Fundamental Exam 2

FDA, ISMP, Joint Commission

FDA: Medications → on the market, safe and ready

Off-Label: FDA-approved drug used in a different way than FDA indications

ISMP - Safe Medication Practices, Watchdog organization

Joint Commission - Accredits hospitals; watches how you pass medications

Right Patient, Indication, Medication, Dose

Right Patient - two unique identifiers, picture, other person, DOB (never rooms)

Right indication - Diagnosis, orange dot?

Right Medication - 3 checks; if opened, put the expiration date sticker; if not on vial, do 28 days; read vial, not box.

Right Dose - right calculations, safe amount; check and not repeat back

Right Route

Right Route -

External oral syringes are different colors,

Parenteral - injections and infusions (Send through tube, syringe, or free-flow; flush 15-30 mL with water); don’t put multiple meds in one syringe (inhalation pMDI, pressurized metered-dose (need motor skills, and rinse mouth afterwards), SMI -soft mist inhaler, DPO -dry powder,

IM - aspirate every time; not vaccines; stinging and staining: Z-track (Stretching)

Right Time

DAILY (not QD), BID, TID, QID, Q, HS bedtime, 30 minutes of order time, 1-2 if not immediate, Document Informed Declined

Documentation

Assessment, double-check, where placed, dose (mg) not the volume, informed declined

Insulin

45-90 degree angle, no aspirate, pinch technique, inject in the abdomen, upper buttocks, outer thigh, or upper arm

Store in the fridge until opened; once opened, store at room temperature

Insulin Syringe

0.3 mL (30 units)

0.5 mL (50 units)

1.0 mL (100 units)

Rapid/Short

Bolus, Pre-meal, highs, and food; fast-acting

Rapid - Glulisine, Lispro, Aspart; onset 10-20 minutes, peak 1-2 hours, duration 3-5 hours (Before each meal, specific amount of CHO)

Short/Regular - Humulin R, Novolin R; onset 30-60 minutes, peak 2-4 hour, duration 4-8 hours

Intermediate/Long

Basal needs

Intermediate - NPH, Humulin N, Novolin N; onset 1-3 hours, 4-10 hours; duration 10-18 hours; AC breakfast/dinner

Long-acting: glargine and detemir; only in syringes; can’t mix; onset 1-5 hours, no peak, duration up to 24 hours (Daily or BID)

Basal vs. Bolus

Basal: Background insulin throughout the day.

Bolus: Extra insulin for meals or high blood sugar.

Memorizing Insulin Drugs

Rapid-acting (food and high) -

Glue a pita close → Glulisine is Apidra

Listen to the human → Lispro is Humalog

If you grow apart you’ll have no vote → Aspart is Novolog

Short-acting (food and high) - Regular

Humalog R and Novolin R

Intermediate-acting (basal needs) -

NPH, ProteiN, Humulin N, Novolin N

Long-acting (basal needs) -

I’m gonna need a large place to land - Glargine is Lantus

That will determine if I Lev or not - Detemir is Levemir

Insulin Pump

Continuous dose (basal rate) of rapid-acting insulin through a subcutaneous cannula; bolus doses to cover CHO; correction/supplemental doses for high blood sugars.

Fiber Rule

>5 g of fiber: subtract fiber from total carbohydrate

20 g CHO − 7 g fiber = 13 g CHO

Example 72 Grams of CHO

1:10, 1:20>120

BG before eating = 240 mg/dL; eating 72 g CHO.

72 ÷ 10 = 7 units

(240 − 120) ÷ 20 = 6 units

Total insulin: 7 + 6 = 13 units

Hypoglycemia vs. Hyperglycemia

Hypoglycemia: below 70 BG, 15/15 15 G of carbs every 15

Sleepiness, sweating, pallor, lack of coordination, Irritability, hunger

Hyperglycemia: >120 dry mouth, increased thirst, blurred vision, weakness, headache, frequent urination

Causes of Hypoglycemia vs. Hyperglycemia

Hypoglycemia: Too much insulin, not enough carbohydrates, increased exercise

Hyperglycemia: Not enough insulin, stress, too many carbohydrates

Concentration of Insulin

Green U-500 symbol, green needle cover, each line is 5 units, doses up to 250 units

Sick Day Protocol - diabetes sick at home

Blood glucose tends to rise during illness; may need more insulin; check blood glucose every 2–3 hours; add urine ketone testing; try to eat 15 g CHO every hour; weigh yourself.

