Safe Medication Administration Flashcards

A practical nurse is preparing to administer a nasogastric (NG) tube feeding and notices the client is also due for an oral medication that is listed as 'enteric-coated.' Which action is most appropriate?

Answer: Hold the enteric-coated medication and notify the prescriber to request an alternative formulation

Enteric-coated medications must never be crushed, split, or altered because the coating is specifically designed to protect the stomach lining or to ensure the drug is released in the intestine. Crushing destroys this protection and can cause mucosal injury, premature drug release, or drug inactivation. Whole tablets cannot pass through an NG tube. The correct action is to hold the medication and notify the prescriber to obtain a suitable alternative (e.g., a liquid formulation or a different drug class). This protects both drug efficacy and client safety.

A practical nurse is administering heparin subcutaneously and notes the order reads '5,000 units subcutaneously every 12 hours.' The available vial is labelled '10,000 units/mL.' The nurse draws up 0.5 mL and is about to inject. Which additional safety action is MOST critical before injecting?

Answer: Have a second nurse independently verify the dose calculation and vial concentration

Heparin is a high-alert medication with a narrow therapeutic index; dosing errors can cause life-threatening bleeding or clotting events. Independent double-checks by a second nurse for high-alert medications such as heparin are a mandated safety standard in most Canadian health authorities and align with ISMP Canada guidelines. Aspiration is NOT recommended for subcutaneous heparin injections (it increases bruising and is not required). Warm compresses can increase absorption unpredictably. The needle gauge and angle described are reasonable but are secondary to the verification of the high-alert drug dose.

During a medication reconciliation on admission, a client reports taking St. John's Wort daily for depression. The client is prescribed cyclosporine post-renal transplant. Which response by the practical nurse reflects the most clinically significant concern?

Answer: St. John's Wort is a CYP3A4 inducer that significantly reduces cyclosporine blood levels, risking transplant rejection

St. John's Wort is a potent inducer of cytochrome P450 3A4 (CYP3A4) and P-glycoprotein. Cyclosporine is extensively metabolized by CYP3A4. Co-administration leads to dramatically reduced cyclosporine plasma concentrations — sometimes by 50% or more — which can precipitate acute transplant rejection, a life-threatening complication. This interaction is well-documented and is a critical drug-natural health product interaction that every nurse must recognize. The nurse must report this immediately and the prescriber will need to discontinue St. John's Wort.

A practical nurse is about to administer IV vancomycin 1g over 60 minutes via peripheral IV. Fifteen minutes into the infusion, the client develops facial flushing, erythema on the neck and upper chest, and pruritus, but denies dyspnea, and vital signs remain stable. What is the nurse's PRIORITY action?

Answer: Slow the infusion rate significantly and notify the prescriber, as this presentation is consistent with Red Man Syndrome

The presentation — flushing, erythema of the face, neck, and upper chest with pruritus, stable vital signs, and no respiratory compromise — is classic Red Man Syndrome (RMS), a rate-dependent, non-immunologic infusion reaction to vancomycin caused by direct mast cell degranulation. It is NOT anaphylaxis. The correct management is to stop or significantly slow the infusion and notify the prescriber; infusing over a longer period (e.g., 90–120 minutes) typically resolves and prevents recurrence. Administering epinephrine would be inappropriate and dangerous without signs of anaphylaxis. Continuing at the current rate would worsen the reaction.

A practical nurse is caring for a client with a known penicillin allergy documented as 'anaphylaxis.' The prescriber has ordered cefazolin 1g IV for surgical prophylaxis. The nurse's best course of action is to:

Answer: Withhold the cefazolin and contact the prescriber immediately to clarify and discuss the allergy history before administration

Although the overall cross-reactivity rate between penicillins and cephalosporins is low (approximately 1–2%), a documented history of penicillin-induced anaphylaxis represents a serious risk. First-generation cephalosporins like cefazolin share structural similarities with penicillin and carry a higher cross-reactivity risk than later generations. The nurse must NOT administer the drug on their own judgment, substitute another drug independently, or perform unauthorized allergy testing at the bedside. The safe and professional action is to withhold the dose and immediately contact the prescriber to review the allergy, consider allergy consultation, or select an alternative agent. Substituting medications independently exceeds the practical nurse's scope of practice.

A practical nurse is preparing to apply a fentanyl transdermal patch 25 mcg/h to a client who was previously opioid-naïve and now has chronic pain. The previous patch was applied 72 hours ago. Upon assessment, the nurse finds two old patches still in place on the client's upper back. What is the FIRST action the nurse should take?

Answer: Remove both old patches immediately, complete a full assessment for opioid toxicity, and hold the new patch until the prescriber is notified

Two fentanyl patches on an opioid-naïve client represent a potential overdose situation — the client may have been receiving double the intended dose for an extended period. The nurse must first remove both old patches to stop further drug absorption, then immediately perform a thorough assessment for signs of opioid toxicity (sedation, respiratory depression, pinpoint pupils, altered consciousness). The prescriber must be notified before the new patch is applied. Applying an additional patch before resolving this error, or leaving any old patches in place, could cause fatal respiratory depression. This is a medication safety incident requiring documentation and likely an incident report.