotension. Patients may experience dizziness, restlessness, or postural blood pressure drops; advise slow position changes and monitor closely. Evaluate for mood changes and suicidality. As with other antidepressants, phenelzine may increase suicidal ideation in young adults, especially during the first few weeks of therapy.
Critical Alerts	Black Box Warning: Antidepressants increase the risk of suicidal thoughts and behaviors in children, adolescents, and young adults. Monitor patients carefully during early treatment and dosage adjustments.

74. Bupropion

Generic & Brand Name	Bupropion (Wellbutrin)
Drug Class	Atypical antidepressant
Mechanism of Action	NDRI: Blocks reuptake of norepinephrine and dopamine (no direct serotonin effects). Mechanism differs from SSRIs.
Key Nursing Considerations	Monitor for seizure risk in high doses or predisposed patients. Bupropion lowers the seizure threshold, especially at doses above 450 mg/day or in those with a history of seizures or eating disorders. Avoid use in patients with eating disorders. Anorexia and bulimia significantly increase the risk of seizures with bupropion use. Assess for neuropsychiatric effects during smoking cessation. When used for smoking cessation (Zyban), monitor for mood changes, agitation, or suicidal ideation. Instruct to avoid abrupt discontinuation. Stopping bupropion suddenly may lead to withdrawal symptoms such as anxiety, irritability, and sleep disturbances. Use cautiously with other serotonergic or dopaminergic drugs. The risk of serotonin syndrome or CNS overstimulation increases when combined with other agents.
Critical Alerts	Caution: Seizure risk is dose-related. Bupropion lowers the seizure threshold. The risk increases at doses above 450 mg/day, or in individuals with eating disorders, alcohol or benzodiazepine withdrawal, or a history of seizures. Suicidality in young patients. Bupropion may increase suicidal thoughts in young patients, especially during early treatment or dose changes.

75. Lithium

Generic & Brand Name	Lithium (Lithobid)
Drug Class	Mood stabilizer (anti-manic)
Mechanism of Action	Mechanism not fully understood; alters sodium transport in nerve and muscle cells and effects on neurotransmitters; stabilizes mood in bipolar disorder (reduces manic episodes).
Key Nursing Considerations	Stabilize mood through sodium-like behavior. Lithium modulates neurotransmitter activity by mimicking sodium in nerve transmission, making it effective for mood stabilization in bipolar disorder. Monitor serum levels regularly. The therapeutic range is narrow (0.6–1.2 mEq/L), and levels above 1.5 mEq/L can cause toxicity, so routine monitoring is required. Maintain consistent sodium and hydration. Dehydration or low sodium increases lithium reabsorption in the kidneys, raising the risk of toxicity; advise stable fluid and salt intake. Assess renal and thyroid function. Lithium can impair kidney function and suppress thyroid hormone levels; monitor BUN, creatinine, and TSH periodically. Teach the patient about toxicity signs. Early signs include nausea, vomiting, tremors, and confusion; severe cases may lead to seizures or coma; report symptoms immediately. Avoid NSAIDs and diuretics unless approved. These medications can increase lithium levels and the risk of toxicity; always check drug interactions.
Critical Alerts	High Alert: Lithium toxicity can be life-threatening. Monitor levels closely and avoid significant changes in fluid or sodium intake. Contraindicated in pregnancy. Especially during the first trimester, since it can cause Ebstein’s anomaly in the fetus.

76. Haloperidol

Generic & Brand Name	Haloperidol (Haldol)
Drug Class	Typical antipsychotic (butyrophenone)
Mechanism of Action	Dopamine D2 receptor antagonist in brain (especially mesolimbic pathway), decreasing positive symptoms of psychosis. Also blocks D2 in nigrostriatal (causing EPS) and tuberoinfundibular (causing ↑ prolactin).
Key Nursing Considerations	Block dopamine to manage agitation. Haloperidol is a typical antipsychotic that works by blocking dopamine receptors, especially effective in controlling acute psychosis, schizophrenia, and agitation. Monitor for extrapyramidal symptoms. Assess regularly for dystonia, akathisia, parkinsonism, and tardive dyskinesia, especially with long-term use. Evaluate QT interval and cardiac status. High doses or IV use may prolong QT interval; baseline and periodic ECGs are recommended, especially in at-risk patients. Avoid in Parkinson’s disease. Dopamine blockade may worsen motor symptoms; contraindicated in patients with Parkinson’s or severe CNS depression. Administer with caution in elderly patients. There is an increased risk of sedation, falls, and adverse effects; use the lowest effective dose. Educate on adherence and side effects. Advise patients on the importance of medication adherence and recognizing signs of EPS, sedation, or orthostatic hypotension.
Critical Alerts	Black Box: Increased mortality in elderly patients with dementia-related psychosis. Avoid use unless benefit outweighs the risk.

