The nurse is preparing to administer medications to a 54-year old client. Which medications taken would be affected by the first-pass effect? (Select All that Apply.)

A. Nitroglycerin 10mg Sublingual Tablet:
Nitroglycerin taken sublingually (under the tongue) bypasses the gastrointestinal tract and the liver’s first-pass metabolism. It is designed to act quickly and directly enter the bloodstream through the mucous membranes, avoiding significant first-pass effect.

B. Morphine 2mg IV (Intravenously):
Morphine administered intravenously bypasses the gastrointestinal tract and liver, thus avoiding the first-pass effect entirely. The drug directly enters systemic circulation, providing immediate effect.

C. Famotidine 10mg Tablet:
Famotidine, when taken orally, undergoes significant first-pass metabolism. This means that a portion of the drug is metabolized by the liver before it reaches systemic circulation, affecting its bioavailability.

D. Nitroglycerin 4mg Sublingual Tablet:
Similar to the 10mg sublingual tablet, nitroglycerin administered sublingually bypasses the first-pass effect. The medication enters the bloodstream directly through the mucous membranes in the mouth.

E. Acetaminophen 325mg Capsule:
Acetaminophen, when taken orally, undergoes first-pass metabolism. A significant portion of the drug is metabolized in the liver before reaching systemic circulation, which can impact its overall effectiveness.

F. Diphenhydramine (Benadryl) 25mg Tablet:
Diphenhydramine, taken orally, is also affected by the first-pass effect. As with other oral medications, a part of the drug is metabolized by the liver before reaching systemic circulation, which can affect its efficacy and bioavailability.

A) Inject a volume of less than 2 mL: While it is generally recommended to inject a volume of less than 2 mL into the deltoid muscle to avoid discomfort and ensure proper absorption, this is not the primary action to focus on when planning the injection.

B) Inject the medication at a 90 degree angle: This is the correct action. Administering an intramuscular (IM) injection at a 90-degree angle ensures that the medication is delivered deep into the muscle tissue, which is necessary for proper absorption and effectiveness.

C) Inject the medication 12.7 cm (5 in) below the client’s acromion process: The correct injection site for the deltoid muscle is typically 2-3 finger widths (approximately 2.5-5 cm) below the acromion process, not 12.7 cm. Injecting too far below the acromion process could result in an incorrect injection site.

D) Use a 21-gauge needle for the injection: While a 21-gauge needle can be used for IM injections, the gauge of the needle is not the primary focus in this context. The angle of injection is more critical to ensure proper delivery of the medication.