Call provider if fever, persistent hyperglycemia, persistent diarrhea, vomiting, abdominal pain, or difficult breathing.

T1 diabetics should check blood glucose before, during, and after exercise; ask about exercise patterns, as blood glucose may lower or rise.

Drug Nomenclature

Chemical Name, Generic Name - Alphabetized, NCLEX, Brand Name

Therapeutic or Functional Class: Condition the drug treats

Pharmacologic or Chemical Classification: Physiologically, what the drug does

Pharmacokinetics

Drugs in the body, Absorption (Rates and bioavailability), Distribution, Metabolism (liver), Excretion (kidneys)

Half Life

Amount of time for drug level to decrease by 50%, four-five half to get out of system

If the half life of a drug is 20 minutes, then how much of the original dose is still in the body after 40 minutes?

25%

Time Release Medications Different Names

Extended Release, Controlled Delivery, long acting, sustained action, timed release

8 oz

1 Cup

30 mLs =

1 fl oz

1 kg =

2.2 lbs

Class 10.14.2026

Therapeutic effect vs Side Effect

Adverse Effects, Side Effects, and Toxic Effects

• Idiosyncratic reactions: The opposite of what is expected.

• Allergic reactions: Trigger an immune response involving antibodies. Reactions can occur through skin contact, injection, or ingestion.

• If a toxic effect or new allergy is suspected, stop the medication as appropriate, ensure patient safety, and notify the prescriber and pharmacist.

• Contraindications: Do not administer the medication.

• Precautions: Administer the medication, but monitor the patient closely.

• Interactions: Any modification of the action of a drug by another substance.

Urticaria (Hives)

• Wheals: Raised, red areas on the skin.

• Pruritus: Itching.

Anaphylaxis

• Swelling of the airways; if not treated immediately, it can be fatal.

• Symptoms can begin within minutes of exposure, often within 5–30 minutes.

• The faster the reaction develops, the more concerning it may be.

• Get help immediately.

• Treatment: Epinephrine (EpiPen), administered intramuscularly (IM).

• Activate the rapid response team or call 911, depending on the setting.

• Administer epinephrine promptly according to the emergency protocol. Anaphylaxis is a life-threatening emergency.

Ampules and Filter Needles

• Ampules are glass containers used for medications.

• Use a filter needle to withdraw medication from a glass ampule to prevent glass particles from being drawn into the syringe.

• Do not inject medication using a filter needle; replace it with an appropriate needle before administration.

• Some medications may bind to the rubber stopper or other container materials, so follow medication-specific instructions.

Prescriptive Authority

• Providers with prescribing authority may include MDs, DOs, NPs, CNMs (Certified Nurse-Midwives), and PAs.

• Prescriptive authority depends on state law, licensure, and applicable practice regulations.

CPOE (Computerized Provider Order Entry)

• Providers can enter medication and other healthcare orders electronically.

• Sometimes, providers give telephone orders (TOs) or verbal orders (VOs).

• Read-back procedure: Write down the order and read it back to the provider to verify accuracy.

The Joint Commission's Do Not Use List

• U: Write “unit” or “units.”

• IU: Write “international unit.”

• QD: Write “daily.”

• Trailing zeros: Do not use trailing zeros after a decimal point (e.g., write 5 mg, not 5.0 mg).

• MS: Write “morphine sulfate” or “magnesium sulfate” in full.

• Write “daily” or “every other day” instead of using abbreviations.

Controlled Substance Schedules

• Controlled substances are classified into Schedules I–V.

• Schedule I substances have a high potential for misuse and are not accepted for medical use under federal law.

• Schedules II–V have varying levels of accepted medical use and potential for misuse.

• Schedule V substances have the lowest potential for misuse among the controlled substance schedules.

• Some cough preparations containing controlled substances may fall under Schedule V.