77. Clozapine

Generic & Brand Name	Clozapine (Clozaril)
Drug Class	Atypical antipsychotic
Mechanism of Action	Blocks dopamine D2 and serotonin 5-HT2A receptors (also blocks many others). Low affinity for D2 in nigrostriatal path → lower EPS, but strong effects on mesolimbic (antipsychotic).
Key Nursing Considerations	Monitor for agranulocytosis risk. Clozapine can severely suppress white blood cell count; obtain baseline and regular CBC with ANC monitoring per protocol. Assess for signs of infection promptly. Even mild symptoms like a sore throat or fever should prompt immediate evaluation due to the risk of agranulocytosis. Track for metabolic syndrome. Regularly monitor weight, glucose, and lipid levels due to increased risk of hyperglycemia, dyslipidemia, and weight gain. Observe for seizure threshold lowering. Clozapine can increase seizure risk, especially at higher doses or in predisposed individuals; caution is required in seizure-prone patients. Monitor bowel function. There is a risk of serious GI hypomotility (constipation, ileus); promote hydration, fiber intake, and early intervention for GI complaints. Educate about sedation and orthostatic hypotension. Counsel on avoiding alcohol, rising slowly, and not operating machinery until the effects are known.
Critical Alerts	Black Box: Severe neutropenia (agranulocytosis) may be encountered. Requires mandatory blood monitoring and registration with the REMS program. Increased risk of seizures, myocarditis, and cardiomyopathy. Monitor for chest pain or arrhythmia. Increased mortality in elderly patients with dementia-related psychosis. Use contraindicated in this population

78. Lorazepam

Generic & Brand Name	Lorazepam (Ativan)
Drug Class	Benzodiazepine (anxiolytic)
Mechanism of Action	Enhances GABA-A receptor activity by increasing frequency of Cl⁻ channel opening, leading to CNS depression (anxiolytic, sedative, anticonvulsant, muscle relaxant effects).
Key Nursing Considerations	Initiate with caution in the elderly. Lorazepam increases fall risk due to sedation and impaired coordination; use the lowest effective dose and reassess regularly. Monitor for respiratory depression. High doses or concurrent CNS depressant use (e.g., opioids, alcohol) can suppress respiration; observe closely in at-risk populations. Assess for signs of dependence and withdrawal. Long-term use may lead to tolerance and dependence; taper gradually to avoid seizures or withdrawal symptoms. Provide fall precautions. Sedative effects impair alertness and mobility; implement safety measures, especially during night shifts or after dose adjustments. Educate on short-term use only. Lorazepam is intended for brief symptom relief in anxiety or agitation; long-term use requires reevaluation. Avoid abrupt discontinuation. Sudden withdrawal can provoke rebound anxiety, insomnia, tremors, or seizures; taper under supervision.
Critical Alerts	High Alert (Caution): Concomitant use with opioids may result in profound sedation, respiratory depression, coma, or death. Prescribe together only when no alternatives exist, and monitor closely.

79. Buspirone

Generic & Brand Name	Buspirone (Buspar)
Drug Class	Anxiolytic (non-benzo)
Mechanism of Action	Partial agonist at 5-HT1A serotonin receptors and some effect on dopamine D2 receptors – mechanism for anxiety relief is not fully understood (non-sedating anxiolytic).
Key Nursing Considerations	Use consistently, not as needed. Buspirone must be taken on a regular schedule to achieve anxiolytic effects; it is not effective for acute anxiety or panic attacks. Expect a delayed onset of action. Therapeutic effects may take 2 to 4 weeks; educate patients to continue taking the medication as prescribed, even if relief is not immediate. Avoid CNS depressant interaction. Although not sedating, combining buspirone with alcohol or other CNS depressants may still impair cognitive and motor function. Monitor for dizziness and nausea. Common side effects include dizziness, headache, and gastrointestinal discomfort; assess for fall risk in vulnerable populations. Teach about grapefruit interaction. Grapefruit juice can increase buspirone levels and the risk of side effects; advise patients to avoid it during therapy. Evaluate for serotonin syndrome risk. When used with other serotonergic agents, monitor for symptoms such as agitation, confusion, tachycardia, or muscle rigidity.
Critical Alerts	Caution: Buspirone is not effective for acute anxiety and requires consistent use for several weeks before therapeutic effects are seen, making patient education important to manage expectations. Though generally well-tolerated and low-risk, it is contraindicated with MAOIs and should be used cautiously with other serotonergic agents due to rare risks like serotonin syndrome or paradoxical anxiety.

80. Zolpidem

Generic & Brand Name	Zolpidem (Ambien)
Drug Class	Sedative-hypnotic (non-benzo)
Mechanism of Action	Selective agonist at benzodiazepine (BZ1) receptors on GABA-A complex (alpha-1 subunit), inducing sleepiness without much anxiolytic effect.
Key Nursing Considerations	Promote consistent sleep routines before use. Zolpidem is indicated for short-term treatment of insomnia; educate patients to use only when a whole night’s sleep (7–8 hours) is possible. Monitor for complex sleep behaviors. Patients may experience sleepwalking, sleep-driving, or other activities while not fully awake; instruct to report these immediately. Avoid abrupt discontinuation after prolonged use. Risk of withdrawal symptoms increases with long-term use; taper under medical supervision. Assess for CNS depression and fall risk. Monitor for daytime drowsiness, dizziness, or impaired coordination, especially in older adults. Advise against alcohol and other CNS depressants. Concurrent use increases the risk of sedation and respiratory depression.
Critical Alerts	Caution: Complex sleep behaviors (e.g., sleepwalking, sleep-driving) may lead to serious injury or death. Discontinue immediately if such events occur. An overdose can cause respiratory depression, especially if combined with other CNS depressants. Treat with supportive care and flumazenil if needed (though flumazenil may precipitate seizures).

