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Study guide · Physiological Integrity

Pharmacological and Parenteral Therapies

14 to 20% of the exam · 22 activity statements

Pharmacological and Parenteral Therapies covers how the practical nurse reconciles, stores, checks, calculates, prepares, gives and evaluates medications by every route, and how the nurse monitors IV infusions, blood products, parenteral nutrition, pain control devices and subcutaneous infusions. REx-PN items test whether you apply the rights of medication administration, check the data that should stop a dose, calculate accurately in metric units, recognize a harmful response early and know when to consult the RN, the pharmacist, the primary health care provider or the employer's policy because parenteral scope differs by province, employer and individual competence.

A study feature written by ExamDragon, not part of the real exam. Each heading is one of the Related Activity Statements the Test Plan lists for this category (22 of them), in our words; the official wording is in the Test Plan.

At a glance

Physiological Integrity
14 to 20%

of the exam (the Test Plan's range)

Activity statements
22
Key terms
14

What this guide covers, statement by statement

  1. Take part in reconciling a client's medications
  2. Store and keep medications safe and secure
  3. Teach the client about their medications
  4. Work out medication doses correctly
  5. Check relevant data, such as allergies, labs and interactions, before giving a medication
  6. Prepare and give medications following the rights of administration
  7. Watch a client who is receiving a blood product
  8. Judge how the client responds to a medication
  9. Handle or give controlled drugs as the law requires
  10. Watch IV infusions and look after the site
  11. Use a peripheral IV access device
  12. Adjust a medication dose within ordered limits based on your assessment
  13. Watch a client on parenteral nutrition and judge the response
  14. Handle or give high-alert medications
  15. Give medications by mouth
  16. Give medications through a feeding tube
  17. Give injections under the skin, into the skin or into muscle
  18. Give medications into the ear, eye or nose, by inhaler, rectally, vaginally or on the skin
  19. Give IV medications as a piggyback
  20. Work out and watch the IV flow rate
  21. Look after pain control devices such as PCA pumps or nerve catheters
  22. Start a subcutaneous infusion that runs continuously, keep it running and take it out

1Take part in reconciling a client's medications

  • Reconciliation compares what the client actually takes with what is prescribed now, at admission, transfer and discharge.
  • A best possible medication history uses at least two sources: the client or caregiver interview plus pharmacy records, containers from home or a recent list.
  • Ask about nonprescription drugs, vitamins, herbal and cannabis products, inhalers, patches, eye drops and injections the client may not think of as medications.
  • Flag every unexplained omission, duplication, dose change or interacting combination to the prescriber; intended changes need a documented reason.
  • The practical nurse gathers the history and identifies discrepancies; the prescriber resolves them.
  1. In practiceA client admitted from home lists five medications, but the community pharmacy record shows a sixth, an eye drop for glaucoma. The nurse adds it to the history and brings the omission to the primary health care provider. Eye drops, patches and inhalers are the products most often missed.
  2. Where questions turnAssuming an omission on the admission prescriptions was intended and recording it that way instead of asking the prescriber.
Practise this activity

2Store and keep medications safe and secure

  • Medications are stored securely: carts and rooms locked, access limited to authorized staff.
  • Follow storage conditions on the label: refrigerated products at 2 to 8 °C, never frozen unless labelled, protected from light when required.
  • Opened multi-dose vials and pens are labelled with the date opened and the discard date, and are used for one client only.
  • Separate look-alike, sound-alike drugs, keep internal and external products apart and remove expired or contaminated stock.
  • Vaccines follow the cold chain: temperatures are logged, and an excursion is reported before the product is used.
  1. In practiceThe nurse finds a client's insulin pen in an unlocked bedside drawer with no date on it. The nurse returns it to secure storage and follows policy for an undated opened pen, which usually means discarding it and obtaining a new one. Safe storage protects both the dose's potency and other people.
  2. Where questions turnUsing a refrigerated product, such as a vaccine, that has been outside its temperature range before the excursion has been assessed.
Practise this activity

