Foundations Final

What are the THREE names every drug has?

Chemical name (molecular structure)| Chemical names are too complex for clinical use.

• Example: N-acetyl-para-aminophenol

Generic/Official name (assigned by first manufacturer, used in NCLEX)

• Example: acetaminophen

Trade/Brand name

• Example: Tylenol®, Panadol®, APAP®

Why are some drugs given IV, sublingual, or transdermally instead of orally?

To BYPASS the first-pass effect. Oral drugs pass through the liver first, which metabolizes a fraction before it reaches systemic circulation.

• Routes that bypass the liver (IV, SL, transdermal, inhalation, rectal suppository) deliver more active drug to the bloodstream.

A patient has liver cirrhosis. Why must you monitor them more closely for drug toxicity?

Decreased liver function = slower metabolism = drug accumulates = TOXICITY RISK. Older adults also need smaller doses — hepatic metabolism declines with age.

• The liver is the primary site of biotransformation. When it fails, drugs reach dangerous concentrations.

You are about to crush a tablet for a patient who has trouble swallowing. Which two types must you NEVER crush, and why?

NEVER crush Enteric-Coated (EC) — coating protects from stomach acid. NEVER crush Extended Release (XL/SR/CR) — crushing dumps the entire dose at once → overdose.

• Altering the drug form destroys the mechanism of controlled release or acid protection.

What is the correct flush protocol for an NG tube before and after medication administration?

15–30 mL water BEFORE → 5 mL BETWEEN each medication → 15–30 mL AFTER all medications.

• Flushing before confirms patency. Between-med flushes prevent drug-drug interactions in the tube. Final flush ensures the full dose reaches the stomach.

A patient on tube feedings needs an oral medication. What are the three most critical nursing considerations?

(1) Verify tube placement before EVERY administration (X-ray is gold standard). (2) Use liquid form; if unavailable confirm tablet can be crushed (never EC or XL). (3) Administer each medication SEPARATELY and hold feedings ≥30 min before/after.

• Incorrect placement = drug goes to lungs. Mixing drugs = drug-drug interactions. Incorrect crushing = overdose.

What is the difference between pharmacokinetics and pharmacodynamics?

Pharmacokinetics = what the BODY does to the DRUG (ADME). Pharmacodynamics = what the DRUG does to the BODY (mechanism of action, target cell effects).

• Knowing ADME helps predict how long a drug works, why doses differ between patients, and when toxicity occurs.

Order fastest to slowest absorption: Oral, IV, SQ, IM, Sublingual, Inhalation, Topical.

• IV (immediate)

• Inhalation

• Sublingual/Buccal

• IM

• SQ

• Oral

• Topical (slowest)

IV has no absorption barrier. Topical must penetrate the full skin barrier. Rate of absorption = onset of action.

What is the difference between phlebitis and infiltration? How do you distinguish them at the bedside?

phlebitis: HOT, red streak along vein, swollen, tender — vein wall inflamed.

Infiltration: COLD, pale, swollen skin, decreased flow, no blood return — IV slipped OUT of vein into tissue. Memory: Phlebitis = HOT & RED. Infiltration = COLD & SWOLLEN.

• Both require IV removal. Wrong treatment (e.g., warm compress on vesicant infiltration) worsens tissue damage.

A patient is receiving a piggyback (IVPB). How does the back-check valve work, and why must the IVPB bag be HIGHER?

IVPB must be higher so gravity drives it to infuse first. The back-check valve at the Y-port stops primary flow while IVPB runs. When IVPB empties (fluid drops below primary drip chamber), the valve opens and primary resumes automatically. R: If IVPB is lower than the primary bag, the primary will infuse first and IVPB won't run.

What is the Z-track technique and when is it required?

Used for irritating medications or those that stain skin (e.g., iron/deferoxamine).

Steps:

(1) Change needle after drawing up

(2) Pull skin 2–3 cm laterally

(3) Insert 90°, inject

(4) Hold 10 seconds

(5) Withdraw and release skin → zigzag path seals drug in muscle.

• Without Z-track, drug leaks back up the needle track into subcutaneous tissue → pain, staining, or sterile abscesses.

Compare ID, SQ, and IM injections: angle, gauge, volume, and site.

• ID: 5–15° bevel UP, 26–27g, 0.01–0.1 mL, inner forearm, expect bleb/wheal.

• SQ: 45–90°, 25g, 0.5–1.5 mL, outer arms/abdomen/thighs.

• IM: 90°, 18–27g, 1–3 mL, ventrogluteal/ dorsogluteal (not recommended), Deltoid/ Vastus Lateralis/

Angle determines tissue layer reached. Gauge matches the tissue depth and volume needed.

Why is the VENTROGLUTEAL site the preferred IM site for adults?

Farthest from major nerves (sciatic), large blood vessels, and GI tract. Best for large, viscous, or irritating meds. Dorsogluteal is no longer recommended due to sciatic nerve proximity.

• Sciatic nerve damage from dorsogluteal injection can cause permanent foot drop and paralysis.

