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Study guide · Physiological Integrity

Pharmacological Therapies

10 to 16% of the exam · 16 activity statements

Pharmacological Therapies covers how the practical nurse checks, prepares, gives, calculates and evaluates medications, intravenous fluids and blood products, and how medications are counted, stored and taught. NCLEX-PN items test whether you apply the rights of medication administration, catch an unsafe prescription, gather the right data first, calculate accurately, recognize a dangerous response early and know which routes and tasks are the LPN/VN's and which belong to the RN.

A study feature written by ExamDragon, not part of the real exam. Each heading is one of the Related Activity Statements NCSBN lists for this category (16 of them), in our words; NCSBN's wording is in its Test Plan.

At a glance

Physiological Integrity
10 to 16%

of the exam (NCSBN's range)

Activity statements
16
Key terms
12

What this guide covers, statement by statement

  1. Apply the medication rights each time you give a drug
  2. Keep the medication list or record accurate and reconciled, including prescriptions, herbals and over-the-counter products
  3. Monitor a blood product transfusion
  4. Work out and watch the IV flow rate
  5. Give medications by mouth
  6. Give medications through gastrointestinal tubes
  7. Give injections by the intramuscular, subcutaneous or intradermal route
  8. Give medications into the ear, eye or nose, by inhalation, rectally, vaginally or on the skin
  9. Do controlled substance counts and report any mismatch
  10. Look after pain management devices such as epidurals, PCA pumps and nerve block catheters
  11. Give secondary (piggyback) IV medications
  12. Gather the data needed before giving a medication, such as contraindications and other drugs taken
  13. Judge how a client responds to a drug, including adverse reactions, interactions, intended effects and critical lab values
  14. Reinforce medication teaching with the client
  15. Keep medications safe through proper storage, expiry checks and compatibility checks
  16. Do the math needed to give medications

1Apply the medication rights each time you give a drug

  • The rights of medication administration: right client, drug, dose, route, time and documentation, plus right reason, right response and the client's right to refuse.
  • Identify the client with two identifiers, such as full name and date of birth, checked against the medication administration record; a room or bed number is never an identifier.
  • Do three checks: when taking the medication from storage, when preparing it and at the bedside before giving it; scanning a barcode supports the checks but does not replace them.
  • Give only medications you prepared yourself, prepare for one client at a time and do not leave doses at the bedside unless a prescription and policy allow it.
  • Document right after giving the dose, never before; if the client refuses, find out why, do not force it, report when it matters and document the refusal.
  • Know the drug before you give it: its purpose, usual dose, route, common adverse effects and what to check first.
  1. In practiceA client asks why today's tablet looks different from the one taken at home. The practical nurse stops, rechecks the prescription and the medication record, and confirms with pharmacy that it is a different manufacturer of the same drug before giving it. A client's question about a medication is a cue to recheck, not to reassure.
  2. Where questions turnAccepting a client's yes to "Are you Mr. Lee?" or a room number as identification instead of two identifiers checked against the record.
Practise this activity

2Keep the medication list or record accurate and reconciled, including prescriptions, herbals and over-the-counter products

  • Medication reconciliation compares what the client was taking before with what is prescribed now, at admission, transfer and discharge, to catch omissions, duplications and interactions.
  • Ask about prescriptions, over-the-counter products, herbal and dietary supplements, eye drops, inhalers, patches and as-needed medications, because clients often leave these out.
  • Record the name, dose, route, frequency and last dose taken, and report discrepancies to the RN or provider rather than deciding alone.
  • Keep the medication administration record current: new prescriptions added, discontinued ones stopped, and allergies and reactions listed.
  • Herbal products can interact (for example ginkgo and garlic increase bleeding risk, St. John's wort lowers the effect of many drugs); report them so the provider can decide.
  • A clear, reconciled list at discharge, taught to the client in plain words, lowers the risk of error at home.
  1. In practiceOn admission a client reports taking warfarin, a daily multivitamin and fish oil, but the admission prescriptions list only warfarin. The practical nurse records all three, notes that fish oil can add to bleeding risk and reports the discrepancy to the RN so the provider can reconcile the list.
  2. Where questions turnWriting down only prescription medications and leaving out herbal and over-the-counter products the client takes.
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3Monitor a blood product transfusion

