Chapter 20: Safe Medication Preparation

The patient is to receive a medication via the sublingual route. Which action by the nurse is appropriate? a. Placing the medication under the tongue b. Crushing the medication before administration c. Offering the client a glass of orange juice after administration d. Using sterile technique to administer the medication

ANS: A Administering a medication by the sublingual route involves placing the solid medication in the mouth under the tongue until the medication dissolves. Crushing the medication is not necessary because it is designed to dissolve under the tongue. Patients are not to take any liquids with medications given by sublingual administration or immediately afterward. The mouth is not sterile. Sterile technique is not necessary for sublingual administration.

To prevent medication errors, which action should be taken by the nurse? a. Clarify illegible orders with the prescriber. b. Document the medication before administration. c. Read medication labels 2 times when preparing. d. Prepare all of the client's medications for the shift at the same time.

ANS: A Do not interpret illegible handwriting; clarify illegible orders with the prescriber. Document all medications as soon as they are given. Be sure to read labels at least 3 times (comparing MAR with label): before, during, and after administering the medication. Prepare medications at the time ordered, and document all medications as soon as they are given.

The nurse is aware that a patient with liver disease and a decreased albumin level may develop which of the following effects? a. Toxicity on normal doses of medication b. Less active medication available in the body c. Reduction in therapeutic effect d. Accelerated biotransformation of the medication

ANS: A Most medications bind to albumin to some extent. When medications bind to albumin, they are unable to exert pharmacological activity. Only the unbound or "free" medication is active. Older adults and patients with liver disease or malnutrition have reduced albumin, which increases their risk for medication toxicity. With less albumin to bind with the medication, more "free" or active medication is present in the body. This would result in an increase in therapeutic effect and possibly in toxicity. Most biotransformation occurs in the liver, although the lungs, kidneys, blood, and intestines also play a role. Patients (e.g., elderly, those with chronic disease) are at risk for medication toxicity if their organs that metabolize medications do not function correctly.

The nurse recognizes that patients with which conditions will have a reduction in the distribution of drugs? (Select all that apply.) a. Peripheral vascular disease b. Heart failure c. Liver disease d. Obesity

ANS: A, B The rate and extent of distribution depend on circulation, cell membrane permeability, and protein binding. Peripheral vascular disease and heart failure result in a decrease in circulation, which reduces distribution. Liver disease causes a reduction in plasma proteins, which results in more free active drug that is distributed more readily. Obesity does not affect distribution.

The hospital has implemented a computerized physician order entry system (CPOE) to eliminate the need for written orders. The benefits of this system include which of the following? (Select all that apply.) a. Automatic drug allergy checks b. Automatic dosage indications c. Identification of potential drug interactions d. Reduced number of medical errors

ANS: A, B, C, D Decision support software, integrated into a CPOE system, allows for automatic drug allergy checks, dosage indications, and identification of potential drug interactions. Use of CPOE systems may significantly reduce medication errors by as much as 55% to 83%.

Medication errors include which of the following? (Select all that apply.) a. Administration of the wrong medication b. Administration via the wrong route c. Inaccurate prescribing d. Failing to administer a medication

ANS: A, B, C, D Medication errors include inaccurate prescribing and administering the wrong medication, by the wrong route, and in the wrong time interval, as well as administering extra doses or failing to administer a medication.

When do most medication errors occur? (Select all that apply.) a. During hospital admission b. During transfer from one unit to another c. During discharge home d. During discharge to another facility

ANS: A, B, C, D Most medication errors occur at patient care transition points such as during hospital admission, transfer from one unit to another, and discharge to home or another facility.

A patient with a history of renal failure and liver disease has been receiving morphine sulfate every 4 hours for the past 2 weeks. The nurse finds the patient lethargic with a respiratory rate of 6 breaths per minute. The health care provider orders naloxone (Narcan). The nurse anticipates which effects when naloxone (Narcan) is given? (Select all that apply.) a. Increase in alertness b. Decrease in urine output c. Complaints of pain d. Increase in respiratory rate

ANS: A, C, D Toxic effects develop after prolonged intake of a medication, when a medication accumulates in the blood as the result of decreased clearance by the liver and/or kidneys (because of impaired metabolism or excretion), or when too high a dose is given. Respiratory depression and sedation are known effects of opioid toxicity. Naloxone reverses the effects of opioids, including pain relief.

The nurse administers a medication to the wrong patient but the patient suffers no harm from the medication error. What actions should the nurse take? (Select all that apply.) a. Prepare a written incident report. b. Document in the nurses' notes that an incident report was completed. c. Report the incident to a manager only if the patient is harmed. d. Notify the prescriber.