Why do you NOT massage after intradermal injections? What does it mean if no bleb forms?

Massaging disperses the medication → test results INVALID. No bleb = drug entered subcutaneous tissue instead of dermis → test results INVALID, must be repeated.

• ID injection requires drug to stay in the dermis. The bleb confirms correct placement.

State all 11 Rights of Medication Administration

(1) Right Medication (2) Right Patient (3) Right Dosage (4) Right Route (5) Right Time (6) Right Reason (7) Right Assessment Data (8) Right Documentation (9) Right Response (10) Right to Education (11) Right to Refuse.

Three things a nurse should NEVER do regarding medication administration — and why?

1. NEVER document before giving — falsifies record if patient refuses or vomits.

2. NEVER administer a med you didn't prepare or witness — can't verify contents.

3. NEVER leave medication at the bedside — wrong timing or unauthorized access.

• Each violation creates a safety gap and is also a licensing violation.

A patient has an order to avoid grapefruit juice. Why?

Grapefruit inhibits CYP3A4 enzymes in the gut → less drug broken down during first-pass → MORE drug reaches the bloodstream than intended → TOXICITY RISK.

• Food-drug interactions are clinically significant. Grapefruit amplifies drug levels by blocking the enzymes that regulate concentration.

What is the difference between a PEAK and TROUGH drug level, and when do you draw each?

Peak = highest plasma concentration (draw after dose at specified time). Trough = lowest concentration just before next dose (draw IMMEDIATELY before next scheduled dose).

• R: Peak identifies toxicity risk; trough identifies subtherapeutic risk. Both must stay within the therapeutic range.

What is half-life and why does it matter clinically? A drug is considered negligible after how many half-lives?

How much time for 50% of drug to be eliminated from blood. Considered negligible after 4 HALF-LIVES.

• Shorter half-life = more frequent dosing. Liver/kidney disease prolongs half-life → toxicity.

• Half-life determines dosing frequency, when plateau is reached, and when the drug is finally cleared.

Differentiate: side effect, adverse effect, toxic effect, idiosyncratic reaction, and allergic reaction.

• Side effect: predictable, unavoidable secondary effect.

• Adverse: unintended, undesirable.

• Toxic: drug accumulation → life-threatening (e.g., morphine → respiratory depression → death).

• Idiosyncratic: abnormal response unique to the patient.

• Allergic: immune-mediated, unpredictable — patient must avoid the drug and wear medical ID.

A patient receives IV pain medication. When should the nurse reassess pain, and why does timing differ by route?

IV = 15 min. IM = 30–45 min. PO = 1 hour. Timing differs because absorption rate varies — IV is immediate, IM faster than PO due to muscle vascularity, PO slowest due to GI absorption and first-pass.

Too-early reassessment shows no effect (drug not absorbed yet). Too-late misses adverse effects or inadequate control.

What is the SAS flush protocol for a saline lock, and why is it performed in this order?

Saline → Action (medication) → Saline. First saline confirms patency. Medication given. Final saline clears catheter of remaining medication.

• If IV is infiltrated, the first saline flush swells the tissue — alerting you before medication is wasted or causes tissue damage.

What is a time-critical medication? Give the window and a clinical example.

Administration 30 minutes before or after scheduled time could cause subtherapeutic or harmful effects. Window: ±30 min.

Examples: insulin, antibiotics, anticoagulants. Non-time-critical: ±1–2 hours.

• Time-critical drugs must maintain consistent serum levels. Insulin late after a meal → hypoglycemia. Antibiotics with wide intervals → treatment failure.

What is the correct technique for a transdermal patch, and what is the most common serious error?

1. Remove OLD patch FIRST.

2. Apply to HAIRLESS area.

3. Rotate sites.

4. Document location. Most common error: leaving the old patch on → DOUBLE DOSING.

Especially dangerous with opioid or nitroglycerin patches — double the dose = toxicity.

What gauge catheter for a trauma patient needing rapid fluid delivery vs. a pediatric patient with fragile veins?

Trauma: 16g — maximum flow rate. Pediatric/fragile: 24g (yellow). Surgery/blood: 18g (green) or 20g (pink). Stable adults: 22g (blue).

• Flow rate is dramatically affected by gauge. In trauma, small gauge = bottleneck. In fragile veins, large gauge causes infiltration and vein damage.

When is aspiration required before IM injection? What do you do if you aspirate blood?

Current evidence: aspiration is OUTDATED for most IM sites. If blood IS aspirated → WITHDRAW immediately, DISCARD syringe and medication, START OVER.

• IV injection of an IM-intended drug delivers it at wrong rate/concentration into the bloodstream — potentially fatal.

What is medication reconciliation, why is it required, and when does it occur?

Compile complete medication list → compare with new prescriptions → resolve ALL discrepancies. Required by The Joint Commission. Occurs at ADMISSION, TRANSFER, and DISCHARGE.

• Medication errors at transitions of care are extremely common. Reconciliation catches double-dosing, missing medications, and dangerous combinations.