  • Before a transfusion, confirm informed consent, a working large-bore IV, a current type and crossmatch, baseline vital signs and that the product is checked at the bedside by two qualified staff against the client's identifiers.
  • Use normal saline (0.9% sodium chloride) with blood; never add medications or other solutions to the blood line.
  • Start slowly and stay with the client for the first 15 minutes, when most severe reactions appear, then recheck vital signs per policy.
  • A transfusion unit is infused within 4 hours to limit bacterial growth.
  • If a reaction is suspected (fever, chills, back or flank pain, hives, dyspnea, hypotension, dark urine), stop the transfusion, keep the line open with saline through new tubing, and report to the RN and provider at once.
  • Monitoring the transfusion is within the practical nurse's role where policy allows; the RN confirms the order and the initial verification, and manages a reaction.
  1. In practiceTwenty minutes into a unit of packed red cells, a client develops a fever, chills and low back pain. The practical nurse stops the transfusion, keeps the IV open with normal saline through new tubing, takes vital signs and notifies the RN and provider, because these are signs of an acute hemolytic reaction.
  2. Where questions turnSlowing the transfusion and continuing to watch when reaction signs appear, instead of stopping it at once and keeping the line open with saline.
Practise this activity

4Work out and watch the IV flow rate

  • Flow rate in mL/h: divide the total volume (mL) by the total time (hours). For example 1,000 mL over 8 hours is 125 mL/h.
  • Drops per minute (gtt/min) by gravity: multiply the mL/h by the drop factor (gtt/mL) and divide by 60 min. Round to the nearest whole drop.
  • Check the drop factor on the tubing package (commonly 10, 15 or 20 gtt/mL for macrodrip, 60 gtt/mL for microdrip).
  • Count the drip rate for a full minute with a watch for gravity infusions, and recheck it when the client moves or the bag is changed.
  • A pump delivers the set mL/h but still needs checks: the right solution and rate, the site for infiltration or phlebitis, and the volume remaining.
  • Report an infusion that is far ahead of or behind schedule rather than simply speeding it up to catch up, especially with fluids that must run at a controlled rate.
  1. In practiceA prescription reads 1,000 mL of lactated Ringer's over 10 hours with tubing of 15 gtt/mL. The practical nurse calculates 100 mL/h, then 100 x 15 / 60 = 25 gtt/min, sets the gravity drip and counts the drops for a full minute to confirm the rate.
  2. Where questions turnOpening the roller clamp wide to catch up an infusion that has fallen behind, which can overload the client.
Practise this activity

5Give medications by mouth

  • Give oral medication with the client sitting up; offer water unless restricted, and stay until it is swallowed.
  • Do not crush enteric-coated, extended-release or sublingual tablets; ask the pharmacist for a liquid or another form when a client cannot swallow.
  • Place sublingual tablets under the tongue and buccal tablets against the cheek, and have the client let them dissolve without chewing or swallowing.
  • Give liquids with a calibrated oral syringe or cup, measured at eye level at the bottom of the meniscus.
  • Hold the dose and check first when the data say to: a heart rate below 60 for many cardiac drugs, a low potassium with a diuretic, or a client who is NPO.
  • Assess swallowing for a client at risk; coughing, a wet voice or pocketing is a reason to stop and report.
  1. In practiceBefore giving oral digoxin, the practical nurse counts an apical pulse for a full minute and gets 54 beats per minute. The nurse holds the dose and reports to the RN, because a pulse below 60 can signal digoxin's effect on the heart rate.
  2. Where questions turnCrushing an extended-release tablet to put in applesauce, which releases the whole dose at once.
Practise this activity

6Give medications through gastrointestinal tubes

  • Confirm tube placement and, where used, gastric residual before giving medication through a gastrointestinal tube, and keep the head of the bed raised.
  • Use liquid forms when available; if a solid must be used, confirm it may be crushed, crush it finely and dissolve it in water.
  • Give each medication separately and flush with water before, between and after medications (commonly about 15 to 30 mL as policy states) to prevent clogging.
  • Do not add medications to the feeding formula.
  • Hold a tube feeding around certain drugs when the reference says to (for example phenytoin), restarting after the set time so absorption is not reduced.
  • If the tube is clogged, try warm water and gentle pressure with a large syringe; do not force it, and report if it stays blocked.
  1. In practiceA client with a nasogastric tube is prescribed two crushable tablets. The practical nurse raises the head of the bed, checks placement, flushes with water, gives each dissolved medication separately with a flush between, then flushes again after the last one.
  2. Where questions turnMixing several crushed tablets together and pushing them down the tube without flushes, which clogs the tube and makes dosing unreliable.
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7Give injections by the intramuscular, subcutaneous or intradermal route