Anticonvulsants/Antiepileptics Medications

81. Phenytoin

Generic & Brand Name	Phenytoin (Dilantin)
Drug Class	Anticonvulsant (Hydantoin)
Mechanism of Action	Blocks voltage-gated Na+ channels in neurons, stabilizing neuronal membranes and preventing repetitive firing (use-dependent blockade).
Key Nursing Considerations	Maintain therapeutic serum levels. Phenytoin requires close monitoring of blood levels (10–20 mcg/mL) to avoid toxicity and promote seizure control. Implement oral hygiene education. Gingival hyperplasia is a common side effect; instruct patients to perform regular dental care and attend routine checkups. Administer IV form with caution. Infuse slowly (not exceeding 50 mg/min) to prevent hypotension and arrhythmias; use only with normal saline. Monitor for CNS effects. Watch for dizziness, ataxia, confusion, or nystagmus as early signs of toxicity, especially in elderly or renally impaired patients. Avoid abrupt withdrawal. Stopping phenytoin suddenly may precipitate status epilepticus; taper gradually under medical supervision. Inform regarding drug interactions. Many drugs and supplements affect phenytoin metabolism; maintain a consistent medication list and notify physician of changes.
Critical Alerts	Black box warnings: Rapid IV administration may result in severe hypotension and cardiac arrhythmias. Continuous cardiac monitoring is essential during administration.

82. Carbamazepine

Generic & Brand Name	Carbamazepine (Tegretol)
Drug Class	Anticonvulsant
Mechanism of Action	Inhibits voltage-gated sodium channels, reducing high-frequency neuronal firing (similar to phenytoin mechanism). Also has mood-stabilizing effect in bipolar disorder and analgesic effect in trigeminal neuralgia.
Key Nursing Considerations	Monitor serum levels and CBC routinely. Carbamazepine requires therapeutic drug level monitoring (4–12 mcg/mL) and frequent blood counts due to the risk of bone marrow suppression. Assess for early signs of toxicity. Watch for dizziness, ataxia, diplopia, or unsteady gait, especially during dose adjustments. Promote adherence and avoid abrupt discontinuation. Sudden withdrawal may trigger seizures; dosing should be tapered under medical supervision. Provide education on drug and food interactions. Grapefruit juice increases serum levels; many drugs alter carbamazepine metabolism due to CYP450 involvement. Screen for rash or hypersensitivity. Stevens-Johnson syndrome and toxic epidermal necrolysis are rare but life-threatening; discontinue immediately if rash develops. Initiate genetic screening in high-risk populations. Test for HLA-B*1502 allele in patients of Asian descent due to elevated risk of severe skin reactions.
Critical Alerts	Black Box: This may cause serious dermatologic reactions, including Stevens-Johnson syndrome and TEN, especially in patients with the HLA-B*1502 allele. It may also cause aplastic anemia and agranulocytosis; monitor blood counts regularly. High Alert: Overdose can cause severe CNS depression and cardiovascular collapse.

83. Valproic Acid

Generic & Brand Name	Valproic Acid (Depakote)
Drug Class	Anticonvulsant / Mood stabilizer
Mechanism of Action	Multiple mechanisms: increases GABA availability, blocks sodium channels, and blocks T-type calcium channels – broad-spectrum anticonvulsant and mood stabilizer.
Key Nursing Considerations	Monitor serum levels and liver function tests regularly. Valproic acid has a narrow therapeutic range of 50–100 mcg/mL and carries a risk of hepatotoxicity, particularly in young children or those on multiple medications. Assess for signs of pancreatitis. Acute abdominal pain, nausea, and vomiting may signal life-threatening pancreatitis, requiring immediate evaluation. Evaluate for CNS effects and sedation. Common adverse effects include tremor, dizziness, and sedation; assess impact on daily functioning and safety. Caution in women of childbearing potential. Strongly teratogenic; promote appropriate contraception and discuss alternatives if pregnancy is planned or possible. Do not stop abruptly. Sudden withdrawal may precipitate seizures; taper gradually under provider supervision.
Critical Alerts	Black Box: May cause fatal hepatotoxicity, especially in children under 2 or those with mitochondrial disorders. Can induce life-threatening pancreatitis at any age. High teratogenic risk. Associated with neural tube defects and decreased IQ in exposed fetuses.