A nurse makes a medication error. What are the three immediate steps in correct order?

1. ASSESS the patient immediately — vitals, symptoms, LOC. Patient safety FIRST.

2. NOTIFY provider ASAP

3. FILE incident/occurrence report — not part of permanent medical record (legally protected). Report near-misses too.

Address clinical status before paperwork. The incident report is a quality/safety tool, not an admission of guilt.

Why can nursing students NOT take verbal/telephone medication orders or administer IV push medications?

Students lack licensure and legal authority. IVP prohibited because once drug enters IV bloodstream it CANNOT be recalled or stopped — errors are immediately and irreversibly dangerous.

• These restrictions exist because consequences of errors are potentially irreversible. Delegation requires competence and licensure the student has not yet achieved.

Acetaminophen 975 mg PO. Have: 325 mg/tablet. How many tablets? Show formula method work.

D/H × S = 975 ÷ 325 × 1 tab = 3 tablets. R: Check units match first (both mg ✓). Never give >3 tablets of the same drug without double-checking — that's a red flag.

Order: Phenobarbital 0.2 g PO. Have: 100 mg tablets. How many tablets?

Convert: 0.2 g × 1000 = 200 mg. Then: 200 ÷ 100 × 1 tab = 2 tablets. R: Most common error = forgetting to convert units first. Order in grams, supply in mg → ALWAYS convert before applying the formula.

Order: 1000 mL LR IV from 8 AM to 8 PM via infusion pump. What rate do you set?

8 AM–8 PM = 12 hours. 1000 ÷ 12 = 83.33 → 83 mL/hr. R: IV pumps program in mL/hr. Always calculate the time span carefully. Round to nearest whole number.

Order: 500 mL D5NS over 4 hours. Tubing drip factor: 20 gtts/mL. What is the manual drip rate in gtts/min?

mL/hr = 500 ÷ 4 = 125. Then: (125 × 20) ÷ 60 = 2500 ÷ 60 = 41.67 → 42 gtts/min. R: Manual drip rates require mL/hr AND the tubing drip factor. Always divide by 60 to convert per-hour to per-minute.

Order: Morphine 6 mg IM. Have: Morphine 10 mg/mL. How many mL? Which syringe and rounding rule?

6 ÷ 10 × 1 mL = 0.6 mL. Use 3 mL syringe → round to nearest tenth (0.1 mL). Already at tenths — no further rounding. R: 3 mL syringe markings = 0.1 mL increments. 1 mL tuberculin syringe = 0.01 mL increments. Wrong rounding rule = incorrect dosing.

What are the three main types of pain by duration and origin?

Duration: Acute (<6 months, expected end) vs. Chronic (>6 months).

Origin: Nociceptive (tissue damage — somatic or visceral) vs. Neuropathic (nerve damage — burning, tingling, shooting).

• Pain type guides treatment. Neuropathic pain requires adjuvants; chronic pain requires a different approach than acute.

What is the difference between pain TOLERANCE and pain THRESHOLD?

Threshold = point at which stimulus is first perceived as painful (relatively consistent).

Tolerance = maximum intensity a person is willing to endure (HIGHLY variable — influenced by culture, anxiety, fatigue, past experience).

• High tolerance doesn't mean low pain. Assessment must be based on patient self-report, not the nurse's judgment.

A patient rates pain 8/10 but refuses opioids. What is the nurse's role?

1. Respect the right to refuse

2. Assess the reason (fear of addiction, side effects, culture)

3. Offer non-pharmacological alternatives

4. Offer non-opioid pharmacological options

5. Document refusal, education given, and alternatives offered.

• Patient refusal is a legal right. The nurse's role is not to override but to ensure the patient is informed and provide alternatives.

What does a comprehensive pain assessment include?Use the OLDCARTS mnemonic.

Onset, Location, Duration, Characteristics (quality), Aggravating/Alleviating factors, Radiation, Timing (constant vs. intermittent), Severity (0–10). Also assess impact on function and current medications.

• R: Pain is subjective. Underassessment → undertreatment → unnecessary suffering.

What must the nurse assess every hour for a patient on PCA?

1. Pain score 0–10.

2. Number of PCA attempts.

3. Total hourly dose.

4. Cumulative dose.

5. Level of consciousness.

6. Side effects (nausea, itching).

7. Respiratory rate — MOST CRITICAL. If RR <12 breaths/min → notify provider immediately.

• R: PCA delivers opioids. Lockout prevents button-press overdose but cumulative doses can still suppress respiration. Naloxone must be available.

A patient on morphine PCA has RR of 9 breaths/min and is difficult to arouse. What do you do?

1. Stop/pause PCA immediately.

2. Stimulate/attempt to arouse.

3. Call for help / notify provider STAT.

4. Prepare NALOXONE (Narcan).

5. Support airway/breathing. Document everything.

• R: RR <12 = opioid-induced respiratory depression — medical emergency. Naloxone has shorter half-life than morphine; watch for re-sedation.

What is the difference between opioid tolerance, dependence, and addiction?