  • Subcutaneous: a 45 to 90 degree angle, a 25 to 30 gauge short needle, small volumes (usually up to 1 mL); sites include the abdomen, upper outer arm and thigh, rotated to prevent lipohypertrophy.
  • Insulin is given subcutaneously; do not aspirate or massage; when mixing, draw up the clear (regular) before the cloudy (NPH).
  • Heparin subcutaneous: a 90 degree angle into the abdomen at least 2 inches from the navel, no aspiration, no massage, and do not rub the site.
  • Intradermal: a 5 to 15 degree angle just under the skin, a small volume forming a bleb, used for tuberculosis testing and allergy testing; do not massage.
  • Intramuscular: a 90 degree angle, a 1 to 1.5 inch needle, into the ventrogluteal site for most adults (away from large nerves and vessels), the vastus lateralis for infants; use the Z-track method for irritating drugs.
  • Document the site, rotate sites, and check an injection site later for redness, swelling or a hard lump, reporting any you find.
  1. In practiceThe practical nurse prepares a morning dose of NPH and regular insulin. The nurse injects air into the NPH vial, then the regular vial, draws up the regular (clear) insulin first and then the NPH (cloudy), and gives it subcutaneously at a 90 degree angle without aspirating or massaging.
  2. Where questions turnDrawing up cloudy NPH before clear regular insulin, which can contaminate the regular vial with the longer-acting insulin.
Practise this activity

8Give medications into the ear, eye or nose, by inhalation, rectally, vaginally or on the skin

  • Eye drops: pull down the lower lid, drop into the conjunctival sac (not on the cornea), then press the inner corner for about a minute to limit systemic absorption; wait 5 minutes between different drops.
  • Ear drops: for an adult pull the pinna up and back, for a child under 3 down and back; warm the drops to room temperature and have the client lie with the ear up for a few minutes.
  • Nasal: have the client blow the nose first; position the head per the drug, and teach correct technique for sprays.
  • Inhalers: shake a metered-dose inhaler, use a spacer when available, press and breathe in slowly, hold the breath about 10 seconds; rinse the mouth after an inhaled corticosteroid to prevent thrush.
  • Rectal and vaginal: provide privacy, position correctly (left side for a rectal suppository), lubricate, and have a vaginal client stay lying down for a time afterward.
  • Topical and transdermal: wear gloves, remove the old patch and clean the skin, rotate sites, and document the location; fold and discard old patches safely because they still hold drug.
  1. In practiceA client with asthma uses a metered-dose inhaler with a corticosteroid. The practical nurse reinforces using a spacer, breathing in slowly, holding the breath, and rinsing the mouth afterward to prevent oral thrush.
  2. Where questions turnDropping eye medication straight onto the cornea or skipping the mouth rinse after an inhaled corticosteroid.
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9Do controlled substance counts and report any mismatch

  • Count controlled substances with a second qualified nurse at shift change and when policy requires, matching the amount on hand to the record.
  • Report any discrepancy right away to the charge nurse or supervisor and follow policy; do not simply adjust the record.
  • Waste a partial dose with a witness at the time of wasting, and both sign; never waste alone or later from memory.
  • Keep controlled substances double-locked, and account for every dose given, wasted or returned.
  • A pattern of discrepancies or signs that a coworker may be diverting drugs is reported through the chain of command.
  • Accurate counts protect clients from undertreatment and protect staff from false suspicion.
  1. In practiceAt shift change the controlled substance count is one tablet short. The practical nurse and the oncoming nurse recount, then report the discrepancy to the charge nurse at once and follow policy to investigate, rather than writing it off.
  2. Where questions turnChanging the count record to make it match instead of reporting and investigating the discrepancy.
Practise this activity

10Look after pain management devices such as epidurals, PCA pumps and nerve block catheters

  • Patient-controlled analgesia (PCA) lets the client press a button for a set dose with a lockout interval; only the client presses the button, never family or staff.
  • Check the pump settings, the dose, the lockout, the total given and the amount of drug remaining against the prescription at the start of care and each shift.
  • Monitor for oversedation and slow breathing; a respiratory rate below the set limit or increasing sedation is reported, and naloxone and resuscitation equipment are kept available.
  • An epidural or nerve catheter site is kept clean and dry; report leakage, redness, numbness that spreads, leg weakness or a fever.
  • Do not give other opioids or sedatives around a PCA or epidural opioid without checking with the RN or provider, because the effects add together.
  • Managing and programming these devices is largely the RN's role; the practical nurse monitors, reinforces how the device works and reports problems.
  1. In practiceA client on a morphine PCA becomes hard to rouse with a respiratory rate of 8. The practical nurse stops further dosing, stimulates the client, applies oxygen, keeps naloxone and the RN at hand and reports at once, because these are signs of opioid oversedation.
  2. Where questions turnPressing the PCA button for a sleeping client to keep the pain controlled, which can cause a dangerous overdose.
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11Give secondary (piggyback) IV medications