3Teach the client about their medications

  • The practical nurse teaches clients about medications within the plan of care: purpose, how and when to take it, key adverse effects and what to report.
  • Teach the safety points that prevent harm first: for example, bleeding signs with anticoagulants or staying upright after an oral bisphosphonate.
  • Use plain language and check understanding with teach-back, asking the client to explain in their own words.
  • Cover interactions with food, alcohol, nonprescription drugs and herbal products, and what to do about a missed dose.
  • Questions beyond the nurse's knowledge or scope go to the pharmacist or prescriber.
  1. In practiceA client going home on a new anticoagulant is taught to report black stools and to avoid ibuprofen. The nurse asks the client to say what they will watch for and which pain reliever they will use. Teach-back reveals gaps that a yes to "Do you understand?" hides.
  2. Where questions turnChoosing a client statement that sounds positive but contains the unsafe practice, such as taking a medication with a food that blocks it.
Practise this activity

4Work out medication doses correctly

  • Use one method consistently: desired over have times quantity, or dimensional analysis.
  • Convert to the same unit before calculating (1 g = 1,000 mg, 1 mg = 1,000 mcg) to avoid tenfold and thousandfold errors.
  • For weight-based doses use kilograms, confirm the weight is current and check the dose falls in a safe range.
  • Round only at the end and as the item states: whole number or a stated number of decimal places.
  • Ask whether the answer makes sense: an oral dose of 12 tablets or an injection of 15 mL means a recheck.
  • Use a leading zero (0.5 mL) and never a trailing zero (5 mL, not 5.0 mL) when writing doses.
  1. In practiceA child weighing 18.4 kg is prescribed acetaminophen 15 mg/kg, and the suspension is 160 mg/5 mL. The nurse works out 276 mg, then 8.625 mL, and rounds at the end to 8.6 mL. Here the dose in milligrams is a whole number; when it is not, the nurse carries the full figure forward and rounds only the volume.
  2. Where questions turnForgetting to convert micrograms to milligrams, or rounding partway through the calculation.
Practise this activity

5Check relevant data, such as allergies, labs and interactions, before giving a medication

  • Before each medication check allergies, the drug's purpose, contraindications and current data that could make the dose unsafe.
  • Check the relevant results: potassium before diuretics and digoxin, kidney function before metformin, INR before warfarin, capillary glucose before insulin.
  • Check vital signs that matter: apical pulse and blood pressure before cardiac drugs, respiratory rate and sedation before opioids.
  • Look for interactions with other drugs, food and nonprescription products, such as nitrates with sildenafil.
  • When a finding makes the dose unsafe, hold it and report to the prescriber; the nurse does not change the dose alone.
  1. In practiceA client is due for furosemide, and this morning's potassium is 3.0 mmol/L (3.5 to 5.0 mmol/L). The nurse holds the dose and reports the result to the primary health care provider. A diuretic would lower the potassium further.
  2. Where questions turnGiving the dose and planning to report the abnormal result afterward, or changing the dose without a prescription.
Practise this activity

6Prepare and give medications following the rights of administration

  • The rights: right client, drug, dose, route, time and documentation, plus right reason, right response and the right to refuse.
  • Identify the client with two identifiers checked against the MAR; a room or bed number is never an identifier.
  • Check the label against the MAR three times, prepare medications for one client at a time and give only what you prepared.
  • Time-critical drugs, such as levodopa and insulin, are planned around tests and therapy so they are not late.
  • A capable client may refuse: explore why, hold the dose, report when it matters and document the refusal.
  • Document only after the dose is taken, and restart your checks after any interruption.
  1. In practiceA resident in long-term care without an identification band says their name and date of birth, and the nurse compares these and the MAR photo before giving medications. Two identifiers are confirmed even when the nurse knows the resident well.
  2. Where questions turnAccepting a yes to "Are you Mrs. Okafor?" or a room number as identification.
Practise this activity