84. Levetiracetam

Generic & Brand Name	Levetiracetam (Keppra)
Drug Class	Anticonvulsant
Mechanism of Action	Precise mechanism not fully understood; binds to synaptic vesicle protein SV2A, thought to modulate neurotransmitter release and inhibit burst firing of neurons.
Key Nursing Considerations	Initiate seizure control through synaptic modulation. Levetiracetam reduces seizure activity by binding to synaptic vesicle protein SV2A, modulating neurotransmitter release. Monitor for mood and behavioral changes. Assess for agitation, anxiety, depression, or suicidal thoughts, especially during initial therapy or dose adjustments. Adjust dose in renal impairment. Renal clearance is significant; monitor kidney function and adjust accordingly in elderly or those with renal dysfunction. Avoid abrupt discontinuation. Taper the dose gradually to prevent rebound seizures or status epilepticus. Educate on adherence and side effects. Inform patients about potential dizziness or fatigue; encourage consistent dosing and follow-up evaluations.
Critical Alerts	High Caution: Monitor for psychiatric symptoms. Levetiracetam may increase the risk of behavioral disturbances, including psychosis or suicidal ideation, particularly in younger patients or those with psychiatric history.

Neurologic Medications

85. Carbidopa-Levodopa

Generic & Brand Name	Carbidopa-Levodopa (Sinemet)
Drug Class	Anti-Parkinson agent
Mechanism of Action	Levodopa is a dopamine precursor that crosses the BBB and is converted to dopamine in the brain, improving movement; Carbidopa inhibits peripheral dopa-decarboxylase, preventing levodopa breakdown in the periphery (thus more reaches the brain and with fewer peripheral side effects).
Key Nursing Considerations	Gold standard therapy for Parkinson’s Disease. Levodopa replenishes brain dopamine to lessen bradykinesia and rigidity, while carbidopa prevents its peripheral breakdown, boosting effectiveness and reducing side effects. Start with low doses and titrate cautiously. Gradual adjustment minimizes the risk of orthostatic hypotension, hallucinations, or dyskinesia. Administer before meals for optimal absorption. Protein-rich foods may interfere with levodopa absorption and should be spaced from dosing. Monitor for motor fluctuations and wearing-off effect. Observe for end-of-dose worsening and report any involuntary movements or behavioral changes. Stress the importance of medication adherence and timing. Encourage consistent timing of doses each day to maintain therapeutic effects and reduce symptom fluctuations.
Critical Alerts	Caution: Abrupt withdrawal can cause neuroleptic malignant syndrome-like syndrome or severe Parkinsonian crisis. Taper slowly if discontinuing. Risk for sudden sleep attacks and impulse control issues. Warn patients about possible sudden drowsiness during activities like driving and monitor for compulsive behaviors such as gambling or binge eating.

86. Benztropine

Generic & Brand Name	Benztropine (Cogentin)
Drug Class	Anticholinergic (antiparkinson)
Mechanism of Action	Blocks central muscarinic receptors, helping to balance dopamine/ACh levels in basal ganglia; reduces excess cholinergic activity that contributes to Parkinson tremor and rigidity.
Key Nursing Considerations	Monitor for anticholinergic side effects. Watch for dry mouth, blurred vision, constipation, urinary retention, and confusion, especially in older adults. Use with caution in heat or physical exertion. It can impair sweating and increase the risk of heat stroke due to decreased thermoregulation. Avoid abrupt withdrawal. Sudden discontinuation may exacerbate Parkinsonian symptoms or trigger withdrawal effects. If drowsiness occurs, instruct the patient on nighttime dosing. If sedation is reported, adjusting the timing may improve tolerance.
Critical Alerts	An overdose can cause delirium and severe ileus or urinary retention. It is typically treated with physostigmine, a reversible cholinesterase inhibitor that counteracts central and peripheral anticholinergic effects. Contraindicated in narrow-angle glaucoma. Use is not advised in patients with glaucoma or severe prostatic hypertrophy due to the risk of acute exacerbation.

87. Donepezil

Generic & Brand Name	Donepezil (Aricept)
Drug Class	Acetylcholinesterase inhibitor
Mechanism of Action	Reversibly inhibits acetylcholinesterase, increasing acetylcholine levels in the CNS, which may help neuronal communication in Alzheimer dementia.
Key Nursing Considerations	Watch for gastrointestinal distress. It may cause nausea, vomiting, or diarrhea; give it with food to minimize symptoms and enhance adherence. Observe for cardiac effects. Monitor closely for bradycardia or syncope; educate patients and significant others to report dizziness or fainting promptly. Caution in respiratory conditions. Use carefully in patients with asthma or COPD due to the risk of bronchoconstriction; monitor respiratory status closely.
Critical Alerts	Caution: Use with caution in patients on beta-blockers or with arrhythmias. Its cholinergic effects can lead to bradycardia, increasing the risk of heart block or syncope. In cases of overdose, donepezil may lead to a cholinergic crisis. Immediate treatment involves the administration of atropine to counteract these symptoms.

