Pharmacological Therapies Study Guide for the NCLEX-PN Exam

Administering Medication

Administering medications requires rigorous adherence to safety protocols, precise data collection, and mastering specific technical procedures across various routes. As an LPN, you serve as the final safety checkpoint before a medication enters the client’s body.

Rights of Medication Administration & Client Identification

While traditionally taught as the “Five Rights,” safety guidelines expand this list to encompass Eight Primary Rights of medication administration:

• Right Client: Verify client identity using two unique identifiers (e.g., full name and date of birth) by comparing the client’s wristband directly against the Medication Administration Record (MAR). Ask the client to state their name and DOB if they are responsive.

• Right Medication: Check the drug label against the MAR three times: when removing it from storage, when preparing/dispensing it, and at the bedside before administration.

• Right Dose: Calculate and verify the dose, paying close attention to unit conversions. Perform independent double-checks for high-alert drugs.

• Right Route: Administer the medication strictly via the prescribed route. Never alter the form of a medication (such as crushing a pill) without verifying safety.

• Right Time: Administer within the facility’s approved time window (typically within 30 minutes before or after the scheduled time).

• Right Documentation: Record administration on the MAR immediately after giving the dose—never before. Document baseline vitals and post-administration evaluation.

• Right Reason: Confirm that the drug rationale aligns with the client’s diagnosis and current clinical picture.

• Right to Refuse: Competent adult clients have the right to decline any medication. If refused, explore their concerns, reinforce teaching, hold the dose, notify the provider, and document the refusal.

Data Collection & Pre-Administration Parameters

Prior to preparing or delivering specific medications, you must collect objective clinical data to determine whether it is safe to proceed.

• Cardiac & Blood Pressure Drugs: Check apical pulse for 1 full minute before giving digoxin (hold if \(< 60\text{ bpm}\)). Check blood pressure before administering antihypertensives (hold if Systolic BP is \(< 100\text{ mmHg}\) or Heart Rate is \(< 60\text{ bpm}\)).

• Respiratory Depressants: Count respiratory rate before administering opioids like morphine or hydromorphone (hold if Respiratory Rate is \(< 12\text{ breaths/min}\)).

• Antidiabetic Therapies: Check capillary blood glucose prior to administering insulin or oral hypoglycemics. If glucose is \(< 70\text{ mg/dL}\), hold rapid/short-acting insulin and initiate hypoglycemia protocols (e.g., 15 grams of fast-acting carbohydrates).

Procedures & Route-Specific Administration Techniques

Oral (PO) & Enteral Tube Administration

• Oral Medications: Position the client upright (\(90^\circ\) High-Fowler’s position) to prevent aspiration. Never crush or chew Extended-Release (ER, XL, XR), Sustained-Release (SR), or Enteric-Coated (EC) medications, as doing so destroys the protective coating and causes rapid, potentially toxic drug absorption.

• Gastrointestinal Tubes (NG, G-Tube, J-Tube): Always verify placement and residual volume before instilling medications.

1. Keep the head of the bed elevated at \(30-45^\circ\) during and for at least 30 to 60 minutes after administration.

2. Flush the tube with \(15-30\text{ mL}\) of water before giving the first drug.

3. Crush approved tablets, dissolve each drug separately in warm water, and administer each medication individually.

4. Flush with \(5-10\text{ mL}\) of water between each drug, and finish with a final \(15-30\text{ mL}\) water flush to clear the tubing.

Parenteral Injections (ID, SubQ, IM)

• Intradermal (ID): Used for allergy testing and TB skin tests (PPD). Insert needle at a \(10-15^\circ\) angle, bevel up, into the dermis. A small skin wheal/bleb must form under the skin. Do not rub the site after injection.

• Subcutaneous (SubQ): Administered into adipose tissue at a \(45-90^\circ\) angle depending on tissue depth (e.g., insulin, heparin).