7Watch a client who is receiving a blood product

  • Before a transfusion, two qualified people check the client's identity and the blood product at the bedside against the prescription.
  • Take baseline vital signs, then monitor as policy sets, watching closely in the first 15 minutes when severe reactions usually start.
  • Use only 0.9% sodium chloride with blood, give nothing else through the blood line and complete each unit within 4 hours of leaving storage.
  • Signs of a reaction: fever of 1 °C or more above baseline, chills, hives, dyspnea, back or chest pain, hypotension or hypertension.
  • For any suspected reaction: stop the transfusion, keep the vein open with 0.9% sodium chloride through new tubing, stay with the client and report.
  • Who may start a transfusion depends on the setting and policy; every nurse caring for the client monitors it.
  1. In practiceAn older client with heart failure becomes short of breath with crackles and a rising blood pressure during a second unit. The nurse stops the transfusion, sits the client up and reports at once. Without a fever, this pattern suggests circulatory overload.
  2. Where questions turnSlowing the transfusion or treating the fever while the blood keeps running instead of stopping it.
Practise this activity

8Judge how the client responds to a medication

  • Evaluate each medication against its purpose: pain relief, lower blood pressure, easier breathing, more urine output, a normal glucose.
  • Know the expected timing: a bronchodilator acts in minutes, an antihypertensive over days to weeks.
  • Separate expected side effects (opioid constipation, tremor with salbutamol) from adverse effects that need reporting (angioedema, respiratory depression).
  • Compare findings with the baseline and document the response, especially after as-needed doses.
  • Report a medication that is not working or a serious adverse effect to the prescriber.
  1. In practiceThirty minutes after an as-needed oral opioid, the nurse reassesses the client's pain, sedation and respiratory rate. Pain is down from 7 to 3 out of 10 and the client is alert. The nurse records the response, which guides the next dose.
  2. Where questions turnChoosing a side effect, such as a faster heart rate after salbutamol, as the sign the drug worked.
Practise this activity

9Handle or give controlled drugs as the law requires

  • Controlled substances are stored under double lock and handled according to federal law and facility policy.
  • Sign out each dose on the controlled drug record when it is removed.
  • Waste any unused portion in front of a second authorized nurse, and both sign the record.
  • Count with a second nurse at shift change; a discrepancy is investigated before the outgoing nurse leaves and reported if unresolved.
  • Never pre-sign, borrow from another client's supply or leave a prepared controlled drug unattended; suspected diversion is reported.
  1. In practiceA client is prescribed hydromorphone 1 mg and the ampoule holds 2 mg. The nurse draws up 1 mg, wastes the rest in front of a second nurse, and both sign. Every milligram is then accounted for.
  2. Where questions turnSigning a count as correct or wasting a dose alone and planning to get a witness's signature later.
Practise this activity

10Watch IV infusions and look after the site

  • Check the IV site and infusion at set intervals and whenever the client reports discomfort: site, dressing, tubing, fluid, rate and volume infused.
  • Infiltration: cool, pale, swollen skin and a slowing infusion; stop the infusion first.
  • Phlebitis: redness, warmth, pain and a cord-like vein; stop the infusion at that site and follow policy.
  • Infection: purulent drainage, redness, swelling and possibly fever; report it.
  • Keep the system closed and the dressing clean, dry and intact; a disconnected or contaminated line is replaced, not reconnected.
  • Removal and restart of a peripheral IV follow employer policy and the nurse's competence.
  1. In practiceOn an hourly check, the nurse finds the area around an IV cool and swollen with the pump behind schedule. The nurse stops the infusion, follows policy to remove the catheter, elevates the arm and reports. Infiltration is caught early by regular site checks.
  2. Where questions turnFlushing or speeding up a slow infusion before checking the site for infiltration.
Practise this activity

11Use a peripheral IV access device

  • Before using a peripheral venous access device, check that it is patent and in the vein: no pain, no swelling and an easy flush.
  • Clean hands, then scrub the needleless connector with antiseptic and let it dry before every access.
  • Flush with 0.9% sodium chloride in a 10 mL syringe using a gentle push-pause technique.
  • If you feel resistance, stop: check clamps, kinks and arm position, and never force a flush.
  • Pain, burning or swelling during a flush means the device is not used; follow policy and report.
  • Who accesses which device follows employer policy and the nurse's competence; central lines usually need added training.
  1. In practiceAs the nurse flushes a saline lock, the client says it burns and the skin swells. The nurse stops and does not use the device. Giving a drug into tissue causes injury and the dose never reaches the circulation.
  2. Where questions turnUsing a small syringe or more force to clear resistance, which can rupture the catheter or push a clot in.
Practise this activity