Controlled Substances and Narcotics

• Controlled substances may have street value and are often stored in secured narcotic drawers.

• Narcotic counts must be performed according to facility policy.

• Medication doses are documented in the prescribed units, such as milligrams (mg) or milliliters (mL), depending on the medication and order.

• Narcotic: A substance that can dull the senses, relieve pain, and induce stupor or sleep.

Drug Diversion

• Drug diversion involving injectable medications can expose patients to bloodborne pathogens, including hepatitis C.

• A healthcare worker may tamper with injectable drugs or use contaminated injection equipment and supplies.

• Contamination may occur in the patient care environment.

• Patients may be exposed to contaminated medications or equipment, potentially resulting in infection.

Accurate Patient Weight

• Document an accurate weight on admission.

• Medication errors can occur when weights are inaccurate.

• Use bed scales when appropriate.

• Do not confuse pounds (lb) with kilograms (kg).

Medication Reconciliation

• Medication reconciliation occurs during transitions of care to ensure that no medications have been missed.

• It is the process of verifying that the medications a patient is currently taking are correct and appropriate.

• Medication errors can occur during transitions of care, including:

  • Admission to or discharge from the hospital.

  • Transfer from the ICU to a general floor.

  • Addition of a new healthcare provider.

• Review all medications the patient was taking at home and in the previous unit or facility.

• Compare and evaluate medications for duplications, omissions, and interactions.

Medication Administration Safety

• Prepare medications for one patient at a time.

• Administer medications promptly after preparation, following medication-specific requirements.

• Observe the patient swallowing oral medications when appropriate.

• Administer only medications that you have personally prepared and verified, following facility policy. Properly prepared, labeled, and verified prefilled syringes may be used.

• One needle, one syringe, one patient, one time.

• Make sure the medication is appropriate for the patient and that the indication matches the patient's diagnosis and clinical condition.

• Read the medication label three times:

  1. When removing the medication from storage.

  2. When preparing the medication.

  3. At the bedside before administration.

• Read the label on the medication container, not just the outer box.

• Check allergies.

• Verify that the medication administration record (MAR), the patient's statements, and the patient's identification band are consistent with the medication order and patient identity.

Reporting Medication Errors and Near Misses

• Report medication errors and near misses according to facility policy.

• BYU nursing students must report incidents to both the College of Nursing and the clinical facility, following applicable reporting procedures.

• Incident reports help healthcare organizations identify problems and improve patient safety.

Intramuscular Injection Safety

• Do not use the dorsogluteal site; use the ventrogluteal site.

• The dorsogluteal site is near the sciatic nerve. Injury to this nerve can cause nerve damage, weakness, and foot drop.

Practice Safety and Develop a Routine

Isolation Precautions - Standard Precautions and Transmission-Based Precautions

Asepsis - Medical Asepsis and Surgical Asepsis

HAI - Healthcare-Associated Infections, Standered and transmission-based

Standard Precautions - HH, PPE, Cough etiquette, Safe injection, disinfect device, clean high-touch surfaces, patient placement, mask for spinal space, linen handling

The PPE is based on anticipated exposure

Anything but sweat we don’t touch

Glasses aren’t safe enough; need goggles, sides are clean, remove goggles after glasses are removed and perform hand hygiene

Goggles are for splash splatter, not for what they have

Respiratory Hygiene/Cough Etiquette, Education of staff, patients, and visitors, posted signs in appropriate languages, source control: cover coughs and sneezes with tissue and dispose promptly, surgical masks on coughing person when tolerated, hand hygiene after contact with respiratory secretions, spatial separation

Cough Etiquette - Mask on when we come in, when they leave the room, put a mask on them

Transmission-Based Precautions, selected infections with known transmission routes, based on patient's symptoms, Dedicated equipment on transmission-based precautions

Contact - gown and gloves (Body discharge, Single patient room)

Droplet - regular/simple Mask

Airborne - Respirator, N95, PAPR

Direct Contact - Herpetic Whitlow (non-glove oral care, Scabies, Head Lice (Pediculosis)

Indirect Contact - transfer of infectious agent through contaminated inanimate objects or person, hands of caregivers, pateint care devices, shared toys, instruments/devises

Always read the whole question and look at the spreadsheet, Ctrl F

Put on upon room setting

Bug, setting, activity

MDROS - multidrug-resistant organisms, contact precautions, duration we don’t know, prolonged colonization, facility outbreaks more cases than baseline, LTCF, enhanced barrier precautions (EBP)

Isolation Precautions - patients' well-being, barrier between them and me, decreased satisfaction with health care, take measures to combat that.