Tolerance: need HIGHER doses for same effect (expected).

Dependence: withdrawal symptoms if stopped abruptly (expected, NOT addiction).

Addiction: psychological compulsion to use despite harm.

• R: Tolerance and dependence are normal physiologic responses. Nurses who confuse them with addiction may under-treat pain.

Name five non-pharmacological pain management strategies and give the rationale for one.

Repositioning/splinting.

Ice/heat.

Distraction (music, TV).

Relaxation/guided imagery.

TENS. Rationale for distraction: activates brain's attention system, competing with pain signals for neural processing (gate control theory).

• R: Non-pharm strategies are the nurse's independent domain. They reduce opioid requirements and have no systemic side effects.

A post-op patient is grimacing but doesn't press the call light because they "don't want to bother anyone." How should the nurse respond?

1. Proactively assess pain every 1–2 hours — don't wait for the patient.

2. Validate: "It's my job to keep you comfortable." (

3. Use validated pain scale.

4. Address fear of "being a bother" as a barrier.

5. (Medicate and reassess.

• R: Patients underreport due to culture or stoicism. Uncontrolled pain delays healing, increases complications, and is unethical to ignore.

What is the WHO analgesic ladder and how does it guide pain management?

Step 1: Non-opioids (acetaminophen, NSAIDs) for mild pain.

Step 2: Mild opioids ± non-opioids (codeine, tramadol) for moderate.

Step 3: Strong opioids ± non-opioids (morphine, hydromorphone) for severe. Adjuvants added at any step for specific pain types.

• R: Ensures systematic stepwise treatment — starting with safest options. Guides when to escalate and prevents under-treatment of severe pain.

What is equianalgesic dosing and why is it important when switching opioids?

Equianalgesic dosing = calculating the equivalent dose of a new opioid providing the same relief. Important because different opioids have very different potencies (e.g., hydromorphone is ~5x more potent than morphine). Wrong conversion = under-treatment or overdose.

• R: When switching opioids due to side effects or tolerance, nurses use equianalgesic tables. Errors here directly cause patient harm.

What type of pain is described as burning, shooting, or tingling and doesn't respond well to standard opioids alone?

Neuropathic pain — caused by nerve damage (e.g., diabetic neuropathy, post-herpetic neuralgia, phantom limb). Requires adjuvants: tricyclic antidepressants (amitriptyline), anticonvulsants (gabapentin, pregabalin), or topical agents.

• R: Neuropathic pain involves abnormal nerve signaling, not just tissue injury — standard analgesics target the wrong mechanism.

patient is scheduled for morphine q4h. They request it after only 2 hours. What is the nurse's FIRST action?

FIRST: Perform a complete pain assessment. Do NOT just give the medication without assessing. If pain is escalating, contact provider to discuss adjusting schedule or dose. Document findings and actions.

• R: Early requests may indicate undertreated pain, developing tolerance, or a new clinical problem (e.g., internal bleeding). Assessment comes before medication.

What are common opioid side effects the nurse must monitor and manage?

Respiratory depression — most dangerous, monitor RR.

Constipation — most common, does NOT resolve with tolerance, use stool softeners prophylactically.

Nausea/vomiting.

Sedation/LOC changes.

Urinary retention.

Pruritus.

• R: Constipation must be treated actively — it never gets better on its own. Respiratory depression is the life-threatening complication.

A patient says their pain is 9/10 but appears calm and is watching TV. Should the nurse believe them?

YES — ALWAYS believe the patient's self-report. Pain is subjective. Patients adapt behaviorally to chronic or persistent pain (habituation). Calm appearance does NOT mean low pain. Judging pain by behavior alone = undertreatment. R: The Joint Commission mandates pain assessment based on patient self-report. Dismissing a patient's rating is unethical and legally indefensible.

What nonpharmacological and pharmacological strategies are appropriate for a patient who CANNOT report pain verbally?

Use a BEHAVIORAL PAIN SCALE (CPOT for critical care, FLACC for children). Observe: facial grimacing, guarding, restlessness, rigid posture, tachycardia, tachypnea. Non-pharm: repositioning, suctioning if ventilated. Pharm: titrate analgesics based on behavioral indicators, reassess after each intervention.

• R: Inability to communicate ≠ inability to feel pain. Validated tools allow inference of pain in non-verbal patients.

What are the differences between STAT, NOW, PRN, and routine medication orders?

• STAT: give immediately, one time, highest urgency.

• NOW: urgent but not STAT — within 90 minutes, one time.

• PRN: give only when patient requires it — assess need first, document response after.

• Routine/Standing: scheduled at regular intervals until discontinued.

R: PRN orders especially require full assessment before and documentation of response after — the nurse uses clinical judgment to determine if criteria are met

What is SBAR and when is it used?

Situation, Background, Assessment, Recommendation. Used when calling a provider about a change in status, handing off care (shift change, transfer), or communicating critical information with any team member.

• R: Communication breakdown is the #1 cause of medical errors. SBAR creates a standard concise format that ensures critical data is communicated first.