  Heparin / Enoxaparin Technique: Inject into the abdomen at least 2 inches away from the umbilicus. Do not aspirate, and do not rub the site after injection, as rubbing causes tissue bruising and hematoma formation.

• Intramuscular (IM): Injected deep into muscle tissue at a \(90^\circ\) angle.

Sites

The Ventrogluteal site is the safest, preferred site for adults (free of major blood vessels and nerves). The Vastus Lateralis (anterolateral thigh) is the preferred site for infants and young children under 18 months. Limit Deltoid injections to volumes of \(1\text{ mL}\) or less.

Z-Track Method

The z-track method is highly recommended for irritating or staining medications (such as Iron Dextran). Pull the skin laterally \(1-1.5\text{ inches}\) before inserting the needle, inject the medication, wait 10 seconds, withdraw the needle, and release the skin. This seals the medication track in the deep muscle layer.

Ear, Eye, Inhalation & Topical Routes

• Otic (Ear Drops): Warm solution to room temperature (cold drops cause severe vertigo/dizziness).

  Adults and Children \(> 3\text{ years}\): Pull the pinna UP and BACK.

  Infants and Children \(< 3\text{ years}\): Pull the pinna DOWN and BACK.

Direct drops along the side of the ear canal and have the client maintain a side-lying position for 5 minutes.

• Ophthalmic (Eye Drops): Have the client look up. Instill drops into the lower conjunctival sac (never directly on the cornea). Apply gentle pressure to the inner canthus (nasolacrimal duct) for \(1-2\text{ minutes}\) post-instillation to prevent systemic drug absorption.

• Inhalers (Metered-Dose Inhalers - MDIs): If a client is prescribed both a bronchodilator (e.g., Albuterol) and a corticosteroid (e.g., Fluticasone), administer the bronchodilator FIRST to open the airways, wait 5 minutes, and then administer the corticosteroid. Have the client rinse their mouth with water and spit after steroid inhaler use to prevent oral candidiasis (thrush).

• Transdermal Patches Remove the old patch, clean residual drug off the skin, and apply the new patch to a hairless, clean, dry area. Never apply heat (e.g., heating pads) over a patch, as heat accelerates absorption to toxic levels.

Intravenous Secondary (Piggyback) & Blood Transfusions

IV Piggyback (Secondary Infusions)

Connect the secondary bag containing the medication to the upper port of the primary IV tubing. When using gravity flow, elevate the secondary bag higher than the primary infusion bag so the secondary fluid flows first. Always verify physical compatibility between the primary IV fluid and the piggyback drug.

Blood Transfusions

Transfusion therapy requires strict adherence to safety protocols due to the risk of fatal hemolytic reactions. On the NCLEX-PN®, initiating, spiking, and administering blood products—including monitoring the crucial first 15 minutes—is an RN-only responsibility. The LPN role is limited to assisting with dual verification, taking baseline vital signs, and performing ongoing monitoring after the initial 15-minute window.

• Tubing & Fluids: Blood products must only be infused with 0.9% Normal Saline. Never run dextrose or lactated Ringer’s with blood, as they cause hemolysis or clotting. Use specialized Y-tubing with an in-line blood filter.

• Dual Verification: Two licensed personnel (RN with another RN or LPN) must independently verify the client’s identity, blood type, Rh factor, unit number, and expiration date at the bedside prior to initiation.

• Reaction Protocols: If signs of a transfusion reaction occur (fever, chills, low back/flank pain, dyspnea, hives):

1. STOP the transfusion immediately.

2. Disconnect the blood tubing directly from the IV catheter hub. never flush the existing blood tubing with saline, as doing so forces the remaining blood in the tubing into the client’s bloodstream.

3. Connect a brand-new primary line with 0.9% Normal Saline directly to the catheter hub to maintain IV access.

4. Notify the RN and PHCP immediately, monitor vital signs, and follow facility protocol (send blood bag and tubing to the lab).