Osmotic Diuretics

88. Mannitol

Generic & Brand Name	Mannitol (Osmitrol)
Drug Class	Osmotic diuretic
Mechanism of Action	Increases osmolality of blood and renal filtrate: draws water out of tissues (including brain, eyes) into bloodstream, and then is filtered in kidney, dragging water with it for excretion.
Key Nursing Considerations	Monitor for signs of fluid and electrolyte imbalance. Assess serum osmolality, sodium, potassium, and fluid status regularly to prevent dehydration and electrolyte shifts. Maintain vigilance for pulmonary edema. Rapid fluid shifts can worsen heart failure or unmask pulmonary complications; auscultate lung sounds frequently. Check the patency of the IV line. Mannitol crystallizes at lower temperatures; use a filter needle when administering, and inspect the solution before use. Adjust dosing in renal impairment. Accumulation may lead to nephrotoxicity or worsen existing kidney injury; monitor renal function closely.
Critical Alerts	High Alert (Caution): Avoid in patients with anuria, active intracranial bleeding (except during craniotomy), or severe pulmonary edema. It can worsen fluid accumulation and pressure. Monitor for rebound increased intracranial pressure after initial reduction. After lowering intracranial pressure, rebound elevation may occur as mannitol shifts back into brain tissue.

Obstetric & Women’s Health Medications

89. Oxytocin

Generic & Brand Name	Oxytocin (Pitocin)
Drug Class	Oxytocic uterotonic
Mechanism of Action	Stimulates oxytocin receptors in uterine smooth muscle, increasing rhythmic contractions; also promotes milk let-down reflex.
Key Nursing Considerations	Monitor fetal heart rate and uterine tone closely. Continuous monitoring is required to detect signs of fetal distress or uterine tachysystole. Assess for water intoxication in prolonged infusions. Due to antidiuretic effects, monitor for headache, vomiting, confusion, or seizures indicating hyponatremia. Teach the patient about the medication’s purpose and expected effects. Explain to the patient that oxytocin is used to start or strengthen labor contractions or to control postpartum bleeding. Use caution in patients with uterine scarring or multiple gestations. Increased risk of uterine rupture or complications requires vigilant assessment.
Critical Alerts	High Alert: Perinatal ISMP high-alert med. Improper use can cause uterine rupture, fetal distress, or maternal/fetal death. Requires constant monitoring and the ability to respond quickly to fetal or uterine signs of overdose. Black Box (FDA requires caution): Should be used only when medically indicated, not for elective convenience. Oxytocin has antidiuretic effects; watch for water intoxication (confusion, headache, drowsiness).

90. Magnesium Sulfate

Generic & Brand Name	Magnesium Sulfate (MgSO₄)
Drug Class	Mineral; anticonvulsant in OB
Mechanism of Action	Blocks neuromuscular transmission and is a CNS depressant; raises seizure threshold. Also relaxes uterine and vascular smooth muscle.
Key Nursing Considerations	Monitor for signs of magnesium toxicity. Check deep tendon reflexes, respiratory rate, urine output, and level of consciousness regularly to detect toxicity early. Use caution in patients with renal impairment. Impaired renal clearance may increase the risk of accumulation and toxicity. Prepare an antidote for emergency reversal. Keep calcium gluconate readily available at the bedside to reverse magnesium toxicity. Educate the patient about possible side effects. Inform patients about potential warmth, flushing, muscle weakness, and sedation during treatment.
Critical Alerts	High Alert: Monitor closely for respiratory depression, loss of reflexes, and cardiac arrest at toxic levels. Discontinue immediately and administer calcium gluconate if toxicity occurs. Caution: MgSO₄ potentiates the effect of other CNS depressants. Avoid concurrent high-dose narcotics if possible.

91. Terbutaline

Generic & Brand Name	Terbutaline (Brethine)
Drug Class	Tocolytic (β2-agonist)
Mechanism of Action	Stimulates beta-2 receptors (selective sympathomimetic) on uterine smooth muscle, causing uterine relaxation; also bronchodilates via β2 in lungs.
Key Nursing Considerations	Monitor maternal heart rate and blood pressure closely. Terbutaline may cause tachycardia, palpitations, or hypotension, requiring frequent maternal vital assessment. Assess fetal status during and after administration. Continuous fetal monitoring is recommended due to potential effects on heart rate. Use caution in patients with cardiac conditions or poorly controlled diabetes. Terbutaline can exacerbate tachyarrhythmias and increase blood glucose levels. Inform the patient about side effects such as tremors, nervousness, or restlessness. Reassure that these are usually transient, but report if severe.
Critical Alerts	High Alert (OB): Avoid prolonged use beyond 48–72 hours for preterm labor. Continuous monitoring is required due to the risk of maternal arrhythmias, pulmonary edema, and the potential for serious cardiac events with prolonged use. Black Box: Oral terbutaline should not be used for acute or maintenance tocolysis (ineffective and risky). It poses serious risks to the mother without proven long-term benefit. Its use should be limited to short-term, monitored settings only.