ANS: A, D When a medication error occurs, the nurse assesses the patient and notifies the prescriber as soon as possible. When the patient is stable, the nurse notifies the appropriate person in the institution (e.g., manager, supervisor). The nurse is responsible for preparing a written incident report usually within 24 hours of the incident. To legally protect the nurse and the institution, the incident report is not referred to in the nurses' notes. All medication errors, including those that do not cause obvious or immediate harm, should be reported.

The prescribed dose of Tylenol is given to a patient. The nurse recognizes the name Tylenol as which of the following? a. Chemical name b. Trade name c. Generic name d. United States Pharmacopeia

ANS: B A medication trade name or brand name is used to market the medication. The trade name has the symbol TM at the upper right of the name, indicating a manufacturer's trademark for the name (e.g., PanadolTM, TempraTM, TylenolTM). The chemical name describes the medication's composition and molecular structure, such as N-acetyl-para-aminophenol, commonly known as Tylenol. The chemical name rarely is used in clinical practice. A manufacturer who first develops a medication gives the generic name of a medication. Acetaminophen is the generic name for Tylenol. The generic name is the official name that is listed in official publications such as theUnited States Pharmacopeia (USP). The USP is a drug book that lists all drugs by generic name.

The nurse is caring for several patients. The patient in which situation can safely receive oral medications? a. Nausea with frequent episodes of vomiting b. Taking a daily dose of vitamins c. Nasogastric tube connected to suction d. Diagnosed with an esophageal stricture

ANS: B Avoid giving oral medications to patients with alterations in gastrointestinal function (e.g., nausea and vomiting), reduced motility (after general anesthesia or inflammation of the bowel), or surgical resection of a portion of the gastrointestinal tract. Oral medications cannot be given when the patient has gastric suctioning and are contraindicated in patients before some tests or surgery. Oral administration is contraindicated in patients who are NPO and unable to swallow (e.g., patients with neuromuscular disorders, esophageal strictures, or lesions of the mouth).

The nurse enters the patient's room to give medications. Which action is most appropriate to identify the "right patient"? a. Ask the patient to state his name. b. Ask the patient to state his name and birth date. c. Ask the primary nurse to identify the patient. d. Say the patient's name and date of birth and request patient validation.

ANS: B Before giving a medication to a patient, always use at least two patient identifiers (TJC, 20121a). Acceptable patient identifiers include the patient's name, an identification number assigned by the health care agency, and the date of birth.

The nurse is preparing to administer medication to a patient who is alert and oriented. When medications are reviewed with the patient, the patient states that he does not take metoprolol. Which action by the nurse is most appropriate? a. Ignore the patient's statement and give the medication. b. Withhold the medication. c. Convince the patient that the doctor ordered it, and he should take it. d. Give the medication and check the order afterward.

ANS: B If a patient questions the medication a nurse prepares, it is important not to ignore these concerns. An alert patient will know whether a medication is different from those received before. Withhold the medication until you are able to recheck the preparation against the order. If a medication order seems incorrect or inappropriate, always consult the prescriber.

The nurse reviews a medication administration record for an anticoagulant that is ordered at 0900 daily. The medication record indicates that the drug was given at the following times over the past 4 days. Which times follow the "right time" of medication administration? (Select all that apply.) a. 0800 b. 0830 c. 0930 d. 1000

ANS: B, C Time-critical medications such as anticoagulants must be administered within 30 minutes of the scheduled time. Non-time-critical medications can be given 1 to 2 hours before or after the scheduled time.

The hospital uses a unit-dose system for medication distribution. The nurse recognizes that this system includes which safety feature? a. All medications are kept in the patient's drawer. b. Liquids are kept in multi-dose containers to prevent spillage. c. Narcotics are kept in an area separate from the patient's regular medications. d. The nurse is responsible for restocking the medication drawers daily.

ANS: C Controlled substances are not kept in the individual patient drawer; they are kept in a larger locked drawer to keep them secure. The unit dose is the ordered dose of medication that the patient receives at one time. Each tablet or capsule is wrapped in a foil or paper container. Liquid doses come in prepackaged foil or paper cups. At a designated time each day, the pharmacist or a pharmacy technician refills the drawers in the cart with a fresh supply.