Client Concerns & PRN Medications

Addressing client concerns with clear, empathetic education is essential for reducing anxiety and promoting safe medication adherence. As an LPN, you will frequently reinforce teaching about drug indications, schedules, and expected responses, clarifying any misunderstandings about why or how often a drug is taken.

PRN Medication Management

PRN (pro re nata) orders allow medications to be administered “as needed” based on client-reported symptoms or specific objective triggers. A complete PRN order must specify the drug name, dose, route, minimum time interval between doses, and a explicit clinical indication (e.g., “Acetaminophen \(650\text{ mg}\) PO q4h PRN for temperature \(> 101^\circ\text{F}\)” or “Morphine \(2\text{ mg}\) IV q3h PRN for severe pain rated 7–10”).

• Fixed Time Intervals: You cannot administer a PRN medication more frequently than the prescribed time interval. If a client experiences pain or nausea before the interval expires, implement non-pharmacological interventions and contact the provider for an order change—never give an early dose.

• Indication Matching: Always ensure the PRN drug matches the client’s specific complaint. For tiered pain orders (e.g., acetaminophen for mild pain 1–3, tramadol for moderate pain 4–6, morphine for severe pain 7–10), select the medication that directly corresponds to the client’s current pain rating scale.

• Pre-Assessment Requirements Collect target baseline data before giving any PRN drug. Assess pain scores before analgesics, check body temperature before antipyretics, listen to bowel sounds before laxatives, and measure blood pressure before PRN antihypertensives.

Self-Administration & Education Strategies

If clients are discharging home or self-administering medications in specialized settings, you must evaluate their ability to safely manage their regimen. The Teach-Back method (asking the client to explain concepts in their own words) and Return Demonstration (having the client physically perform the skill) are the gold standards for verifying comprehension.

High-yield self-administration topics to reinforce include:

• Subcutaneous Insulin Injections: Teach clients to rotate injection sites systematically across the abdomen (at least 1 inch apart) to prevent lipodystrophy (fatty tissue alteration that impairs insulin absorption). Subcutaneous injections are given at a \(90^\circ\) angle (\(45^\circ\) for extremely thin clients).

• Subcutaneous Insulin Pumps: Instruct clients to change the infusion set and cannula site every 2 to 3 days using strict aseptic technique. Teach them to keep a backup supply of long-acting insulin and syringes ready in case of pump failure, and to check blood glucose frequently to detect early signs of hyperglycemia or diabetic ketoacidosis (DKA) caused by tubing kinks.

• Emergency Epinephrine Auto-Injectors (EpiPen): Instruct clients to inject firmly into the outer thigh at a \(90^\circ\) angle (can be given through clothing), hold in place for 3 to 10 seconds, and massage the site. Emphasize that they must call 911 immediately after use because epinephrine’s effects wear off in 10 to 20 minutes, allowing severe anaphylaxis to return.

Pain Management Principles & Assessment

Pain is a complex, subjective experience defined as “whatever the experiencing person says it is, existing whenever they say it does.” Effective pain management relies on objective assessment, choosing the correct tool, and combining pharmacological therapies with comfort measures.

Identifying Client Need & Selecting Pain Scales

Never assume a client is pain-free simply because they are quiet or sleeping. Always use a validated, age-appropriate pain assessment tool to quantify pain intensity:

• Numeric 0–10 Scale: Used for cognitively intact adults and children older than 8 years of age (0= no pain, 10 = worst possible pain).

• Wong-Baker FACES Scale: Used for children ages 3 and older, as well as adult clients with language barriers or mild cognitive impairment. Clients choose from six cartoon faces ranging from smiling (0) to crying (10).

• FLACC Scale (Face, Legs, Activity, Cry, Consolability): Used for infants, toddlers (ages 2 months to 7 years), or non-verbal, unconscious, or severely cognitively impaired adults. Each of the five categories is scored from 0 to 2, giving a total score between 0 and 10.

