Chapter 20: Safe Medication Preparation Perry et al.: Clinical Nursing Skills & Techniques, 10th Edition

The prescribed dose of Tylenol is given to a patient. the nurse recognizes the name Tylenol as which of thefollowing?

A. Chemical name

B. Trade name

C. Generic name

D. United States Pharmacopeia

ANS: B

The trade name, brand name, or proprietary name is the name under which a manufacturer markets a medication. the trade name has the symbol (™) at the upper right of the name,

indicating that the manufacturer has trademarked the name of the medication. Acetaminophen is an example of thegeneric name for Tylenol. the generic name becomes the official name listed in official publications such as the United States Pharmacopeia (USP).

The nurse is aware that a patient with liver disease and a decreased albumin level may develop which of thefollowing effects?

A. Toxicity on normal doses of medication

B. Less active medication available in thebody

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 theunbound 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 thebody. 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.

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. Non compliance

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. They are either harmless or cause injury. the intensity of side effects is

often dose dependent. If the side effects are serious enough to outweigh the benefits of the therapeutic action of a medication, the health care provider will likely discontinue

the medication. Patients commonly stop taking medications because of side effects such as anorexia, nausea, vomiting, dizziness, drowsiness, dry mouth, constipation, and diarrhea.

Report any side effect to the health care provider to ensure that it is not incorrectly interpreted as a more serious adverse medication reaction.

An 80-year-old patient who complains of feeling ―anxious is given lorazepam. 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 theblood 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, thepatient 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.

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. thenurse documents these symptoms as which of thefollowing?

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 themedication. 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 thecause of the anaphylaxis in the allergy alert section of the patient record.

A patient with chronic back pain has been taking oral morphine sulfate 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 the diminished response to a medication with repeated use and occurs over time. A patient receives the same medication for long periods of time and then requires higher doses to produce the same desired effect. Patients taking various pain medications may develop tolerance over time. It may take a month or longer for tolerance to occur.

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 and 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 thelowest 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's trough level is drawn as a blood sample 30 minutes before the drug is administered.

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

A cart also contains limited amounts of prn and stock medications for special situations.

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 thevial. How should the nurse document the correct dosage?

A. 1/2 mL

B. .5 mL

C. 0.5 mL

D. 0.50 mL

ANS: C

Many actual or potential medication errors happen with the use of fractions or decimal points. Use practice standards when medications are ordered in fractions to prevent errors. For example, never use a trailing zero (e.g., 1.0 mg), use 1 mg, and always include a zero before a decimal point (e.g., 0.1 mL).

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.

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 Codeine immediately.

B. Give the Tylenol with Codeine now.

C. Give the morphine sulfate immediately.

D. Ask the patient which medication he would like first.

ANS: C

Single (one-time) orders are common for preoperative medications or medications given before diagnostic procedures. the medication is ordered to be given only once at a specified time. A stat order means that you give a single dose of medication immediately and only once. Stat orders are used for emergencies when a patient's condition changes suddenly. A now order is more specific than a one-time order and is used when a patient needs a medication quickly but not as soon as a stat order. When you receive a now order, you have up to 90 minutes to give the drug (see agency policy). A medication can be ordered to be given only when a patient requires or requests it. This is a prn (as needed) order.

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 a medication, stop and recheck to be certain that there is no mistake. An alert patient or family caregiver will know whether a medication is different from those received before. In most cases the medication order has been changed, or the drug is manufactured by a different company than the patient has been using at home. However,

attention to a patient's question is how errors are identified and prevented.

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.

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.

When controlled substances are administered, which action is required by the nurse?

A. Discard and sign for unused quantities.

B. Count theamount 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 there cord.

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.

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 patient's medications for theshift 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 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 patient 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.

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 themouth).