An 80-year-old patient who complains of feeling "anxious" is given lorazepam (Ativan). The patient becomes agitated and delirious. The nurse documents this reaction to Ativan as which of the following? a. Toxicity b. Side effect c. Idiosyncratic reaction d. Allergic reaction

ANS: C Medications often cause unpredictable effects such as an idiosyncratic reaction, in which a patient overreacts or underreacts to a medication or has a reaction different from normal. Predicting which patients will have an idiosyncratic response is impossible. For example, Ativan, an antianxiety medication, when given to an older adult, may cause agitation and delirium. Toxic effects develop after prolonged intake of a medication, when a medication accumulates in the blood because of impaired metabolism or excretion, or when too high a dose is given. Side effects are predictable and often unavoidable secondary effects produced at a usual therapeutic drug dose. Allergic reactions are unpredictable responses to a medication. The medication acts as an antigen, and this causes antibodies to be produced. With repeated administration, the patient develops an allergic response. Sudden constriction of bronchiolar muscles, edema of the pharynx and larynx, severe wheezing, and shortness of breath are characteristic of severe or anaphylactic reactions. Some patients become severely hypotensive, necessitating emergency resuscitation measures. Anaphylaxis is potentially fatal.

The nurse is preparing a liquid medication. Which action is most appropriate? a. Pour the liquid medication toward the label. b. Draw the liquid quickly into a syringe. c. Place the medication cup on a flat surface at eye level. d. Measure the poured liquid to the top of the meniscus.

ANS: C Pour liquid medication into a medication cup with the cup on a flat surface at eye level, so you can accurately see the desired amount. The amount of poured liquid should be even with the base of the meniscus. Pour liquid medications away from a label to ensure that liquid will not run down a label, making it difficult to read. Draw liquid medication into a syringe (without a needle) slowly, to prevent air bubbles from entering the syringe. Air displaces medications, which leads to inaccurate measurement of doses.

During the admission process, the patient states that he stopped taking daily aspirin because of nausea. The nurse documents the nausea as which of the following? a. Noncompliance b. Toxic effects of the medication c. Side effects of the medication d. Allergic reaction to the medication

ANS: C Side effects are predictable and often unavoidable secondary effects produced at a usual therapeutic drug dose. For example, some antihypertensive medications cause impotence in male patients. Noncompliance is almost an accusatory name given to patients who do not follow their medical regimen such as by not taking their medications. Usually, however, there is a reason for noncompliance, and in this case, the reason is the side effect of the medication. Be careful with this term because it carries a negative connotation. Toxic effects develop after prolonged intake of a medication, when a medication accumulates in the blood because of impaired metabolism or excretion, or when too high a dose is given. Allergic reactions are unpredictable responses to a medication. Exposure to an initial dose of a medication causes a patient to become sensitized immunologically. The medication acts as an antigen, and this causes antibodies to be produced. Nausea is not an antigen-antibody response.

The nurse is teaching a patient how to measure medication dosages at home. The prescription is written for 30 mL of the medication. Which household measurement will the nurse teach the patient to use? a. Drops b. Teaspoon c. Tablespoon d. Cup

ANS: C The equivalents of measurement are as follows: 15 drops = 1 mL, 1 teaspoon = 5 mL, 1 tablespoon = 15 mL, and 1 cup = 240 mL; therefore, a tablespoon is most appropriate, with 2 tablespoons = 30 mL.

A patient is receiving vancomycin IV every 8 hours at 0800, 1600, and 2400. A serum peak and trough level is ordered after the third dose, which will be given at 1600. When should the nurse order the trough level? a. 1630 b. 1800 c. 2330 d. 2400

ANS: C The point at which the lowest amount of drug is in the serum is the trough concentration. Some medication doses (e.g., vancomycin, gentamicin) are based on peak and trough serum levels. A patient's trough level is drawn as a blood sample 30 minutes before the drug is administered, and the peak level is drawn whenever the drug is expected to reach its peak concentration. The third dose will be given at 1600, which means that the lowest level of drug will be present 30 minutes before the fourth dose at midnight. A patient's trough level is drawn as a blood sample 30 minutes before the drug is administered. 1630 is 30 minutes after the drug is administered. 1800 is 2 hours after the drug is administered. If the medication reaches its peak concentration in 2 hours, this could be a peak concentration, because the peak level is drawn whenever the drug is expected to reach its peak concentration. 2400 is the time that the next dose is due. A patient'strough level is drawn as a blood sample 30 minutes before the drug is administered.

The patient is complaining of severe leg pain. No pain medication is ordered, so the nurse calls the health care provider. An order for Tylenol with Codeine prn is given, in addition to a one-time order for morphine sulfate to be given stat. Which action by the nurse is most appropriate? a. Give the morphine sulfate and Tylenol with b. Codeine immediately. c. Give the Tylenol with Codeine now. d. Give the morphine sulfate immediately. e. Ask the patient which medication he would like first.

ANS: C Types of orders based on frequency and/or urgency of medication administration include prn orders (given only when a patient requires it) and stat orders (given immediately and only once).