12Adjust a medication dose within ordered limits based on your assessment

  • A titration order gives a range and a target: a dose range for pain, a correction scale for glucose, or hold parameters for heart rate and blood pressure.
  • Assess first, then choose the dose within the range that fits the findings and the target.
  • Read hold parameters as written: if any listed parameter is outside its limit, hold the dose, recheck and report.
  • Reassess after each adjustment and document the findings and the dose chosen.
  • Never go above or below the prescribed range without a new prescription; report when the target is not met.
  1. In practiceA client with a hydromorphone range of 1 to 2 mg had little relief from 1 mg four hours ago and is alert with normal respirations. The nurse gives 2 mg and reassesses sedation and pain in 30 to 60 minutes. The range lets the nurse respond to the assessment.
  2. Where questions turnGiving a dose because one parameter is within limits while another listed parameter is outside its limit.
Practise this activity

13Watch a client on parenteral nutrition and judge the response

  • Parenteral nutrition runs on a pump at a constant prescribed rate through a dedicated lumen.
  • Never speed it up to catch up or stop it abruptly; a delay or interruption is handled by policy and reported.
  • Monitor capillary glucose as prescribed, daily weight, intake and output, temperature and the catheter site.
  • Hyperglycemia (thirst, polyuria) and infection are the main risks; rebound hypoglycemia follows a sudden stop.
  • Nothing is added to the bag or the line except by pharmacy; medications and blood draws use another lumen.
  • The practical nurse monitors and reports; central line care follows employer policy and competence.
  1. In practiceA client on parenteral nutrition says they are very thirsty and urinating often. The nurse checks capillary glucose first and then acts on the prescribed parameters or reports the result. The high dextrose load commonly causes hyperglycemia.
  2. Where questions turnIncreasing the rate to make up for time lost when the infusion was paused.
Practise this activity

14Handle or give high-alert medications

  • High-alert medications cause serious harm when given in error: insulin, heparin and other anticoagulants, opioids, concentrated electrolytes and some others.
  • Follow policy for an independent double check: a second qualified person verifies the prescription, product and dose on their own before comparing.
  • Check concentrations carefully, because strengths look alike; use standard concentrations and smart pumps where provided.
  • Insulin pens and vials are for one client only; a new needle does not make sharing safe.
  • Know the antidote and the warning signs: hypoglycemia with insulin, bleeding with anticoagulants, sedation with opioids.
  1. In practiceBefore giving insulin from a vial, the nurse asks a second nurse to check. The second nurse reads the prescription and the vial and works out the dose without being told it. The two answers match, and the dose is given.
  2. Where questions turnTreating a second nurse who only watches or is told the dose as an independent double check.
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15Give medications by mouth

  • Check that the client can swallow safely and sit the client upright before giving oral medications.
  • Do not crush or split extended-release, enteric-coated or sublingual products; ask the pharmacist for another form.
  • Sublingual tablets dissolve under the tongue and buccal products sit between cheek and gum; neither is swallowed.
  • Measure liquids with an oral syringe or a marked medicine cup at eye level.
  • Stay until the client takes the medication; do not leave doses at the bedside unless prescribed and allowed by policy.
  • Before surgery or a test, check which oral medications to give with a sip of water and which to hold.
  1. In practiceA client who has trouble swallowing is prescribed an extended-release tablet. The nurse asks the pharmacist or prescriber for another form instead of crushing it. Crushing would release the whole dose at once.
  2. Where questions turnCrushing a modified-release tablet into applesauce to make it easier to swallow.
Practise this activity