Re-Evaluation Timelines & Opioid Monitoring

Re-evaluating pain after administering analgesics is a mandatory nursing responsibility. Always document the client’s post-intervention pain score using the same scale applied during baseline assessment.

Mandatory re-assessment timeframes based on route:

• Intravenous (IV) Analgesics: Re-assess pain level within 15 to 30 minutes.

• (PO) Analgesics: Re-assess pain level within 45 to 60 minutes.

• Intramuscular (IM) / Subcutaneous (SubQ) Analgesics: Re-assess pain level within 30 to 45 minutes.

When monitoring clients receiving opioid analgesics (e.g., morphine, hydromorphone, fentanyl), remember that opioid-induced sedation always precedes respiratory depression. Use the Pasero Opioid-Induced Sedation Scale (POSS) to monitor sedation depth:

• POSS Grade 1–2: Awake or easily aroused; slightly drowsy \(\rightarrow\) Safe to continue therapy.

• POSS Grade 3: Frequently drowsy, drifts off to sleep during conversation \(\rightarrow\) Action: Unacceptable sedation; reduce opioid dose by \(25–50\%\) and notify provider.

• POSS Grade 4: Somnolent, minimal or no response to verbal/physical stimulation \(\rightarrow\) Action: Stop opioid immediately, notify provider, monitor respiratory rate, and prepare to administer Naloxone if respiratory rate is \(< 12\text{ breaths/min}\) or shallow.

Advanced Pain Control Devices

When oral or intermittent IV pain medications are insufficient, advanced delivery systems may be used. As an LPN, you must understand device safety, site monitoring, and complications associated with these modalities.

Patient-Controlled Analgesia (PCA)

A PCA pump allows the client to self-administer small, controlled doses of intravenous opioids (such as morphine, hydromorphone, or fentanyl) by pressing a hand-held button connected to an infusion pump programmed with specific lockout intervals.

• The Cardinal PCA Safety Rule: ONLY the client is permitted to push the PCA button. Educate family members and staff that “PCA by proxy” (anyone else pushing the button for the client, even while sleeping) is strictly prohibited due to fatal overdose risks.

• Monitoring Requirements: Assess respiratory rate, pulse oximetry (\(\text{SpO}_2\)), and sedation score every 1 to 2 hours for the first 24 hours. Check cumulative dose totals and the number of attempted vs. delivered doses recorded on the pump.

Epidural Analgesia

Epidural analgesia involves a catheter inserted into the epidural space of the spine to deliver continuous or bolus doses of opioids (fentanyl, morphine) combined with local anesthetics (bupivacaine).

• Side Effects & Monitoring: Monitor continuously for hypotension (caused by sympathetic nerve blockade), urinary retention, pruritus (itching), and respiratory depression.

• Motor & Sensory Checks: Perform frequent sensory and motor function assessments (e.g., checking dermatome levels with ice, asking the client to bend their knees and wiggle their toes).

• Complications: Report sudden ascending numbness, severe back pain, or sudden lower extremity motor weakness immediately—these are cardinal signs of an epidural hematoma, which is a surgical emergency.

Peripheral Nerve Catheters (Continuous Local Anesthetic Infusions)

Peripheral nerve catheters (e.g., On-Q pumps) deliver continuous local anesthetics (such as ropivacaine or bupivacaine) directly adjacent to a peripheral nerve plexus following major orthopedic surgeries (e.g., total knee or shoulder replacements).

• Site Care: Inspect the insertion site regularly for signs of infection, fluid leakage, or catheter dislodgement.

• Local Anesthetic Systemic Toxicity (LAST): Monitor closely for systemic absorption of the local anesthetic into the bloodstream. Early signs of toxicity include a metallic taste in the mouth, numbness/tingling around the lips (perioral numbness), ringing in the ears (tinnitus), confusion, and muscle twitching. Severe toxicity leads to seizures, severe bradycardia, and cardiac arrest. If LAST is suspected, stop the infusion pump immediately and alert the RN and primary healthcare provider.