What are the five rights of delegation, and why can an RN NOT delegate nursing assessment?

1. Right Task

2. Right Circumstance

3. Right Person

4. Right Direction/Communication

5. Right Supervision/Evaluation.

Assessment CANNOT be delegated because it requires professional nursing judgment and licensure — interpreting findings is a licensed function.

• R: The RN remains accountable after delegating. Delegating assessment to a CNA means a non-licensed person is making clinical judgments — outside their scope.

What are the nurse's essential responsibilities during a patient ADMISSION?

1) Head-to-toe assessment, Full medication history including allergies, herbals, OTCs; Medication reconciliation, Orient to unit, Assess educational needs, Fall/skin/DVT risk assessments, and Baseline vital signs.

R: Incomplete medication reconciliation at admission is a leading cause of adverse drug events.

What must a discharge teaching plan include, and why is "teach-back" essential?

Medication name/purpose/dose/timing/side effects, activity restrictions, diet modifications, follow-up appointments, when to call provider/go to ER, signs of complications. Teach-back: ask patient to explain in THEIR OWN WORDS — confirms understanding, not just hearing.

R: Providing information ≠ patient understanding. Teach-back catches misunderstandings before the patient goes home and acts on incorrect information.

A patient is being transferred from ICU to a medical floor. What are the nurse's responsibilities?

1) SBAR report to receiving nurse. (2) Confirm all current orders transfer. (3) Medication reconciliation at transfer. (4) Accompany patient if condition requires monitoring. (5) Document transfer assessment and time. (6) Receiving nurse verbally accepts patient.

• R: Transfer transitions are high-risk for information loss. Medication reconciliation at EVERY transition is a Joint Commission requirement.

Who makes up the interprofessional team, and what is the nurse's collaborative role?

RN/LPN, physician/NP/PA, pharmacist, PT/OT, respiratory therapist, dietitian, social worker, case manager, chaplain, patient/family. Nurse's role: coordinate care, communicate changes, advocate for patient, ensure care plan reflects all team input.

• R: The nurse spends the most time with patients and serves as the central communication hub. Effective collaboration reduces errors and improves outcomes.

What precautions are required for airborne, droplet, and contact transmission?

Airborne: N95 respirator + negative pressure room (TB, measles, chickenpox).

Droplet: surgical mask + private room or 3-foot separation (influenza, COVID, meningitis).

Contact: gown + gloves upon entry + dedicated equipment (C. diff, MRSA, wound infections).

A patient has C. diff. Which precautions, and why is alcohol-based hand rub NOT sufficient?

Contact precautions: gown + gloves, private room, dedicated equipment.

Use SOAP AND WATER — alcohol does NOT kill C. diff spores.

Only the mechanical action of washing removes spores.

• R: C. diff forms spores that survive months on surfaces. Alcohol kills most bacteria/viruses but cannot destroy spores.

What is the correct order for DONNING and DOFFING PPE?

Donning: Gown → Mask/Respirator → Goggles/Face Shield → Gloves.

Doffing: Gloves (most contaminated) → Goggles/Face Shield → Gown → Mask/Respirator (least contaminated last). Hand hygiene between each doffing step.

• R: PPE is removed outside-in, most contaminated first. Gloves carry the most external pathogens.

What are the WHO 5 moments of hand hygiene?

1. Before touching a patient.

2. Before a clean/aseptic procedure.

3. After exposure to body fluids.

4. After touching a patient.

5. After touching patient surroundings (even without touching the patient).

• R: Hand hygiene is the SINGLE most effective infection control measure. Each moment targets a specific transmission risk.

A patient's temperature is 39.2°C. What is that in Fahrenheit, and what are the four temperature measurement routes?

39.2 × 9/5) + 32 = 102.6°F — this is a fever (normal: 97.6–99.6°F). Routes: Oral (most common), Axillary (least accurate, 1° below core), Rectal (most accurate, 1° above core), Tympanic (fast but position-dependent). R: Route matters for interpretation. Always document the route used. Fever ≥100.4°F (38°C) requires further assessment.

What are normal adult vital sign ranges

HR: 60–100 bpm (Brady <60, Tachy >100)

RR: 12–20 breaths/min

BP: <120/80 normal; HTN ≥130/80; Hypotension <90/60

Temp: 97.6–99.6°F.

O2 sat: ≥95% (concern <90%)

Pain: 0–10 (5th vital sign).

A patient has BP of 88/50 and is diaphoretic and restless. What is your priority action?

1. Assess LOC and quality of pulse.

2. Place supine with legs elevated (unless contraindicated)

3. Notify provider IMMEDIATELY.

4. Prepare for IV fluid bolus.

5. Continuous monitoring. Do NOT leave patient alone.

• R: BP 88/50 + restlessness + diaphoresis = signs of shock. Restlessness = early sign of cerebral hypoperfusion. Time-sensitive — organ damage increases every minute.

What is the proper technique for a blood glucose fingerstick (FS), and what values require immediate action?