16Give medications through a feeding tube

  • Confirm tube placement according to policy before giving anything through the tube.
  • Pause the feeding and flush with water before, between and after each medication, using an enteral syringe.
  • Give medications one at a time, in liquid form where available; never mix them into the formula.
  • Do not crush enteric-coated or modified-release products; some drugs need the feeding held longer, as prescribed.
  • If the flow slows, do not force it; check for kinks and follow policy for a blocked tube.
  • Keep enteral and IV supplies separate to prevent wrong-route errors.
  1. In practiceA client on a continuous gastrostomy feeding has three medications due. The nurse pauses the feed, flushes with water, gives each medication separately with a flush between, then flushes and restarts the feed. Separate doses prevent interactions and blockage.
  2. Where questions turnAdding crushed medications to the feeding bag to save time.
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17Give injections under the skin, into the skin or into muscle

  • Subcutaneous: 45 to 90 degrees depending on needle length and tissue; abdomen, thigh or upper arm; rotate sites.
  • Intradermal: bevel up, about 5 to 15 degrees, a small bleb forms; do not massage.
  • Intramuscular: ventrogluteal for adults and larger volumes, deltoid for small volumes such as most vaccines, vastus lateralis for infants.
  • Enoxaparin from a prefilled syringe: keep the air bubble, inject into the abdomen and do not rub.
  • Use a safety-engineered needle and discard it at once in a sharps container; do not recap.
  1. In practiceAn infant of 4 months needs an intramuscular vaccine. The nurse uses the vastus lateralis in the anterolateral thigh. The deltoid is too small in infants.
  2. Where questions turnChoosing the deltoid for a large intramuscular volume or massaging an intradermal or enoxaparin site.
Practise this activity

18Give medications into the ear, eye or nose, by inhaler, rectally, vaginally or on the skin

  • Eye: drop into the lower conjunctival sac without touching the eye, then gentle pressure on the inner corner; wait between different drops.
  • Ear: warm drops to room temperature; adults pinna up and back, young children down and back.
  • Inhaled: shake the metered-dose inhaler, use a spacer, give the bronchodilator before the corticosteroid and rinse the mouth after the corticosteroid.
  • Rectal: left side-lying with the upper knee bent; insert the suppository past the internal sphincter.
  • Skin and patches: wear gloves, remove the old patch or ointment, rotate sites and avoid heat over patches.
  • Nasal and vaginal products follow the label and the client's position for retention.
  1. In practiceA client uses salbutamol and fluticasone inhalers. The nurse reinforces using salbutamol first, waiting about a minute and rinsing the mouth after fluticasone. This opens the airways and prevents oral thrush.
  2. Where questions turnPulling an adult's pinna down and back, or using the corticosteroid inhaler first or for acute symptoms.
Practise this activity

19Give IV medications as a piggyback

  • A secondary (piggyback) infusion runs through the primary line; its bag hangs higher than the primary bag.
  • Check compatibility of the secondary drug with the primary fluid and any other drug in the line; consult pharmacy when unsure.
  • Program the secondary rate and volume on the pump, open the secondary clamp and confirm the secondary is running.
  • After the secondary finishes, check that the primary has resumed at its prescribed rate.
  • Which IV medications the practical nurse gives follows employer policy, provincial scope and individual competence; IV push is not assumed.
  1. In practiceFive minutes after starting a piggyback, the nurse sees the secondary bag still full. The nurse finds it hanging level with the primary bag, raises it and confirms the drip chamber is now filling from the secondary. Height decides which bag runs.
  2. Where questions turnConnecting a secondary medication labelled as incompatible with the primary fluid and watching for a precipitate.
Practise this activity

20Work out and watch the IV flow rate

  • Pump rate: mL/h = total volume (mL) / time (h).
  • Gravity rate: gtt/min = (volume (mL) x drop factor (gtt/mL)) / time (min).
  • Time to infuse: hours = volume (mL) / rate (mL/h).
  • Check the rate and volume infused against the prescription at each check and at the start of the shift.
  • If an infusion is behind or ahead, do not catch up or slow down on your own; correct a pump error to the prescribed rate and report.
  • Signs of fluid overload from a fast rate: dyspnea, crackles, rising blood pressure and distended neck veins.
  1. In practiceA client's pump is running at 150 mL/h instead of the prescribed 75 mL/h, and the client is short of breath with crackles. The nurse slows the infusion, sits the client up and reports. The error is documented after the client is safe.
  2. Where questions turnSpeeding up a behind-schedule infusion to finish on time, or rounding before the last step of the calculation.
Practise this activity