92. Rho(D) Immune Globulin

Generic & Brand Name	Rho(D) Immune Globulin (RhoGAM)
Drug Class	Immunoglobulin (IgG anti-D antibody)
Mechanism of Action	Binds to and destroys Rh-positive fetal RBCs that enter maternal circulation in an Rh-negative mother, preventing maternal immune system from forming anti-Rh antibodies.
Key Nursing Considerations	Time administration with sensitizing events. Administer within 72 hours of potential fetal-maternal hemorrhage events (e.g., delivery, abortion, trauma, amniocentesis) for effectiveness. Verify Rh status and antibody screen. Confirm maternal Rh-negative status and negative indirect Coombs test before administration to avoid giving it when antibodies are already formed. Use standard dosing guidelines. The standard dose is 300 mcg IM, covering up to 15 mL fetal RBCs; a microdose (50 mcg) may be used in early pregnancy losses under 13 weeks. Monitor for local reactions and hypersensitivity. Observe for injection site pain or allergic response; anaphylaxis is rare but possible—have emergency support available.
Critical Alerts	Caution: Do not administer to Rh-positive or sensitized patients (positive antibody screen). As this offers no benefit and may obscure antibody titer trends. Use caution in individuals with known immunoglobulin A (IgA) deficiency. Due to the risk of anaphylactic reactions.

93. Tamoxifen

Generic & Brand Name	Tamoxifen (Nolvadex)
Drug Class	SERM (selective estrogen receptor modulator)
Mechanism of Action	Estrogen receptor antagonist in breast tissue (blocks estrogen stimulation of ER+ breast cancer cells), and estrogen agonist in uterus and bone (stimulates endometrium and preserves bone density).
Key Nursing Considerations	Schedule regular gynecologic monitoring. Monitor for endometrial changes, as tamoxifen may increase the risk of uterine cancer; instruct patients to report abnormal vaginal bleeding. Monitor for thromboembolic events. Assess for signs of deep vein thrombosis or pulmonary embolism, such as leg swelling or shortness of breath, especially in prolonged therapy. Teach on menopausal-like side effects. Hot flashes, mood swings, and vaginal dryness are common and should be anticipated as part of treatment. Evaluate liver function and visual changes. Periodic liver function tests are recommended; report visual disturbances such as blurred vision, which may signal ocular toxicity.
Critical Alerts	Black Box Warnings: Tamoxifen carries a black box warning for increased risk of uterine malignancies and life-threatening thromboembolic events, including stroke and pulmonary embolism. Weigh the benefits and risks in women with a history of clotting disorders or endometrial cancer.

94. Ethinyl Estradiol / Norgestimate

Generic & Brand Name	Ethinyl Estradiol / Norgestimate (e.g., Ortho Tri-Cyclen, Sprintec, MonoNessa)
Drug Class	Combined Oral Contraceptive (COC) – Estrogen and Progestin Combination
Mechanism of Action	Ethinyl estradiol (estrogen) and norgestimate (progestin) work together to prevent ovulation by suppressing the hypothalamic-pituitary-ovarian axis. They inhibit the secretion of gonadotropins (FSH and LH), preventing follicle development and release. Additionally, they thicken cervical mucus to block sperm penetration and alter the endometrial lining to inhibit implantation.
Key Nursing Considerations	Assess for thromboembolic risk factors. Evaluate personal and family history of clotting disorders before starting; monitor for leg pain, chest pain, or vision changes as potential signs of blood clots. Monitor blood pressure and smoking status. Combined oral contraceptives may elevate blood pressure and increase cardiovascular risk, especially in smokers over 35 years old. Educate on consistent daily dosing. Advise patients to take the pill at the same time daily to maintain hormonal levels and prevent unintended pregnancy. Inform about the common side effects. Nausea, breast tenderness, and breakthrough bleeding are common during the first few cycles; reassure patients and advise when to seek further evaluation. Advise on drug and supplement interactions. Rifampin, certain anticonvulsants, and St. John’s Wort may decrease effectiveness; recommend backup contraception if using these agents.
Critical Alerts	Black Box Warning: Cigarette smoking increases the risk of serious cardiovascular events from combined oral contraceptives. This risk increases with age (especially >35 years) and with the number of cigarettes smoked.

Pain Management & Anesthesia Medications

95. Morphine

Generic & Brand Name	Morphine (MS Contin, etc.)
Drug Class	Opioid analgesic (Schedule II)
Mechanism of Action	Mu-opioid receptor agonist in CNS and periphery; modulates perception of pain and emotional response; also causes CNS and respiratory depression, and decreases GI motility.
Key Nursing Considerations	Monitor for respiratory depression with opioid use. Morphine can suppress respiratory drive, especially at higher doses or in opioid-naïve patients; monitor respiratory rate and oxygen saturation closely. Assess the level of consciousness and sedation. CNS depression may lead to drowsiness, confusion, or unresponsiveness; use sedation scales and reassess frequently during titration. Evaluate pain before and after administration. Regularly assess pain using standardized scales to guide dosing and effectiveness of pain control. Administer with caution in patients with head injury. Morphine can elevate intracranial pressure and mask neurologic symptoms, complicating neuro assessments. Prevent constipation with routine bowel care. Opioids reduce GI motility; encourage fluid, fiber, and laxatives as needed to prevent opioid-induced constipation. Inform the patient of the orthostatic hypotension risk. Morphine may cause blood pressure drops when rising; advise patients to change positions slowly and with assistance if needed. Be alert for signs of tolerance or dependence. Long-term use may result in physical dependence; monitor for signs of misuse, withdrawal, or escalating dose needs.
Critical Alerts	High Alert: Serious, life-threatening, or fatal respiratory depression may occur, especially during initiation or dose increases. Concomitant use with benzodiazepines or other CNS depressants may result in profound sedation, respiratory depression, coma, or death.