  • An IV piggyback (secondary) is a small-volume infusion of a medication that runs into an existing primary line, often over 30 to 60 minutes.
  • Check compatibility of the medication with the primary fluid and with anything else running; when in doubt, ask pharmacy.
  • Hang the piggyback bag higher than the primary bag so it infuses first, and set the rate the prescription states.
  • Inspect the IV site for infiltration, phlebitis and patency before and during the infusion, and flush per policy.
  • Stay alert for an infusion reaction, especially with the first dose of an antibiotic; stop and report flushing, rash, itching or dyspnea.
  • IV piggyback is in the PN statements; IV push is in most states the RN's (the PN gives it only where state law and facility policy allow), and chemotherapy and many high-risk IV drugs remain the RN's.
  1. In practiceThe practical nurse hangs an antibiotic piggyback and, ten minutes in, the client reports itching and a spreading rash. The nurse stops the infusion, keeps the line open with the compatible primary fluid, takes vital signs and reports to the RN, because these can be the start of an allergic reaction.
  2. Where questions turnHanging the piggyback lower than the primary bag, so it does not infuse as intended, or ignoring compatibility with the running fluid.
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12Gather the data needed before giving a medication, such as contraindications and other drugs taken

  • Before giving a medication, gather the data the drug requires: allergies, current medications, the reason for the drug and the relevant vital signs or laboratory values.
  • Common checks: apical pulse before many cardiac drugs, blood pressure before antihypertensives, blood glucose before insulin, potassium before and during diuretics, and an INR before warfarin.
  • Know the contraindications: do not give a drug the client is allergic to, or one held by a parameter the prescriber set (for example hold if systolic blood pressure is below 100).
  • Check for interactions, including food and herbal products, and for pregnancy or breastfeeding when it matters.
  • Confirm the client is not NPO for a procedure when that would change whether a dose is given.
  • If the data show the dose could harm the client, hold it and report to the RN or provider before giving it.
  1. In practiceBefore a scheduled dose of metoprolol, the practical nurse checks the blood pressure at 92/58 and the heart rate at 56, both below the hold parameters the prescriber set. The nurse holds the dose, documents the readings and reports to the RN.
  2. Where questions turnGiving a rate-control or blood pressure medication without checking the pulse and blood pressure the prescription set as hold parameters.
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13Judge how a client responds to a drug, including adverse reactions, interactions, intended effects and critical lab values

  • After a medication, watch for the intended effect (for example a lower blood pressure, relief of pain, a fall in blood glucose) and document whether it worked.
  • Watch for adverse effects and allergic reactions: rash, itching, swelling, wheeze and hypotension can mean anaphylaxis and are an emergency.
  • Know the signs of toxicity for narrow-range drugs: digoxin (nausea, visual changes, slow or irregular pulse), lithium (tremor, confusion, diarrhea) and report with the related level.
  • Review critical laboratory values linked to the drug, such as potassium with digoxin or a diuretic, INR with warfarin and glucose with insulin, and report values outside the range.
  • Report a serious or unexpected response to the RN or provider, and hold further doses when the response makes that unsafe.
  • Document what you observed and what you reported, and reassess at the time the drug is expected to act.
  1. In practiceA client on digoxin reports nausea and seeing yellow-green halos, and the apical pulse is 50 and irregular. The practical nurse holds the next dose, reports to the RN and asks that a digoxin level and potassium be checked, because these are classic signs of digoxin toxicity.
  2. Where questions turnTreating nausea and visual changes in a client on digoxin as unrelated complaints instead of possible toxicity.
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14Reinforce medication teaching with the client