1) Verify order/ID. (2) Wash hands, gloves. (3) Warm/massage finger. (4) Clean with alcohol, let DRY. (5) Lancet to SIDE of fingertip. (6) Wipe away FIRST drop. (7) Apply second drop to strip.

• Critical values: <70 mg/dL (hypoglycemia — treat immediately) or >400 mg/dL (notify provider).

• R: Wiping first drop removes residual alcohol or interstitial fluid that dilutes sample → false low. Side of finger = fewer nerves + better blood flow.

What is the correct technique for collecting a stool specimen for occult blood (guaiac) testing?

(1) No toilet paper or urine in sample.

(2) Sample TWO different areas of stool.

(3) Apply thin smear to guaiac card.

(4) Patient may need 3 days of dietary restriction (no red meat, vitamin C, aspirin) — false positives.

• R: Two-site sampling improves sensitivity because blood isn't uniformly distributed in stool. False positives lead to unnecessary invasive follow-up.

Walk through SBAR for a patient with new onset chest pain.

S:"This is Nurse Jones on 4W. Mr. Smith in 412 has new onset chest pain, 8/10."

B: "65-year-old post-op day 2 CABG, history of hypertension and DM."

A: "BP 90/60, HR 112, RR 22, O2 sat 91% on 2L NC, diaphoretic."

R: "Request immediate evaluation, cardiology consult, and 12-lead EKG now."

• R: SBAR gives the provider everything needed in structured, time-efficient format. Starting with the Situation grounds the listener immediately.

A nurse is caring for 4 patients and receives a new admission. Which patient gets care FIRST?

Use Maslow + ABCs:

1. Airway compromise/respiratory distress — FIRST.

2. Hemodynamic instability.

3. Acute pain or new symptoms.

4. Stable patients. New admission = lower priority unless unstable. Delegate stable tasks (hygiene, meal setup) to UAP/CNA.

• R: ABCs provide a systematic framework. Delegation allows the RN to stay with high-acuity patients. Assessment and IV management cannot be delegated — those stay with the RN.

What is the correct technique for administering eye drops, and where exactly does the drop go?

Position patient supine or seated with head tilted back. Drop goes into the LOWER CONJUNCTIVAL SAC — NOT directly on the cornea. Press the nasolacrimal duct 30–60 seconds after. If patient blinks, repeat the drop. Multiple drops same eye: wait 5 minutes between each. Eye ointment: thin ribbon from inner → outer canthus.

• R: Dropping directly on the cornea triggers a blink reflex and the drop is lost. Pressing the nasolacrimal duct prevents systemic absorption through the tear duct — especially important for drugs like beta-blocker eye drops that can cause systemic bradycardia.

How do you straighten the ear canal for an adult vs. a child under 3, and why does it matter?

Adults: pull auricle UPWARD and OUTWARD. Children under 3: pull DOWN and BACK. Hold dropper 1 cm above canal. Gently press on tragus after (unless painful). Remain side-lying 2–3 min. Do NOT push cotton ball deep into canal.

• R: The ear canal curves differently in children vs. adults. Wrong direction = medication hits the canal wall instead of traveling to the eardrum. Deep cotton ball blocks drainage and traps bacteria.

What is the correct position and technique for vaginal medication administration?

Position: supine, knees bent, feet flat (dorsal recumbent/modified lithotomy). Insert suppository 7.5–10 cm (3–4 in) along posterior wall. Creams/foams: 5–7.6 cm (2–3 in). Remain supine ≥5 min after. Wash reusable applicators with soap and water; discard disposables.

• R: Supine position after administration uses gravity to keep medication in contact with vaginal mucosa for absorption. Incorrect insertion depth or immediate ambulation = medication expelled before it can work.

What is the correct position for rectal suppository administration and how far is it inserted?

Position: left lateral (Sims) position. Insert just BEYOND the internal sphincter using a lubricated gloved finger. Rounded end first prevents trauma. Patient should remain in position to retain.

• R: Sims position relaxes the external sphincter. The internal sphincter is 2.5–4 cm inside — the suppository must pass it to be retained and absorbed. Rounded end minimizes tissue trauma on insertion.

What is the difference between MDI and DPI inhalers, and what is the purpose of a spacer?

MDI (Metered-Dose Inhaler): uses a chemical propellant, requires 5–10 lbs pressure on canister, common for asthma/COPD/emphysema.

DPI (Dry Powder Inhaler): breath-activated, no propellant. Spacer (4–8 inch tube): slows the particles, allows more time for inhalation, improves lung deposition, reduces oropharyngeal deposition.

• R: Without a spacer, many MDI particles hit the back of the throat and never reach the lungs. The spacer acts as a reservoir that the patient inhales from — improving therapeutic effect and reducing local side effects (e.g., oral candidiasis from inhaled steroids).

What patient teaching points are essential for inhaler use?

(1) Inhale SLOWLY and DEEPLY. (2) Hold breath 10 seconds after each puff (allows particles to deposit in airways). (3) Wait 1 minute between puffs of the same inhaler. (4) Rinse mouth after corticosteroid inhalers (prevents oral candidiasis). (5) Refill 7–10 days BEFORE running out. (6) Prime the inhaler if new or unused for several days.

