Pharmacological and Parenteral TherapiesLesson 6.1
Medication Administration Fundamentals
Every dose passes through your hands last. Check the rights, assess before you give, master each route, and teach so it sticks.
By the end you can
- Apply the rights of medication administration and know when to hold, notify, and document
- Give medications safely by every route, from oral to intradermal to inhaled
- Use reconciliation, safety systems, error response, and teach-back to protect the client
Your case
Telemetry · heart failure, atrial fibrillation · discharge tomorrow
Mr. G, 74. On digoxin, metoprolol, and warfarin, which was started this admission. His 0900 meds are on your cart.
He says food has tasted off since yesterday and he feels queasy. Tomorrow he goes home and manages all three on his own.
Apical HR 54BP 96/60K+ 3.2 mEq/LINR 2.4
Hold that thought
- Which of his 0900 meds do you hold?
- In what order do you hold, call, and chart?
- How do you know he understands his warfarin teaching?
You will answer all three at the end of the lesson.
Concept 1 · The rights
Three checks, two identifiers, zero shortcuts
The core six
- Client: two identifiers (name plus DOB or MRN). Never the room number. Have the client state them
- Medication: check the label 3 times: from storage, during prep, at the bedside
- Dose: calculate it yourself. Over 2 tablets, or over 2 mL of a concentrated injectable? Recheck
- Route: must match the formulation. An oral drug given IV can be fatal
- Time: within the facility's window, classically 30 minutes either side. Never pre-pour
- Documentation: right after you give it, never before. Drug, dose, route, time, site, response
Pearl: pediatric and high-alert doses get an independent double check by a second nurse. Skipping a check because "I know this client" is how the error chain starts.
Concept 2 · Expanded rights
Reason, assess, evaluate, refuse
- Right reason: does the drug fit the diagnosis? A beta-blocker with no cardiac history: clarify
- Right assessment: pulse, BP, RR, or glucose before the drugs that need it
- Right evaluation: go back. Did the pain ease? Did the BP drop?
- Right to refuse: a competent adult can refuse any medication
The client refuses a med. Do or don't?
Tap an action, then tap the box it belongs in.
Pearl: the one exception is court-ordered medication in psychiatric settings, which follows its own legal process.
Concept 3 · Digoxin
Count a full minute before digoxin
- Apical pulse
- Full 60 seconds before every dose
- Hold, adult
- HR under 60
- Hold, child
- Under 70. Infant: under 90 to 110
- Potassium
- Low K+ raises the risk of toxicity
- Toxicity
- Bradycardia, nausea and vomiting, yellow-green halos, dysrhythmias
- Level
- 0.5 to 2.0 ng/mL
In practice now: for digoxin, heart failure guidelines aim for 0.5 to 0.9 ng/mL.
Quick check 1 of 4
Digoxin 0.125 mg PO is due for a 78-year-old. Apical pulse 54, the client reports nausea, and K+ is 3.2 mEq/L. What does the nurse do first?
Three red flags at once: HR under 60, nausea (an early toxicity sign), and hypokalemia, which raises toxicity risk. Any one warrants a hold. A repeat potassium is reasonable, but the data you have is enough to hold and report now.
Concept 4 · BP and HR drugs
Check the numbers before they drop further
- Drugs: metoprolol, atenolol, propranolol
- Check: HR and BP before each dose
- Hold: HR under 60 or SBP under 90, or per ordered parameters
- Watch: orthostatic hypotension
- Drugs: lisinopril, losartan
- Hold: SBP under 90 to 100
- Labs: potassium (they cause hyperkalemia), BUN, creatinine
- ACE inhibitors: dry cough. Lip or tongue swelling is angioedema: stop, treat as an emergency
- Drugs: amlodipine, diltiazem, verapamil
- Diltiazem and verapamil slow the heart: hold if HR under 60
- Amlodipine mainly lowers BP
- Watch: peripheral edema, dizziness, constipation
Quick check 2 of 4
Metoprolol 25 mg PO is due. BP 92/58, HR 56, RR 18. What is most appropriate?
Metoprolol lowers both HR and BP, and both are already below safe parameters. Hold and report. Halving a dose needs a provider order, and rechecking the BP only delays a clear decision.
