CPNRE Safe Medication Administration 2 — Questions and Answers
Question 1: A client is prescribed metoprolol (Lopressor) 50 mg oral twice daily. The heart rate is 48 bpm before administration. What should the practical nurse do?
- Administer since it is within therapeutic range
- Hold the medication, document the heart rate, and notify the physician (Correct answer)
- Crush and mix in applesauce since the client has difficulty swallowing
- Administer half the dose since the heart rate is low
Correct answer: Hold the medication, document the heart rate, and notify the physician
Metoprolol is a beta-blocker that slows heart rate. A pre-dose rate of 48 bpm (bradycardia) is a reason to hold the medication and notify the physician.
Metoprolol is a selective beta-1 blocker for hypertension, angina, and heart failure. It reduces heart rate and blood pressure. Standard parameter: hold and notify physician if HR <60 bpm (facility policy may use <50 bpm). A heart rate of 48 bpm indicates bradycardia. Administering a beta-blocker could cause dangerous bradycardia or heart block. Never crush extended-release (ER/XR) tablets. Notify the physician with full SBAR including current HR, BP, symptoms, and current medications. Document hold, notification, and physician response.
Question 2: A client's INR result is 4.8 and they are prescribed warfarin. What should the practical nurse do?
- Administer since it may be within therapeutic range for some conditions
- Hold the warfarin dose and notify the physician with the INR result (Correct answer)
- Double the warfarin dose since high INR means poor anticoagulation
- Administer and schedule a repeat INR in 24 hours
Correct answer: Hold the warfarin dose and notify the physician with the INR result
INR 4.8 is supratherapeutic (therapeutic range is typically 2.0-3.0). Warfarin must be held and the physician notified.
Warfarin therapeutic INR: standard range 2.0-3.0 for most indications (DVT, AF, PE); 2.5-3.5 for mechanical heart valves. INR 4.8 indicates supratherapeutic anticoagulation with significantly increased bleeding risk. Actions: hold warfarin; notify physician immediately with INR result, bleeding signs assessment, current medications; physician will reduce dose or hold temporarily; may order vitamin K (phytonadione) if clinically indicated. Monitor for bleeding signs: bruising, hematuria, melena, hemoptysis. INR monitoring and warfarin management is critical medication safety in Canadian practical nursing.
Question 3: A client is to receive amoxicillin (Amoxil) 500 mg. Available is amoxicillin 250 mg/5 mL oral suspension. How many mL should be administered?
- 5 mL
- 10 mL (Correct answer)
- 7.5 mL
- 15 mL
Correct answer: 10 mL
500 mg divided by 250 mg multiplied by 5 mL = 10 mL.
Calculation: Desired = 500 mg; Available = 250 mg per 5 mL. Formula: (500/250) x 5 = 2 x 5 = 10 mL. Always double-check medication calculations, especially with oral liquid medications. Use a calibrated oral syringe for accurate measurement. Medication calculation is a core safe medication administration competency. Canadian practical nurses must be proficient in calculation methods (ratio-proportion, dimensional analysis, formula method) for oral, parenteral, and IV medications. Second nurse check is often required for high-alert medications per ISMP Canada standards.
Question 4: A client receiving IV vancomycin develops diffuse flushing, erythema, and pruritus over the face and upper body during the infusion. No dyspnea or hypotension is noted. What should the practical nurse do?
- Stop the infusion immediately and administer epinephrine
- Slow the infusion rate and notify the physician, consistent with Red Man Syndrome (Correct answer)
- Continue at the same rate since the reaction is not anaphylaxis
- Stop the infusion permanently as the client is allergic to vancomycin
Correct answer: Slow the infusion rate and notify the physician, consistent with Red Man Syndrome
Diffuse flushing, erythema, and pruritus during vancomycin without systemic signs is Red Man Syndrome, a rate-related reaction managed by slowing the infusion.
Red Man Syndrome is a rate-related infusion reaction to vancomycin (not a true allergic reaction): caused by too-rapid infusion triggering mast cell degranulation and histamine release; symptoms: diffuse erythema, flushing, pruritus, warmth over face, neck, and upper chest; no bronchospasm, angioedema, or hypotension (unlike anaphylaxis). Management: slow infusion rate significantly (over 60-90 minutes minimum); notify physician; antihistamines (diphenhydramine) may be ordered; resume at slower rate once symptoms resolve. If true anaphylaxis: stop infusion, maintain IV, administer epinephrine. Vancomycin should always be infused slowly (at least 60 minutes).
Question 5: A client is prescribed insulin glargine (Lantus) 20 units at bedtime. Which practice is incorrect?
- Drawing up glargine in a separate syringe
- Injecting glargine subcutaneously in the abdomen
- Mixing glargine with regular insulin in the same syringe (Correct answer)
- Administering glargine at the same time each day
Correct answer: Mixing glargine with regular insulin in the same syringe
Insulin glargine (Lantus) must NEVER be mixed with other insulins as mixing alters its pH and destroys the long-acting profile.
Insulin glargine (Lantus) has a unique formulation: acidic pH (4.0) that, when injected subcutaneously, forms microprecipitates that slowly release insulin over 24 hours. Mixing with other insulins disrupts this pH-dependent mechanism, altering the pharmacokinetic profile and causing unpredictable insulin action. NEVER mix glargine with other insulins in the same syringe or cartridge. Administer at the same time daily for consistent basal coverage. Rotate injection sites within one region. This is a critical insulin safety principle included in Diabetes Canada practice guidelines and ISMP Canada high-alert medication standards.
Question 6: Which high-alert medication requires a two-nurse independent double-check (IDC) per Canadian medication safety standards?
- Acetaminophen (Tylenol) 650 mg oral
- Concentrated electrolytes (e.g., KCl 40 mEq/100 mL IV) (Correct answer)
- Metformin (Glucophage) 500 mg oral
- Pantoprazole (Pantoloc) 40 mg IV
Correct answer: Concentrated electrolytes (e.g., KCl 40 mEq/100 mL IV)
Concentrated electrolytes (potassium chloride) are a high-alert medication per ISMP Canada and require independent double-check due to fatal error potential.
ISMP Canada identifies high-alert medications as drugs that bear heightened risk of causing significant harm when used in error. Mandatory IDC medications at most Canadian facilities: concentrated electrolytes (KCl, NaCl, phosphates; can cause fatal cardiac arrest if administered rapidly or in excess); heparin infusions; insulin infusions; concentrated opioid infusions; chemotherapy. IDC requires two nurses independently (without showing each other the calculation first) verify drug, dose, concentration, rate, and patient identity before administration. Endorsed by Accreditation Canada and ISMP Canada as a critical safety measure.
CPNRE Safe Medication Administration 2
A client is prescribed metoprolol (Lopressor) 50 mg oral twice daily.
The heart rate is 48 bpm before administration.
What should the practical nurse do?