NCLEX-RN · Physiological Integrity
NCLEX-RN: Pharmacological and Parenteral Therapies Concepts
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Overview
This chapter covers giving medicines safely by any route, watching for side effects and interactions, giving blood products, caring for IV lines and managing pain. Errors here can be fatal, so the exam tests safety checks and early warning signs.
Every dose is checked against the rights of medication administration, including the right client, drug, dose, route, time and documentation. Some drugs need a check before each dose. Take an apical pulse for one full minute before digoxin. Warfarin is monitored with the INR and reversed with vitamin K, while heparin is monitored with the aPTT and reversed with protamine sulfate. When mixing insulins, draw up the clear insulin before the cloudy one.
High-alert drugs such as insulin, heparin, opioids and concentrated potassium chloride cause the most harm when given wrong; potassium chloride is never pushed IV. During a blood transfusion, stay with the client at the start, when reactions are most likely. If a reaction appears, stop the blood at once, keep the IV open with normal saline, and notify the provider and the blood bank.
Key concepts
Rights of medication administration
Checks done before every dose: right client, right drug, right dose, right route, right time and right documentation. Many lists add right reason and right response.
Memory tipDo the checks at the bedside with two client identifiers, not only at the medicine cart.
Digoxin monitoring
Before giving digoxin, count the apical pulse for one full minute and hold the dose if it is below the ordered limit, often 60 in adults. Low potassium raises the risk of toxicity.
Memory tipNausea, poor appetite and yellow-green vision or halos can be early signs of toxicity.
Warfarin and heparin
Warfarin is a pill monitored with the PT/INR and reversed with vitamin K. Heparin is given by injection or IV, monitored with the aPTT, and reversed with protamine sulfate.
Memory tipTeach warfarin clients to keep vitamin K foods, such as leafy greens, steady rather than avoid them.
Mixing insulin
When drawing regular and NPH insulin into one syringe, draw the clear regular insulin first, then the cloudy NPH. Long-acting insulins such as glargine are not mixed with others.
Memory tip'Clear before cloudy.'
High-alert medicines
Drugs that cause serious harm if given wrongly, including insulin, heparin, opioids and concentrated potassium chloride. Many facilities require a second nurse to double-check them.
Memory tipPotassium chloride is never given by IV push.
Transfusion reaction
Signs include fever, chills, back pain, itching, hives, low blood pressure and trouble breathing. Stop the transfusion, keep the IV open with normal saline using new tubing, and notify the provider and blood bank.
Memory tipStay with the client for the first part of the transfusion, when reactions are most likely. Use only normal saline with blood.
Opioid safety
Opioids relieve pain but can slow breathing. Check sedation level and breathing before and after doses. Naloxone reverses opioid effects.
Memory tipIncreasing sleepiness comes before slowed breathing; act early.
Often tested
- Check the apical pulse for one full minute before digoxin.
- Match each blood thinner to its lab test and antidote.
- Draw clear insulin before cloudy when mixing.
- Never give potassium chloride by IV push.
- For a transfusion reaction, stop the blood, keep the line open with normal saline and notify.
- Watch sedation and breathing with opioids; naloxone reverses them.
Easy to confuse: Heparin and warfarin
| Point | Heparin | Warfarin |
|---|---|---|
| Route | Injection or IV | By mouth |
| Lab test | aPTT | PT/INR |
| Antidote | Protamine sulfate | Vitamin K |
| Onset | Fast | Slow, takes days |
3 sample questions
Verified practice questions from this unit.
Question 1. A client receiving a continuous IV heparin infusion develops bleeding from the gums and new blood in the urine. The provider stops the heparin. Which medication does the nurse expect to be ordered to reverse the heparin?
- ① Flumazenil
- ② Naloxone
- ③ Protamine sulfate
- ④ Vitamin K (phytonadione)
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Answer: ③ Protamine sulfate
Key point: Protamine sulfate reverses heparin; vitamin K reverses warfarin
Heparin is a high-alert blood thinner. When a client on heparin shows signs of serious bleeding, the drug is stopped and protamine sulfate may be given. Protamine binds to heparin in the blood and makes it inactive within minutes.
It helps to remember the pairs:
- Heparin → protamine sulfate
- Warfarin → vitamin K (phytonadione)
- Opioids → naloxone
- Benzodiazepines → flumazenil
Wrong choices
- "Vitamin K": this reverses warfarin, not heparin. It works slowly, over hours.
- "Naloxone": reverses opioids such as morphine. It has no effect on bleeding.
- "Flumazenil": reverses benzodiazepines such as lorazepam. It has no effect on bleeding.
Question 2. A client is taking warfarin at home to prevent clots from atrial fibrillation. Which lab test does the nurse use to check whether the warfarin dose is working safely?
- ① Activated partial thromboplastin time (aPTT)
- ② Platelet count
- ③ International normalized ratio (INR)
- ④ Serum potassium
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Answer: ③ International normalized ratio (INR)
Key point: Warfarin is monitored with the INR (PT/INR)
Warfarin slows the liver's use of vitamin K to make clotting factors. Its effect is measured with the prothrombin time (PT), reported as the INR (international normalized ratio). The INR lets results be compared between labs. The provider sets the target INR for each client, and the dose is adjusted to keep the client in that range.
An INR above the target means a higher bleeding risk. An INR below the target means the client is less protected from clots.
Wrong choices
- "aPTT": this is used to monitor IV heparin, not warfarin. Mixing up these two tests is a common error.
- "Platelet count": important to watch with heparin (for heparin-induced thrombocytopenia), but it does not show warfarin's effect.
- "Serum potassium": not related to warfarin's effect on clotting.
Question 3. The nurse is about to give oral digoxin to an adult client with heart failure. Which action is most important right before giving the dose?
- ① Weigh the client on the bedside scale
- ② Check the fingerstick blood glucose
- ③ Count the apical pulse for 1 full minute
- ④ Check the blood pressure in both arms
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Answer: ③ Count the apical pulse for 1 full minute
Key point: Before digoxin, count the apical pulse for a full 60 seconds
Digoxin slows the heart rate and makes each heartbeat stronger. Because it slows the heart, the nurse listens to the apical pulse (over the heart, at the apex) for one full minute before every dose. A common rule for adults is to hold the dose and notify the provider if the apical pulse is below 60 beats per minute, unless the provider has given a different limit.
A full minute is needed because clients on digoxin often have irregular rhythms, and a 15- or 30-second count can be wrong.
Wrong choices
- "Blood pressure in both arms": blood pressure is useful, but it is not the key check for digoxin.
- "Weigh the client": daily weight is good for heart failure, but it is not the safety check right before digoxin.
- "Fingerstick blood glucose": this is the check before insulin, not digoxin.