• R: Rapid inhalation causes particles to impact the oropharynx instead of reaching the bronchioles. Holding the breath maximizes deposition time. Running out of a rescue inhaler in an asthma emergency is life-threatening.

What are the key rules for needle safety and sharps disposal?

Use safety syringes with sheath/guard (mandated by Needlestick Safety and Prevention Act). If needle MUST be recapped: one-scoop method only (cap on flat surface, scoop in with one hand — never use two hands). Dispose in puncture-proof, leak-proof, clearly marked sharps container. Never force into a FULL container. Never place in pocket, wastebasket, meal tray, or patient bedside.

• R: Needlestick injuries transmit HIV, Hepatitis B/C, and other bloodborne pathogens. Two-handed recapping is the leading cause of needlestick injuries — the one-scoop method keeps the non-dominant hand away from the needle tip.

What are the legal requirements for narcotic/controlled substance administration and wasting?

Wasting MUST be witnessed by another nurse. Taking a patient's medication is a CRIMINAL OFFENSE. Nurses must follow federal and state regulations. Report ALL discrepancies immediately. Different pharmaceutical waste receptacles exist for different drug types — know your facility policy.

• Controlled substances are federally regulated under the DEA. Diversion (taking patient medications for personal use) is a felony, grounds for license revocation, and a patient safety violation. Witnessed wasting creates an accountability trail.

What is the difference in technique between drawing medication from an ampule vs. a vial?

AMPULE (glass, single dose): tap neck to move medication down → break away from face at scored ring → draw up with a FILTER NEEDLE (prevents glass fragments) → change to appropriate needle before injecting. VIAL (rubber seal top): inject air EQUAL TO volume being withdrawn BEFORE withdrawing → wipe rubber top with alcohol before each use.

• R: Filter needle is critical for ampules — glass fragments are invisible and would be injected IV/IM without it. Injecting air into a vial first equalizes pressure in this closed system, making fluid withdrawal easy. Skipping air injection creates a vacuum that makes withdrawal very difficult.

What is protein binding and why does it matter clinically?

Most drugs bind to albumin in the blood. Only the UNBOUND ("free") drug is pharmacologically active — bound drug cannot cross membranes or act on target cells. Low albumin (malnutrition, liver disease, elderly) = more free drug = MORE drug effect = TOXICITY RISK even at normal doses.

• R: Two patients can receive the same dose but have very different drug effects based on albumin levels. This is why malnourished or elderly patients often need dose reductions — more of the drug is "free" and active.

What factors affect drug DISTRIBUTION throughout the body?

1. Vascularity of tissues — more blood supply = faster distribution (brain, heart, liver get drug first).

2. Membrane permeability — lipid-soluble drugs cross more easily.

3. Protein binding — only free drug distributes to tissues.

4. Blood-brain barrier — only lipid-soluble drugs penetrate CNS.

   • R: Distribution explains why some drugs work quickly in some organs but slowly in others. It also explains why brain infections require specific antibiotics that can penetrate the blood-brain barrier.

What are the three systems used to classify drugs, and give an example of a drug with multiple classifications?

(1) Body system (e.g., cardiovascular, CNS, respiratory drugs).

(2) Chemical composition (e.g., beta-blockers, ACE inhibitors, benzodiazepines). (

3) Clinical/therapeutic use (e.g., analgesic, antipyretic, anti-inflammatory).

> Example: Aspirin = analgesic + antipyretic + anti-inflammatory + antiplatelet — all four classifications apply.

• R: One drug can have multiple classifications because it acts on multiple systems or has multiple therapeutic uses. Understanding classification helps predict effects, side effects, and contraindications.

What is a synergistic drug effect and why is it dangerous?

Two drugs together produce a GREATER effect than each drug alone — more than additive.

Example: opioids + benzodiazepines → combined CNS/respiratory depression far greater than either alone → respiratory arrest risk. Monitor closely — increased toxicity risk even at normal doses of each.

• R: Synergism is exploited therapeutically (e.g., combination chemotherapy) but is dangerous when unintended. The nurse must recognize drug combinations that amplify each other's effects and monitor accordingly.

A patient has chronic kidney disease. How does this affect drug excretion and what is your nursing priority?

Kidneys are the PRIMARY organ of drug excretion. Kidney impairment → drug is not eliminated adequately → accumulates in bloodstream → TOXICITY. Nursing priority: monitor renal function (BUN, creatinine, eGFR), watch for signs of toxicity, anticipate dose reductions, and be especially cautious with renally-cleared drugs (digoxin, metformin, aminoglycosides).

• R: Renal impairment is as dangerous as hepatic impairment for drug accumulation. Both the liver (metabolism) and kidneys (excretion) must function adequately for drugs to clear safely.

What are the chain of infection links, and breaking which link is the nurse's primary strategy?