Concept 5 · Anticoagulants
Know the lab and the antidote
| Drug | Lab and target | Antidote |
|---|---|---|
| Warfarin | PT/INR 2 to 3. Mechanical valve 2.5 to 3.5 | Vitamin K (phytonadione) |
| Heparin | aPTT 1.5 to 2.5 times control | Protamine sulfate |
| Enoxaparin | No routine labs. Check renal function | Protamine (partial) |
- Warfarin: hold and notify if INR is over 3 or outside ordered parameters
- Bleeding watch: gums, hematuria, black tarry stool, bruising, petechiae
- Enoxaparin: subQ in the abdomen. Don't aspirate, don't rub. Adjust if CrCl under 30
HIT: platelets falling more than 50% from baseline on heparin is life-threatening. Monitor the platelet count.
Concept 6 · Insulin
Glucose first, clear before cloudy
- Check glucose before every dose. Under 70: hold, treat, notify
- Rule of 15: 15 g fast carbs, recheck in 15 minutes, repeat if still under 70
- Rapid-acting (lispro, aspart): within 15 minutes of a meal
- Regular: 30 minutes before a meal. NPH: intermediate, not meal-timed
- Glargine: same time daily. Never mix it with other insulins
Finish the rule
When mixing, draw up first.
NPH is cloudy, so you .
Glucose is 62 before a rapid-acting dose. You .
Concept 7 · Opioids
Count the breaths, check the arousal
- RR before every dose. Hold if under 12
- Sedation: hard to arouse means no dose, even with an acceptable RR
- Pain score before and after. Recheck 15 to 30 min after IV, 30 to 60 min after PO
- Bowel regimen from the start: stool softener plus stimulant laxative
- Naloxone: works in 1 to 2 minutes IV but wears off first. Watch for re-sedation
Work it out
Order: morphine 4 mg IV. The vial holds 10 mg/mL. How many mL do you give?
mL
Worked answer: 4 mg divided by 10 mg/mL = 0.4 mL. Do the math yourself, every time.
Hold, notify, document: when your assessment says the drug is unsafe, hold it, tell the provider, and chart the finding, the hold, and the call.
Concept 8 · Oral and transdermal
Don't crush it, don't double it
- Oral: slowest onset (30 to 60 min). Not if NPO, vomiting, unconscious, or unable to swallow
- Never crush enteric-coated, extended-release (SR, ER, XL, XR), or sublingual tablets
- By tube: verify placement, one med at a time, flush 15 to 30 mL before and after
- Sublingual, buccal: bypass first-pass metabolism. Never to an unconscious client
- Patch: remove the old one first. Clean, dry, hairless, intact skin. Rotate sites
Fentanyl patch: 12 to 24 hours to take effect. Never cut it or apply heat. Duplicate patches have killed. Fold used ones sticky sides together.
Nitroglycerin SL: under the tongue, no food or drink until it dissolves. Repeat every 5 minutes, 3 doses max. Call 911 if pain isn't better 5 minutes after the first.
Concept 9 · Injections
Depth decides the needle
| Route | Needle and angle | Key rules |
|---|---|---|
| IM | 1 to 1.5 inch, 90 degrees | Z-track for irritants (iron dextran): hold 10 seconds, then release |
| SubQ | 1/2 to 5/8 inch, 25 to 30 gauge, 45 or 90 degrees | Up to about 1 mL. Rotate sites. No aspiration |
| Intradermal | 1/4 to 1/2 inch, 26 to 27 gauge, 5 to 15 degrees, bevel up | A wheal must form. No massage, no bandage |
Match the site to its use
Pearl: aspirate only at the dorsogluteal site, which is now avoided. No aspiration at other IM sites or for subQ. Never massage after heparin or enoxaparin.
Concept 10 · TB skin test
No wheal, no test
- Mantoux: intradermal, inner forearm, bevel up, 5 to 15 degrees
- Wheal of 6 to 10 mm confirms the dermis
- No wheal: too deep. Repeat about 2 inches away or on the other arm
- Read in 48 to 72 hours. Measure induration, not redness
Positive induration
Say the cutoff, then tap to check.
- Immunocompromised client:
- Healthcare worker:
- No risk factors:
Quick check 3 of 4
After a Mantoux test on the inner forearm, no wheal is visible. What does the nurse do?
No wheal means the antigen went into subcutaneous tissue, so the result can't be trusted. Repeat it about 2 inches away. Documenting it risks a false negative, massage disperses the antigen, and TB test sites are never bandaged.