21Look after pain control devices such as PCA pumps or nerve catheters

  • Patient-controlled analgesia is safe because only the client presses the button; a drowsy client stops pressing.
  • Family and staff do not press the button for the client; teach this at the start.
  • Check pump settings against the prescription, and assess sedation, respiratory rate and pain at set intervals.
  • Increasing sedation is the earliest sign of opioid toxicity: stop the PCA, rouse the client, call for help and give naloxone per protocol.
  • With a peripheral nerve catheter, the blocked limb is numb and protected; tinnitus, metallic taste or perioral numbness suggest local anesthetic toxicity.
  • Only the prescriber changes settings; the nurse maintains the device as policy and competence allow.
  1. In practiceThe nurse sees a family member press the PCA button while the client sleeps. The nurse explains that only the client presses it because sleep shows the dose is enough. Pressing by proxy removes the safety design.
  2. Where questions turnAssuming the lockout makes it safe for someone other than the client to press the button.
Practise this activity

22Start a subcutaneous infusion that runs continuously, keep it running and take it out

  • A continuous subcutaneous infusion delivers fluids or medications, such as palliative symptom drugs, through a small cannula in the fatty tissue.
  • Choose a site with enough subcutaneous tissue: upper chest, abdomen, upper arm, thigh, or the subscapular area for a restless client.
  • Avoid edematous, bony, irradiated, broken or bruised skin.
  • Blood in the tubing after insertion means a vessel was entered: remove and place a new cannula elsewhere.
  • Check the site at set intervals for redness, swelling, hardness, leaking and pain; any of these means a new site.
  • To remove: stop the infusion, remove the dressing and cannula, apply pressure and confirm the cannula is intact.
  1. In practiceA palliative client with delirium keeps pulling at lines. The nurse places the subcutaneous cannula below the shoulder blade, out of reach. Choosing the site well keeps the infusion running and the client comfortable.
  2. Where questions turnPlacing the cannula in a swollen limb, or continuing an infusion at a site that is red, hard and leaking.
Practise this activity

Key terms

Rights of medication administration
Right client, drug, dose, route, time and documentation, plus right reason, right response and the right to refuse.
Best possible medication history
A complete list of what the client actually takes, built from at least two sources.
Medication reconciliation
Comparing the client's medication history with current prescriptions at each transition to catch discrepancies.
High-alert medication
A drug that causes serious harm when given in error, such as insulin, heparin, opioids and concentrated electrolytes.
Independent double check
A second qualified person verifies the prescription, product and dose on their own before comparing results.
Drop factor
The number of drops per mL a gravity tubing delivers, such as 10, 15, 20 or 60 gtt/mL.
Secondary (piggyback) infusion
An intermittent IV medication run through the primary line from a bag hung higher than the primary.
Infiltration
IV fluid leaking into surrounding tissue, shown by cool, pale, swollen skin.
Phlebitis
Inflammation of the vein, shown by redness, warmth, pain and a cord-like vein.
Circulatory overload
Fluid excess from an infusion or transfusion, with dyspnea, crackles and rising blood pressure.
Parenteral nutrition
Nutrients given intravenously through a dedicated central or peripheral line at a constant rate.
Patient-controlled analgesia (PCA)
A pump that lets the client give themselves set opioid doses within programmed limits.
Continuous subcutaneous infusion
Fluids or medications infused steadily into fatty tissue through a small cannula (hypodermoclysis for fluids).
Controlled substance
A drug regulated by federal law, counted and signed for at every step, such as opioids.

After this guide: After this guide you should be able to give any medication safely by the routes in the practical nurse's practice, calculate doses and flow rates in metric units, recognize transfusion, infusion and opioid complications early, and know when to stop, report or consult policy because parenteral scope varies.

Practise Pharmacological and Parenteral Therapies