(1) Infectious agent → (2) Reservoir → (3) Portal of exit → (4) Mode of transmission → (5) Portal of entry → (6) Susceptible host.

The nurse primarily breaks the TRANSMISSION link — through hand hygiene, PPE, and isolation precautions. Also breaks portal of entry (sterile technique for invasive procedures) and reduces host susceptibility (immunizations, nutrition, skin care).

• R: You cannot always eliminate the infectious agent or reservoir, but you CAN consistently interrupt transmission. Hand hygiene breaks multiple links simultaneously — that's why it's the single most effective infection control measure.

What is the difference between medical asepsis (clean technique) and surgical asepsis (sterile technique), and when is each used?

Medical asepsis: reduces the number and spread of microorganisms — used for routine care, hand hygiene, standard precautions, oral medications. Surgical asepsis: ELIMINATES ALL microorganisms including spores — used for invasive procedures (IV insertion, urinary catheterization, wound care on open wounds, injections).

• R: Using medical asepsis for a procedure that requires surgical asepsis introduces microorganisms directly into a sterile body cavity or bloodstream — causing infection. The level of asepsis must match the invasiveness of the procedure.

What are the normal ranges of WBC, hemoglobin (male/female), hematocrit, and platelets?

• WBC: 4,500–11,000/mm³ (elevated = infection/inflammation; decreased = immunosuppression).

• Hemoglobin: Male 13.5–17.5 g/dL, Female 12–15.5 g/dL (low = anemia).

• Hematocrit: Male 41–53%, Female 36–46% (low = anemia, bleeding).

• Platelets: 150,000–400,000/mm³ (low = bleeding risk; high = clotting risk).

What isolation precaution category requires a NEGATIVE PRESSURE ROOM, and what are examples of diseases requiring it?

• AIRBORNE precautions require a negative pressure room (air flows INTO the room, not out — containing airborne particles).

• Examples: TB (tuberculosis/Mycobacterium), measles (rubeola), chickenpox (varicella), disseminated herpes zoster. N95 respirator required — surgical mask is NOT sufficient.

• R: Negative pressure rooms prevent airborne particles from escaping into the hallway when the door is opened. Regular surgical masks have gaps that allow particles <5 microns (airborne size) to pass through — N95 filters 95% of particles ≥0.3 microns.

NON-PARENTERAL Vs PARENTERAL routes

• Non-parenteral = NOT injected (oral, mucosal, topical)

• Parenteral = injected (ID, SQ, IM, IV)

Parenteral routes bypass the GI tract → faster absorption and higher risk. Non-parenteral routes are safer but slower.

key steps for administering medications through an enteral tube (NG/G-tube)?

• Verify placement first

• Use liquid meds if possible

• Crush only if allowed (NO EC or extended-release)

• Give each medication separately

• Flush: before 15–30 mL, between meds 5 mL, after 15–30 mL

• Hold tube feeding if required

Prevents aspiration, clogging, and drug interactions. Mixing meds or feeds alters absorption and can block the tube.

Why should sublingual medications NEVER be given through a feeding tube?

They must dissolve under the tongue and absorb through mucous membranes.

• Giving via tube sends drug to stomach → destroys intended rapid absorption and bypass mechanism.

What is the correct order for flushing an IV saline lock (SAS)?

Saline → Administer medication → Saline

• Maintains patency and ensures full medication delivery without mixing incompatibilities.

difference between a saline lock and a continuous IV line?

• Saline lock: intermittent access (no continuous fluid)

• Continuous IV: constant infusion running
  Saline locks reduce fluid overload risk and allow intermittent medication administration.

What are the three main IV medication administration methods?

• Continuous infusion (large volume)

• IV push (IVP/bolus)

• IV piggyback (secondary infusion)

Each differs in speed and risk — IV push is the MOST dangerous because it acts immediately.

priority nursing action BEFORE administering IV medication?

Assess IV site for patency (open/ unobstructed) and complications.

If IV is infiltrated or blocked, medication will not enter bloodstream → tissue damage risk.

What is the FIRST action if infiltration or phlebitis occurs?

STOP infusion and remove IV.

Continuing infusion worsens tissue damage and complications.

What is a key safety consideration when administering vancomycin?

• Infuse slowly over at least 60 minutes.

Prevents Red Man Syndrome (flushing, hypotension, tachycardia).

When should you use the Z-track technique?

• For irritating or staining IM medications (e.g., iron).
  Prevents medication from leaking into subcutaneous tissue and causing irritation.

Why should you NOT massage after SQ or ID injections?

It alters absorption and can cause bruising.

• Especially dangerous with heparin → increases bleeding risk.

What are time-critical medications?

Medications that must be given 30 minutes BEFORE/ After of scheduled time.

What are non–time-critical medications?

Medications that can be given within 1–2 hours of scheduled time.
Less risk if slightly delayed, but still should be timely.

Which routes bypass the first-pass effect?

• IV, sublingual, buccal, transdermal, inhalation, rectal (partial)
  

• They enter bloodstream directly → faster and stronger effect.