Concept 11 · Eyes, ears, airways
Up and back for adults, down and back under 3
- Pull the lower lid down. Drop into the conjunctival sac, never onto the cornea
- Press the inner canthus 1 to 2 minutes to limit systemic absorption
- Wait 5 minutes between different eye meds
- Adult: pull the pinna up and back. The canal angles upward
- Under 3: pull the pinna down and back. The canal is straighter and more horizontal
- Nasal spray: aim away from the septum to prevent nosebleeds
- MDI: shake, exhale fully, press and inhale slowly over 3 to 5 seconds, hold 10 seconds
- Poor coordination: add a spacer
- Bronchodilator first to open the airways, wait, then the corticosteroid
- Rinse the mouth after a steroid inhaler to prevent thrush
Pearl: the ear pull is one of the most tested route details. Adults up and back, children under 3 down and back.
Concept 12 · Safety systems
When the system flags it, stop
- Reconcile at every transition: admission, transfer, handoff, discharge
- Include OTC drugs, herbals, supplements, vitamins, recreational substances
- Discrepancies: the nurse finds them, the provider resolves every one
- Barcode scan: never work around a flag. Stop and investigate
- Cabinet: overrides for emergencies only. Always check the drug against the MAR
Quick check 4 of 4
The order reads hydrOXYzine 50 mg PO PRN anxiety. The cabinet drawer the nurse opens is labeled hydrALAZINE. What does the nurse do?
HydrOXYzine is an antihistamine anxiolytic and hydrALAZINE is a vasodilator, so the wrong one could drop the BP dangerously. Stop and verify before removing anything. The cabinet is not infallible, and pill appearance is not a reliable check.
Tall-man lettering flags look-alikes: hydrALAZINE and hydrOXYzine, predniSONE and prednisoLONE, DOPamine and DOBUTamine.
Concept 13 · Medication errors
Client first, paperwork last
Put the error response in order
The chart
- What was given, your findings, the call, the interventions
- Objective facts. No word "error"
- Never mention the incident report
The incident report
- A separate document
- Goes to risk management
- For system improvement, not punishment
The incident report never goes in the chart. Filing it there, or referencing it, makes it discoverable in a lawsuit.
Concept 14 · Teaching
Teach-back, not "Do you understand?"
What every client needs to know
- Names: generic and brand, so they don't double up (Tylenol and acetaminophen)
- Purpose, dose, timing, and whether to take it with food
- Missed dose: take it if close to the time, skip it if close to the next. Never double
- Expected vs reportable: dizziness on standing may ease. Lip swelling or chest tightness: call 911
Interactions: warfarin and vitamin K foods, MAOIs and tyramine, grapefruit with statins or calcium channel blockers, St. John's wort with antidepressants or birth control. Storage: refrigerate insulin and some antibiotics, keep nitroglycerin in its dark glass bottle, check expiration dates, and keep all meds away from children.
Teach-back
- Teach at the client's literacy level, without jargon
- Ask them to explain it in their own words
- Reteach what they missed, then document that teach-back was done
High-risk drugs (anticoagulants, insulin, opioids, narrow therapeutic index): written instructions, involve family, teach-back every time.
Decide it
The 0900 med pass
Back to Mr. G · apical 54 · BP 96/60 · K+ 3.2
Due now: digoxin 0.125 mg, metoprolol 25 mg, and warfarin 5 mg. His INR is 2.4 and he has no bleeding.
Which meds do you give?
A low dose does not make digoxin safe with HR 54, nausea, and K+ 3.2.
Right. HR 54, nausea, and low potassium are red flags for digoxin toxicity, and HR 54 is below beta-blocker parameters, with a soft BP of 96/60. INR 2.4 is therapeutic, so the warfarin goes.
INR 2.4 is in range. Holding warfarin without a reason is its own error.
What is your next move?
The provider needs to know now. Low potassium on digoxin needs orders, not a handoff.
Changing a dose needs a provider order. Hold and notify.
Right. Hold, notify, document. The chart shows what you found, what you held, and who you told.
Before discharge he says, "So I just stop eating salads." What do you do?
Right. Consistency, not avoidance, then teach-back. If he can't explain it, the teaching failed, so reteach.
He will likely say yes. That proves nothing.
Avoidance is the wrong teaching. Steady intake keeps his INR steady.