96. Hydromorphone

Generic & Brand Name	HydroHydromorphone (Dilaudid)morphone (Dilaudid)
Drug Class	Opioid analgesic (Schedule II)
Mechanism of Action	Mu-opioid agonist (semi-synthetic); similar mechanism to morphine but ~5–7 times more potent.
Key Nursing Considerations	Assess sedation level and cognitive changes. Monitor closely for excessive drowsiness, confusion, or lethargy, which may signal toxicity or overdose. Implement a bowel regimen to prevent opioid-induced constipation. Hydromorphone slows gastrointestinal motility; initiate laxatives and hydration strategies to prevent fecal impaction. Use caution with concurrent CNS depressants. Combining with benzodiazepines, alcohol, or other sedatives may increase the risk of life-threatening sedation or respiratory compromise. Adjust dose for renal or hepatic impairment. Metabolism and excretion may be altered in organ dysfunction, requiring lower doses and close monitoring for accumulation. Teach the patient about fall risk and orthostatic hypotension. Dizziness and low blood pressure may occur; assist with ambulation and advise slow position changes.
Critical Alerts	Black Box Warning: Risk of fatal respiratory depression, especially during initiation or dose escalation. Black Box Warning: Concomitant use with other CNS depressants, including benzodiazepines, may lead to profound sedation, coma, or death.

97. Oxycodone

Generic & Brand Name	Oxycodone (OxyContin, Roxicodone)
Drug Class	Opioid analgesic (Schedule II)
Mechanism of Action	Mu-opioid receptor agonist; semi-synthetic derivative of morphine. Provides analgesia and CNS depression similar to morphine.
Key Nursing Considerations	Assess for respiratory status with each dose. Monitor for respiratory depression, especially during initiation or dose increase, as it may become life-threatening. Monitor for CNS depression and sedation. Watch for excessive drowsiness, confusion, or slowed mental status, which may indicate opioid toxicity. Institute a bowel regimen proactively. Opioids like oxycodone commonly cause constipation; encourage fluids, fiber, and laxatives to prevent complications. Avoid alcohol and sedatives unless approved. Concomitant use with CNS depressants increases the risk of fatal respiratory and CNS depression. Educate patients on safe storage and misuse prevention. Oxycodone has high potential for abuse and dependence; store securely and follow prescribing guidelines strictly.
Critical Alerts	Black Box Warning: Serious, life-threatening, or fatal respiratory depression may occur. Especially if taken inappropriately or at high doses, it requires careful dose monitoring. High potential for abuse, addiction, and misuse. Can result in overdose and death, particularly with long-term or nonmedical use. Concomitant use with benzodiazepines or other CNS depressants. This may result in profound sedation, respiratory depression, coma, or death.

98. Fentanyl

Generic & Brand Name	Fentanyl (Sublimaze, Duragesic)
Drug Class	Opioid analgesic (Schedule II)
Mechanism of Action	Potent mu-opioid agonist (~100x potency of morphine). Causes analgesia, sedation, respiratory depression by acting on CNS opioid receptors
Key Nursing Considerations	Monitor respiratory and cardiovascular status continuously. Assess for signs of respiratory depression, hypotension, and bradycardia, especially during IV use or patch initiation. Avoid applying heat over transdermal patches. External heat increases fentanyl absorption, raising the risk of overdose and respiratory depression. Teach patients how to dispose of and handle their patches properly. Improper disposal can lead to accidental exposure or misuse; fold and flush used patches if directed. Reassess sedation level regularly. Sedation often precedes respiratory depression; frequent monitoring is vital during titration or post-op use. Use with extreme caution in opioid-naïve patients. Fentanyl can cause a rapid onset of toxicity in those not tolerant to opioids; start with the lowest effective dose.
Critical Alerts	High Alert: High risk for life-threatening respiratory depression, especially with initial dosing, dose increases, or opioid-naïve use. Close monitoring is essential to avoid fatal outcomes. Potential for misuse, abuse, and addiction. Even at prescribed doses, fentanyl carries a strong potential for misuse, abuse, and addiction. This can lead to serious complications, including overdose. Avoid concurrent use with benzodiazepines or CNS depressants. Increases the risk of excessive sedation, slowed breathing, coma, or death. Such combinations should be avoided or closely supervised. Accidental exposure to transdermal patches (especially in children) can result in fatal overdose. Used patches should be disposed of safely to prevent unintentional exposure.