  • Reinforce the teaching the RN or provider started: the drug's name, purpose, how and when to take it, and what to do about a missed dose.
  • Teach the common adverse effects and which ones to report, in plain language and the client's own language with an interpreter when needed.
  • Cover key safety points: take an antibiotic exactly as prescribed and do not stop early without asking the prescriber, do not stop a beta blocker or steroid suddenly, avoid alcohol with sedatives, and know which foods or drugs to avoid.
  • For warfarin, teach a steady intake of vitamin K foods and to report bleeding; for an MAOI, teach to avoid tyramine-rich foods.
  • Have the client teach back the key points so you can confirm understanding and correct gaps.
  • Report questions beyond your scope or a need to change the plan to the RN or provider; the practical nurse reinforces, and does not start new teaching on a new diagnosis.
  1. In practiceA client going home on an oral antibiotic says she usually stops when she feels better. The practical nurse reinforces taking it exactly as prescribed, not stopping early without asking the primary health care provider, explains why, and asks the client to repeat the plan back before discharge.
  2. Where questions turnTelling a client it is fine to stop an antibiotic on her own once symptoms improve, instead of taking it exactly as prescribed.
Practise this activity

15Keep medications safe through proper storage, expiry checks and compatibility checks

  • Store medications as labeled: some need refrigeration, some protection from light, and some are stable only for a set time once opened or reconstituted.
  • Check the expiration date every time and do not use an expired or discolored medication; return or discard it per policy.
  • Keep medications in their labeled containers, keep look-alike and sound-alike drugs apart, and keep high-alert drugs where policy directs.
  • Keep controlled substances double-locked and counted, and keep all medications out of reach of children and confused clients.
  • Check compatibility before mixing or co-infusing drugs, using a reference or pharmacy.
  • Label anything you prepare with the drug, dose, date and time, and never give a medication from an unlabeled container.
  1. In practiceThe practical nurse finds a multidose vial of insulin with no opening date and a reconstituted antibiotic past its stability time. The nurse removes both from use per policy, because a drug past its stability or expiry can be weakened or unsafe.
  2. Where questions turnGiving a medication from an unlabeled syringe or cup because you believe you remember what it is.
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16Do the math needed to give medications

  • Set up the calculation so units cancel (dimensional analysis): desired dose over available dose, times the amount, leaves the unit you want.
  • Convert to the same units first: 1 g = 1,000 mg, 1 mg = 1,000 mcg, 1 kg = 1,000 g, 1 L = 1,000 mL, 1 kg = 2.2 lb.
  • Weight-based dose: multiply the dose per kg by the client's weight in kg; convert pounds to kilograms first.
  • For tablets and liquids, Desired / Have x Quantity gives the amount to give; a reasonable answer is usually a whole or half tablet, not many tablets.
  • Round as the prescription or policy states, label the answer with its unit, and do an independent double check for high-alert drugs such as insulin, heparin and pediatric doses.
  • Sanity-check the result: a dose that comes out as many tablets or a huge volume is a signal to stop and recheck.
  1. In practiceA child who weighs 22 lb is prescribed a medication at 5 mg/kg/day in two divided doses. The practical nurse converts 22 lb to 10 kg, calculates 50 mg/day, divides into 25 mg per dose, and has a second nurse check the pediatric calculation before giving it.
  2. Where questions turnUsing the weight in pounds instead of kilograms in a weight-based dose, which more than doubles the calculated amount.
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Key terms

Rights of medication administration
Right client, drug, dose, route, time and documentation, plus right reason, right response and the right to refuse.
Medication reconciliation
Comparing a client's prior medications with those prescribed now to catch omissions, duplications and interactions.
High-alert medication
A drug that can cause serious harm when given in error, such as insulin, heparin, opioids and potassium chloride.
Drop factor
The number of drops per mL a gravity tubing delivers, such as 10, 15, 20 or 60 gtt/mL.
Dimensional analysis
A calculation method that writes units as fractions so unwanted units cancel and the wanted unit remains.
Z-track method
An intramuscular technique that pulls the skin aside before injection so an irritating drug does not track back out.
Independent double check
Two nurses each verify a medication and its calculation separately, then compare results.
Acute hemolytic reaction
Destruction of transfused red cells, usually from ABO incompatibility, with fever, back pain, hypotension and dark urine.
PCA
Patient-controlled analgesia: a pump the client activates for a set dose within a lockout interval; only the client presses the button.
Trough level
The lowest blood level of a drug, drawn just before the next dose.
Therapeutic range
The blood level that gives benefit without toxicity; narrow for drugs such as digoxin and lithium.
Infiltration
Leakage of a nonvesicant IV solution into the tissue around the catheter.

After this guide: After this guide you should be able to give medications safely as a practical nurse by the routes within your scope, calculate doses and flow rates accurately, gather and act on the right data before and after a dose, and know what to report to the RN or provider.

Practise Pharmacological Therapies