How it ends
- Digoxin level drawn and potassium replaced before any more digoxin
- Metoprolol parameters reviewed with the provider
- He explains warfarin, vitamin K, and bleeding signs back in his own words
Lock it in
Three hooks to carry into the exam
Two more
- Grown-ups up, little ones down: pull the pinna up and back for adults, down and back under 3
- Clear before cloudy: draw up regular insulin before NPH
Rapid fire
The room number is an acceptable second identifier.
Never. Use name plus DOB or medical record number.
Read a TB skin test by measuring induration, not redness.
Induration is the firm, raised area. Redness alone does not count.
The incident report is filed in the client's chart.
It goes to risk management. The chart never mentions it.
Remove the old fentanyl patch before applying a new one.
Duplicate patches have caused fatal overdoses.
Use the corticosteroid inhaler before the bronchodilator.
Bronchodilator first to open the airways, then the steroid. Rinse after.
NCLEX traps
What the exam will try to trick you with
Leading question. Have the client state their name and DOB, and check the band.
Assessment wins. If the findings say unsafe, hold, notify, and document.
Assess first. The findings decide whether an antidote is needed, and the provider orders it.
Facts only. Chart what was given and what you did. No "error," no mention of the incident report.
Roll it gently. Shaking creates bubbles and can damage the insulin.
Cheat card
The whole lesson on one card
Rights
- Two identifiers, never room number
- Label check 3 times
- Document after, never before
- Refusal: educate, document, notify
Hold for
- Digoxin: apical under 60
- Beta-blocker: HR under 60, SBP under 90
- Opioid: RR under 12 or hard to arouse
- Insulin: glucose under 70
Routes
- Never crush ER or enteric-coated
- Ear: adult up, under 3 down
- Bronchodilator first, rinse after steroid
- TB: wheal, read at 48 to 72 hours
Safety
- Error: assess the client first
- Incident report never in the chart
- Reconcile at every transition
- Teach-back every time
The printable version is in the Cheat Sheets library.
Lesson quiz · 1 of 5
A client with asthma uses an albuterol inhaler and a fluticasone inhaler. Which instruction is correct?
The bronchodilator opens the airways so the steroid can reach deeper. Rinsing after the steroid prevents oral thrush. Steroid first reverses the logic, and skipping the rinse leaves the mouth open to candidiasis.
Lesson quiz · 2 of 5
At transfer from the ICU, the reconciliation form still lists a heparin infusion that was stopped 2 hours ago. Enoxaparin 40 mg subQ daily starts tomorrow. What does the nurse do?
Every reconciliation discrepancy is resolved with the provider. Restarting heparin contradicts the order, and giving both doubles the anticoagulation. Crossing it off alone skips verification: the nurse finds the discrepancy, the provider resolves it.
Lesson quiz · 3 of 5
The nurse realizes morphine 10 mg IV was given instead of the ordered 4 mg. What does the nurse do first?
Assessment comes first after any error, because the findings guide every next step. The provider call follows right after, with the client's status. Naloxone may be needed, but only if the assessment shows respiratory depression or oversedation, and the incident report is never first.
Lesson quiz · 4 of 5
A client on warfarin for 6 months says a friend recommended fish oil for cholesterol. What is the best response?
Fish oil has antiplatelet effects that add to warfarin and raise bleeding risk, so the provider weighs in first. Natural does not mean safe, a ban on all supplements is not evidence-based, and starting first risks a bleed in the meantime.
Lesson quiz · 5 of 5
A newly diagnosed client is learning insulin self-injection. Which statement shows effective learning?
Rotating within one region prevents lipodystrophy while keeping absorption consistent. The same spot causes lipodystrophy, and insulin on a low glucose deepens the low (treat with the Rule of 15 first). Shaking damages insulin: cloudy insulin is rolled gently.
Wrap-up
0 / 5
Quiz score
Back to Mr. G · discharge day
Which meds do you hold? Digoxin, because HR 54, nausea, and K+ 3.2 are toxicity red flags, and metoprolol, because HR 54 is below parameters and his BP of 96/60 is soft. The warfarin goes: INR 2.4 is therapeutic.
In what order? Hold, then notify the provider with your findings, then document the assessment, the held doses, and the notification.
How do you know he understands? Teach-back. He explains in his own words that he keeps his vitamin K intake steady, not zero. If he can't, you reteach.
Keep going