Droplets - simple mask, organisms carried through respiratory droplets, not infectious, 3-6 feet, put the mask on them if transported out of the room

Droplet precautions requirements - single patient or separate by 3 feet, simple mask upon entry, teach cough etiquette, no goggles on droplet precautions, safe distance, 6-10 feet, curtain is enough

High-pressure irrigation - splatter mask and goggles

Airborne transmission - over time and space, even not in the same room, requires single-patient EIIR Airborne infection Isolation Room, negative pressure room, 12 air exchanges per hour, vented outside or HEPA filter, wear N95 or PAPR, respirator use, put on prior to room entry, dedicated equipment, many airborne have vaccines, ideally immune healthcare workers

Zoom Recording

• Avoid verbals, miscommunication, read backs>repeat back, written down in your notes for whats going to be on the order

• Written order that you can’t understand, contact provider

• A patient keeps throwing up, you give antimetic (anti nausea and vomiting) and it doesnt help, call provider to get another/different medication

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  Route	What it means	Examples
  Enteral	Given through the digestive system	By mouth (PO), or through an NG or feeding tube; some classes also include rectal medications
  Parenteral	Given outside the digestive system, usually by injection	IV, IM, subcutaneous (SubQ), and intradermal (ID)

Sublingual - under tongue, blood vessels, bypass liver, first pass effect

PMDI - pressurized metered dose inhaler

MDI - metered dose inhaler, wash mouth out after, thrush/yeast infection

two medicaotns of same medicaiotns, time between, dilate the airways and the puffs can go deeper, wait between puffs

MDIs can be hard for people with strength or corillation, a spacer can help kids without corridaitlation

DPI - capsul, crush and inahler the poweder

QID - 4 times a day, Q6H - every 6 hours, same thing, why Q6H instead of QID - make sure your in the therapeutic range, for drugs with narrow therapeutic range, antibiotics around the clock

Transdermal patch - Wear gloves, document smal patches and label

7 rights - medication, patient, dose, indication, time, and documentation

Buccal drug - Check drug, don’t give with water

Aspiration - injection, vein, vascular, IM, ventral gluteal, no aspriaiton in SubQ, which drug always aspirate IM - if harmful for blood stream

Z-tracked- IM, sting or stain, rosephin, Pull needle out before you release the Z-track

SubQ injections - pinch in the SubQ fat, pinch easy to dart in

Lovenox injection - bubble in prefilled syringes, don’t do that with a pre filled syringe, with the volume make sures all injection goes into tissue, exact amount of air for the needle, do not expel bubble

Aspiration with medications: don’t give every medication at the same time, high fowlers, water, cup no straw, one bite of applesause, don’t put it into a large volume

If they have a weak side, do we want them to have the pill on the weak or strong side? Turn the head to the weak side so that hte strong side has like something to push against. Always let them take their meds if they can

S/S of aspiration: chocking, coughing, hypoxic, site up, pneumonia, if they are still aspiration try to get a different med for a different route, or swallow study

Can nurses change route without order: no, can nurses set time of day without order, yes they can change time/schedule

Schedule example Q6H, tIme is by the nurse, according to the provider orders

Range of medication: Morphine 4-8 PRN, last time it’s been, the last dose, and how did it work, to help trend, clinical decision-making; if it doesnt work, contact the provider, call the order if not enough pain medications, advocate, SBAR recommednation

Oral medicaiton yes shake the bottal is its a suspensio and most likly yes shake it

Oral liquid single-dose vial, ,you don’t need to measure it out, you can loose the dose, or use oral syring

Oral syringe instead of IV syringe, Oral is color, don’t want to mix them up, safety issue