# A 70-year-old client with type 2 diabetes (on glyburide) and a history of paroxysmal atrial fibrillation (on amiodarone and ondansetron PRN for nausea) is started on IV levofloxacin for hospital-acquired pneumonia. Which combined nursing action is most appropriate before and during therapy?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=375231&lang=en  
> language: en  
> subject: Adverse Effects/Contraindications/Interactions  
> category: PA

## Question

A 70-year-old client with type 2 diabetes (on glyburide) and a history of paroxysmal atrial fibrillation (on amiodarone and ondansetron PRN for nausea) is started on IV levofloxacin for hospital-acquired pneumonia. Which combined nursing action is most appropriate before and during therapy?

## Option

1. Increase glyburide dose during levofloxacin to overcome any interaction.
2. Obtain baseline 12-lead ECG and serum potassium and magnesium; communicate with the prescriber and pharmacist about the cluster of QT-prolonging drugs (levofloxacin, amiodarone, ondansetron); monitor cardiac rhythm and QTc, glucose (hypo- and hyperglycemia risk increased by sulfonylurea + fluoroquinolone), tendon and CNS symptoms, and consider an alternative antibiotic if QTc baseline is prolonged. **✔ Correct answer**
3. Add another QT-prolonging antiemetic to address future nausea preemptively.
4. Administer levofloxacin without further checks because broad-spectrum cover is urgent.

**Correct answer: 2**

## Explanation

Levofloxacin combined with amiodarone and ondansetron creates a stacked QT prolongation risk that can lead to torsades de pointes, especially in older adults with hypokalemia, hypomagnesemia, or pre-existing prolonged QT. The patient also has diabetes on glyburide, which compounds with fluoroquinolone-induced glucose dysregulation, creating both hypoglycemic and hyperglycemic risk; sulfonylureas in particular have severe hypoglycemia reports. Standard combined nursing action: (1) baseline 12-lead ECG and electrolyte panel including potassium and magnesium before starting, with replacement if low; (2) communicate concerns to the prescriber and pharmacist about the QT-prolonging cluster; consider alternative antibiotic such as ceftriaxone with macrolide or doxycycline as appropriate based on susceptibility, or shorter fluoroquinolone course; (3) telemetry monitoring with QTc trending; (4) frequent fingerstick glucose with patient/caregiver education; hold sulfonylurea or reduce dose if hypoglycemia recurrent and reassess; (5) standard fluoroquinolone surveillance — tendon symptoms, CNS, GI, photosensitivity, C. difficile; (6) hydration to limit crystalluria; (7) document allergies and review all home medications including OTC and herbal for additional QT-prolonging agents and CYP interactions. Administering without checks, increasing glyburide, and stacking antiemetics are unsafe.

## In-depth explanation

QT polypharmacy plus diabetes plus elderly = high-risk levofloxacin patient. Baseline ECG, electrolytes, glucose vigilance, communication with the team. Consider alternatives.

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