99. Naloxone

Generic & Brand Name	Naloxone (Narcan)
Drug Class	Opioid antagonist
Mechanism of Action	Competitively blocks opioid receptors (mu, kappa) – displaces opioids and reverses their effects (respiratory depression, analgesia, sedation).
Key Nursing Considerations	Monitor respiratory rate and level of consciousness closely. Frequent reassessment is necessary, as naloxone’s effects may wear off before the opioid is fully cleared. Anticipate withdrawal symptoms in opioid-dependent patients. Naloxone can trigger acute withdrawal, including agitation, vomiting, tachycardia, and hypertension. Prepare for repeated dosing or continuous infusion. Due to its short half-life, naloxone may require redosing, especially with long-acting opioids like methadone or extended-release morphine. Administer via the appropriate route and titrate carefully. Can be given IV, IM, subcut, or intranasally; titrate to restore adequate ventilation without complete reversal of analgesia if appropriate.
Critical Alerts	Caution: No black box warning, but close monitoring is needed to avoid rebound sedation or recurrent respiratory depression after initial reversal.

100. Succinylcholine

Generic & Brand Name	Succinylcholine (Anectine)
Drug Class	Neuromuscular blocker (depolarizing)
Mechanism of Action	Depolarizing neuromuscular blocker: binds to acetylcholine receptors at the neuromuscular junction causing persistent depolarization (fasciculations) and then paralysis (muscle can’t repolarize).
Key Nursing Considerations	Anticipate respiratory support needs immediately. Patients will require full ventilatory support as spontaneous breathing is halted. Avoid use in patients with hyperkalemia risks. Succinylcholine can cause sudden, life-threatening potassium release; it is contraindicated in burns, trauma, neuromuscular diseases, or renal failure. Monitor for signs of malignant hyperthermia. This rare but fatal reaction includes a rapid rise in temperature, muscle rigidity, and tachycardia; treat with dantrolene and immediate cooling measures. Confirm full recovery of neuromuscular function before extubation. Spontaneous movement and respirations return before discontinuing ventilatory support.
Critical Alerts	Reserved for emergency intubation in children and adolescents. Due to the risk of sudden cardiac arrest from undiagnosed myopathies or electrolyte imbalances. Use only when necessary.

101. Dantrolene

Generic & Brand Name	Dantrolene (Dantrium)
Drug Class	Skeletal muscle relaxant (direct-acting)
Mechanism of Action	Inhibits calcium release from sarcoplasmic reticulum of skeletal muscle (binds ryanodine receptor), leading to reduced muscle contraction.
Key Nursing Considerations	Primary treatment for malignant hyperthermia. The only definitive therapy is also used for chronic spasticity in conditions such as multiple sclerosis and spinal cord injury. Reconstitute and administer quickly in an MH crisis. Mix 20 mg vials with sterile water (no preservatives) and give a rapid IV push; large doses are often required based on weight. Monitor for muscle rigidity and hyperthermia reversal. Administer with cooling and supportive measures to reverse MH symptoms effectively. Continue IV post-crisis to prevent recurrence. Maintain IV dantrolene therapy for 24–48 hours after stabilization to avoid relapse. Oral dosing for spasticity. Give with food to minimize gastrointestinal upset; used for long-term symptom management. Watch for common side effects. Muscle weakness, drowsiness, and nausea may occur, especially during oral use. Black Box Warning – Hepatotoxicity Risk. Monitor liver function tests during long-term use; risk increases with high doses and female sex. Use the lowest effective dose long-term. Minimizes hepatic injury risk; evaluate need regularly and adjust dose as needed. Warn about activity impairment. It may cause generalized weakness and drowsiness, so caution patients when driving or performing tasks requiring coordination. Check MH cart supply and drug expiry. Make sure >30 vials are stocked and not expired; dantrolene is weight-based and must be rapidly available.
Critical Alerts	Act immediately in MH emergencies. Dantrolene must be administered promptly when MH is suspected; do not delay in obtaining full confirmation. Time-consuming preparation requires team coordination. Each vial requires reconstitution; newer formulations like Ryanodex allow faster administration with higher concentration per vial. Monitor for life-threatening complications. Track EKG, electrolytes, core temperature, and urine output to detect rhabdomyolysis and myoglobinuria. Black Box Warning – Hepatotoxicity with chronic use. Liver toxicity is rare with short-term IV use, but monitor LFTs and discontinue if AST/ALT reach 3–5× normal. Avoid in hepatic disease for chronic Use. Increased hepatotoxic risk in patients with liver conditions or in older women receiving long-term therapy. Educate on photosensitivity risk. Advise patients to use sunscreen and protective measures when exposed to sunlight. Critical in MH, though not technically “High-Alert.” While not a standard high-alert drug, incorrect dosing or delay in MH management can be fatal—treat urgently and precisely.

Sneak-review a handful of meds whenever downtime strikes and tie each to a patient you’ve met. Soon the mechanisms click, your confidence climbs, and the NCLEX pharmacology section feels like familiar ground.