Module 7 of 9 · Free NCLEX Prep Course · The RN Network
The second-largest category. You cannot memorize every drug — learn classes by suffix, the high-alert medications with their labs and antidotes, and safe administration rules, and most pharm questions open up.
Safe Medication Administration
Rights of administration: right client (two identifiers), drug, dose, route, time, documentation — plus right to refuse, right education, and right evaluation.
Question any order that is illegible, uses unsafe abbreviations (U, IU, QD, trailing zeros), or seems outside normal dose ranges — the nurse who administers shares liability.
Never document before giving, never give a med someone else prepared, and never leave meds at the bedside (exceptions per policy).
High-alert meds requiring independent double checks: insulin, heparin and other anticoagulants, opioids (especially PCA), chemotherapy, concentrated electrolytes (K+ is NEVER IV push).
Dose calculation habit: desired/have × quantity; weight-based doses use kg (divide lb by 2.2); always sanity-check — a dose requiring 14 tablets is a math error.
Drug Classes by Suffix
-pril = ACE inhibitors (lisinopril): dry cough, hyperkalemia, angioedema, contraindicated in pregnancy. -sartan = ARBs: similar without the cough.
-olol = beta blockers (metoprolol): hold for bradycardia/hypotension per parameters, mask hypoglycemia signs, never stop abruptly. -dipine = calcium channel blockers: edema, hypotension; avoid grapefruit.
-statin = antilipemics: report muscle pain (rhabdomyolysis), monitor liver enzymes, take many in the evening. -prazole = PPIs; -tidine = H2 blockers.
-floxacin = fluoroquinolones: tendon rupture risk; -mycin/-micin = aminoglycosides: ototoxic and nephrotoxic — monitor peaks/troughs and creatinine.
Prednisone/steroids: give with food, never stop abruptly, watch glucose, infection masking, and mood changes.
Anticoagulants, Insulin, and Their Labs
Heparin: monitored by aPTT (therapeutic roughly 1.5–2.5× control); antidote protamine sulfate; watch platelets for HIT (drop >50% — stop heparin, no LMWH either).
Warfarin: monitored by INR (usual target 2–3); antidote vitamin K; steady vitamin K diet; many drug interactions — always check before adding antibiotics or NSAIDs.
DOACs (apixaban, rivaroxaban, dabigatran): no routine lab monitoring; renal function matters; reversal agents exist (idarucizumab for dabigatran, andexanet alfa for -xabans).
Insulin timing: rapid (lispro/aspart) onset ~15 min — food must be present; regular ~30 min; NPH intermediate with a peak (hypoglycemia risk at peak); glargine/detemir long-acting, no pronounced peak, never mixed in a syringe with other insulins.
Mixing NPH and regular: clear before cloudy (draw regular first). Hypoglycemia (<70 with symptoms): 15 g fast carbs, recheck in 15 minutes; unconscious — IV dextrose or glucagon IM, nothing by mouth.
Only regular insulin is given IV; potassium shifts with insulin — watch K+ during DKA and insulin infusions.
Drug Levels, Toxicities, and Antidotes
Digoxin (0.5–2.0 ng/mL): toxicity — anorexia, nausea, visual halos, arrhythmias; hypokalemia potentiates toxicity; hold for apical pulse below 60 (adult) per order; antidote digoxin immune fab.
Lithium (~0.6–1.2 mEq/L), phenytoin (10–20 mcg/mL — gum hyperplasia, ataxia at toxicity), theophylline (10–20), vancomycin troughs per protocol, aminoglycoside peaks/troughs.
Acetaminophen max ~4 g/day (less with liver disease); antidote N-acetylcysteine. Opioids — naloxone. Benzodiazepines — flumazenil. Magnesium sulfate — calcium gluconate. Heparin — protamine. Warfarin — vitamin K. Iron — deferoxamine.
Serotonin syndrome vs. NMS: both hyperthermic emergencies; serotonin syndrome has clonus/hyperreflexia after serotonergic drugs; NMS has lead-pipe rigidity after antipsychotics.
Nephrotoxic short list (protect the kidneys, check creatinine): aminoglycosides, vancomycin, NSAIDs, contrast dye, ACE inhibitors in renal artery stenosis.
Teach photosensitivity (tetracyclines, sulfonamides, amiodarone), and no grapefruit with statins and many calcium channel blockers.
IV Therapy and Blood Products
Phlebitis (red, warm, cordlike) and infiltration (cool, pale, swollen): stop the infusion, remove the IV, elevate; vesicant extravasation — stop, aspirate per protocol, notify — do not flush.
Central lines: sterile dressing changes per protocol, scrub the hub, daily necessity review; air embolism precaution — clamp and left-side Trendelenburg if suspected.
Blood administration: verify with two licensed staff at the bedside, use normal saline only, filter tubing, stay with the client for the first 15 minutes, complete within 4 hours of leaving the blood bank.
Transfusion reactions — stop the blood FIRST for any reaction, keep the line open with new saline tubing: febrile (fever/chills), allergic (hives, itching), hemolytic (fever, flank pain, dark urine, hypotension — emergency), TACO (volume overload — crackles, dyspnea), TRALI (acute lung injury).
After stopping: assess, notify provider and blood bank, recheck identifiers, send the bag/tubing and specimens per policy.
Potassium replacement: always on a pump, never exceed protocol rates, verify urine output first.
Practice Questions
Answer each question, then read the rationale — the rationale is where the learning happens.
1.A client receiving IV heparin has an aPTT of 110 seconds (control 30). Which action should the nurse anticipate?
Rationale: An aPTT of 110 with a control of 30 is far above the therapeutic 1.5–2.5× control range — the client is dangerously anticoagulated. Stop the heparin; protamine sulfate is the antidote. Vitamin K reverses warfarin, not heparin.
2.The nurse prepares 10 units of regular insulin and 20 units of NPH in one syringe. Which sequence is correct?
Rationale: Clear before cloudy: air into NPH, air into regular, draw regular (clear) first, then NPH (cloudy). This prevents contaminating the fast-acting vial with intermediate-acting insulin.
3.Fifteen minutes into a packed red blood cell transfusion, the client reports flank pain and chills; temperature has risen 2°F. What should the nurse do FIRST?
Rationale: Flank pain, chills, and rising temperature suggest an acute hemolytic reaction. Stop the blood immediately and keep IV access with fresh saline tubing — then assess, notify the provider and blood bank, and follow reaction protocol. Every other option continues the exposure.
4.A client taking digoxin and furosemide reports nausea and seeing yellow halos around lights. Which lab value is MOST important for the nurse to check?
Rationale: Nausea and visual halos are classic digoxin toxicity. Furosemide causes hypokalemia, which potentiates dig toxicity — check the digoxin level and potassium together, hold the dose, and notify the provider.
5.Which new prescription should the nurse question for a client who is 8 weeks pregnant?
Rationale: ACE inhibitors are contraindicated in pregnancy due to fetal renal damage and other injury. Folic acid and levothyroxine are indicated when needed, and acetaminophen is the preferred analgesic in pregnancy at recommended doses.
6.The nurse notes a client's IV site is cool, pale, and swollen, and the infusion has slowed. What is the correct first action?
Rationale: Cool, pale swelling indicates infiltration — fluid is entering tissue, not vein. Stop the infusion and discontinue the site first; then elevate and apply compresses per policy. Flushing or continuing forces more fluid into the tissue.