Safe Medication Administration Flashcards

A practical nurse is preparing to administer methotrexate 15 mg orally to a client with rheumatoid arthritis. The pharmacy has dispensed methotrexate 2.5 mg tablets. The nurse calculates a dose of 6 tablets. Before administering, which action is MOST critical given methotrexate's high-alert status?

Answer: Contact the prescriber to verify whether the order is a weekly dose before administering

Methotrexate for non-oncologic indications (e.g., rheumatoid arthritis) is prescribed WEEKLY, not daily. Daily administration of methotrexate in this context is a known, potentially fatal medication error. The nurse must verify the dosing frequency with the prescriber before administering 6 tablets, as this dose given daily could cause severe toxicity. Independent double-checking and clarification of high-alert medications is a mandatory safety step.

A nurse is preparing to administer a subcutaneous injection of enoxaparin (Lovenox) 40 mg to a postoperative client. Upon assessment, the nurse notes the client's platelet count has dropped from 210,000/mm³ to 78,000/mm³ over the past 5 days of heparin therapy. What is the PRIORITY nursing action?

Answer: Hold the dose and notify the prescriber immediately, documenting the platelet trend and suspecting HIT

A platelet drop of greater than 50% occurring 5–10 days after heparin initiation is the hallmark of Heparin-Induced Thrombocytopenia (HIT), an immune-mediated, potentially life-threatening condition. Critically, enoxaparin (LMWH) cross-reacts with the HIT antibody and is CONTRAINDICATED. The nurse must hold all heparin products and notify the prescriber immediately. Administering any heparin product — including LMWH — risks catastrophic thrombosis in HIT.

A practical nurse is administering medications via a client's nasogastric (NG) tube. The medication administration record includes sustained-release morphine sulfate (MS Contin) 30 mg. What is the CORRECT action?

Answer: Contact the prescriber to request a substitute formulation appropriate for NG tube administration

Sustained-release (SR/XR/ER) formulations must NEVER be crushed, split, or altered, as this destroys the time-release matrix and causes immediate release of the entire dose — a potentially fatal morphine overdose. NG tube administration requires an immediate-release liquid or crushable formulation. The nurse must withhold the medication and contact the prescriber for an appropriate order (e.g., immediate-release morphine oral solution or an IV/SC route). This is a patient safety imperative.

A nurse is caring for a client prescribed warfarin 5 mg daily for atrial fibrillation. The client's INR today is 4.8, and the client reports no active bleeding. The prescriber's order reads: 'Hold warfarin and repeat INR in 24 hours.' While reviewing the client's chart, the nurse notes a new order for vitamin K 2.5 mg orally was added by the on-call physician. Which action is MOST appropriate?

Answer: Clarify the vitamin K order with the prescribing physician and the client's anticoagulation team before administering

An INR of 4.8 without active bleeding does not universally require vitamin K reversal — guidelines (e.g., CHEST) suggest vitamin K is indicated for INR >10 without bleeding, or 4.5–10 with bleeding risk factors. Administering vitamin K can make re-anticoagulation difficult and increase clotting risk. The on-call physician may be unaware of the target INR or the anticoagulation management plan. The nurse must clarify this order with both the prescribing physician and ideally the anticoagulation team before administering, as this is a complex clinical decision requiring reconciliation of conflicting management strategies.

A client with chronic kidney disease (CKD Stage 4, eGFR 22 mL/min) is admitted for a UTI. The prescriber orders trimethoprim-sulfamethoxazole (TMP-SMX) DS one tablet twice daily for 7 days. The nurse recognizes this order warrants further action because:

Answer: TMP-SMX is renally cleared and can accumulate in CKD, causing hyperkalemia and nephrotoxicity requiring dose adjustment or alternative selection

TMP-SMX is primarily renally eliminated. In CKD Stage 4 (eGFR 22 mL/min), standard dosing leads to drug accumulation, increasing the risk of serious adverse effects including severe hyperkalemia (trimethoprim blocks tubular potassium secretion), nephrotoxicity, bone marrow suppression, and Stevens-Johnson syndrome. While TMP-SMX is not absolutely contraindicated at eGFR >15–30 mL/min, dose reduction is required and the risks versus benefits must be weighed, necessitating prescriber clarification. This reflects the nurse's role in applying pharmacokinetic principles to protect patients with altered drug clearance.

A practical nurse is preparing to administer insulin glargine 20 units subcutaneously at 2200h as ordered. Upon drawing up the dose, the nurse notices the insulin solution appears slightly cloudy. The nurse's MOST appropriate action is:

Answer: Discard the vial and obtain a new one, as insulin glargine should always be a clear, colourless solution

Insulin glargine (Lantus, Basaglar, Toujeo) is a clear, colourless solution — unlike NPH insulin, it should NEVER be cloudy, as cloudiness indicates contamination, precipitation, or degradation. Administering compromised insulin glargine is unsafe and will not provide predictable glycemic control. The nurse must discard the vial and obtain a new one. This is a critical distinction from NPH or pre-mixed insulins, which are intentionally cloudy and require gentle mixing — confusing these properties is a common and dangerous error.