The nurse is calculating a medication dosage using the metric system. A vial contains 1 mL of fluid, and the nurse calculates the correct dosage to be half of the medication in the vial. How should the nurse document the correct dosage? a. 1mL b. .5mL c. 0.5 mL d. 0.50 mL

ANS: C When writing medication dosages in metric units, convert fractions to decimals. Always include a zero before a decimal point (e.g., 0.1 mL is correct). Never use a trailing zero (e.g., 1.0 mL is incorrect).

A patient admitted to the hospital with pneumonia has IV antibiotics ordered. He receives the first dose with no problem, but during the second dose, he begins to complain of shortness of breath and difficulty breathing. The nurse notes wheezes throughout the lung fields. The nurse documents these symptoms as which of the following? a. Idiosyncratic reaction b. Toxic effect of the antibiotic c. Side effect of the medication d. Anaphylactic reaction

ANS: D An allergic reaction ranges from mild to severe, depending on the patient and the medication. Among the different classes of medications, antibiotics cause a high incidence of allergic reactions. Sudden constriction of bronchiolar muscles, edema of the pharynx and larynx, severe wheezing, and shortness of breath are characteristic of severe or anaphylactic reactions. Some patients become severely hypotensive, necessitating emergency resuscitation measures. Anaphylaxis is potentially fatal. Medications often cause unpredictable effects, such as an idiosyncratic reaction, in which a patient overreacts or underreacts to a medication or has a reaction that is different from normal. However, the symptoms displayed by this patient are classic anaphylactic symptoms. Toxic effects develop after prolonged intake of a medication, when a medication accumulates in the blood because of impaired metabolism or excretion, or when too high a dose is given. Two doses of a medication usually are not enough to develop toxic effects. Side effects are predictable and often unavoidable secondary effects produced at a usual therapeutic drug dose. Anaphylaxis is usually unpredictable initially and is avoided after the first reaction by listing the cause of the anaphylaxis in the allergy alert section of the patient record.

When controlled substances are administered, which action is required by the nurse? a. Discard and sign for unused quantities. b. Count the amount of medication daily. c. Keep narcotics to be given with other patient medications. d. Have a second nurse witness disposal of unused portions and sign the record.

ANS: D If you give only part of a premeasured dose of a controlled substance, a second nurse must witness disposal of the unused portion. Both nurses sign their names on the required form. Store all narcotics in a locked, secure cabinet separate from the patient's routine medications. (Computerized, locked cabinets are preferred.) The computerized dispensing system should maintain the inventory of medications.

A patient with chronic back pain has been taking oral morphine sulfate (MS Contin) for the past 2 years. Upon admission to the hospital, the patient receives morphine sulfate for back pain but reports no pain relief. The nurse notifies the health care provider, recognizing that the reason for the lack of pain relief is which of the following? a. Side effect of the morphine b. Drug dependence c. Idiosyncratic response to the morphine d. Medication tolerance

ANS: D Medication tolerance is a decreased physiological response that occurs after repeated administration of a medication. Side effects are predictable and often unavoidable secondary effects produced at a usual therapeutic drug dose. Drug dependence can be physical or psychological. In psychological dependence, patients have an emotional desire for a drug to maintain an effect. A person believes that a desirable effect will result when taking the medication. Physical dependence is a physiological adaptation to a medication that manifests itself by intense physical disturbance when the medication is withdrawn. Medications often cause unpredictable effects, such as an idiosyncratic reaction, in which a patient overreacts or underreacts to a medication or has a reaction that is different from normal.

The nurse receives an order to give a drug parenterally. The nurse will administer this medication by which route? a. Oral b. Topical c. Sublingual d. Intramuscular

ANS: D Parenteral medications can be intramuscular, subcutaneous, intradermal, epidural, or intravenous. Medications given orally are given by mouth. Topical medications are applied on the skin (as a cream or patch) and as eye/eardrops. Sublingual medications are given under the tongue.

When medications are administered, which action by the nurse is appropriate? a. Administering medications prepared by another nurse b. Using sterile technique for nonparenteral medications c. Leaving medication at the bedside when the patient is in the bathroom d. Documenting the reason for medication refusal in the nurse's notes

ANS: D When a patient refuses a medication, determine the reason for it, and take action. Document refusal of medications, and notify the prescriber. Never administer a medication prepared by another nurse. Use good medical aseptic technique and perform hand hygiene before preparing a dose of medication. Avoid touching tablets and capsules. Use sterile technique for parenteral medications. Remain with the patient as the patient takes the medication. Provide assistance if necessary (e.g., for the patient who is weak and unable to administer eyedrops). Do not leave medications at a patient's bedside without a prescriber's order to do so.