To ensure safe and effective medication delivery, nurses must adhere to evidence-based practices when applying topical ointments. These practices are essential for promoting optimal drug absorption, minimizing adverse effects, and ensuring therapeutic outcomes. One of the most critical steps in this process is proper skin preparation before application.

Rationales:

4. Cleaning and drying the skin before application:
Cleaning removes debris, oil, or contaminants, and drying prevents dilution or interference with absorption. This step ensures that the ointment contacts the skin effectively for localized or systemic effect.

1. Applying a large amount over a wide area:
Using excessive medication may not improve absorption and could increase the risk of systemic side effects. The goal is to apply only the prescribed amount to the affected area.

2. Massaging the medication vigorously into the skin:
Vigorous massage may irritate the skin or cause unintended systemic absorption. Gentle application is preferred unless otherwise specified by the medication guidelines.

3. Applying to moist, inflamed skin:
While inflamed skin may absorb more medication, it can also increase the risk of irritation or toxicity. Medication should generally be applied to intact, clean, and dry skin unless directed otherwise.

Take-home points:

• Clean, dry skin enhances absorption and reduces the risk of contamination or irritation.
• Avoid overuse or excessive application of ointments to prevent side effects.
• Follow product-specific instructions for massage or application pressure.

Patch testing is a diagnostic procedure used prior to the administration of certain topical medications or substances to evaluate for delayed hypersensitivity reactions. It helps identify substances that may cause contact dermatitis or other localized allergic responses.

Rationales:

3. To detect localized allergic responses:
Patch testing is designed to detect delayed-type (Type IV) hypersensitivity reactions. The test helps identify whether a patient has a localized allergic reaction, such as erythema, edema, or vesicle formation, to specific allergens.

Rationale for incorrect answers:

1. To assess the effectiveness of a transdermal drug:
Patch testing is not used to assess drug efficacy. It does not involve therapeutic drug dosing but rather small quantities of substances to detect hypersensitivity reactions on the skin.

2. To evaluate systemic absorption of topical agents:
Patch tests are limited to observing local skin responses and do not provide information about systemic absorption or bioavailability of topical drugs.

4. To treat minor dermatologic conditions:
Patch testing is a diagnostic, not a therapeutic, procedure. It does not treat dermatologic conditions but instead helps determine which substances to avoid.

Take-home points:

• The primary role of patch testing is to identify localized allergic skin reactions to substances like medications or environmental allergens.
• It is diagnostic and used before prescribing or continuing specific topical treatments.
• It helps prevent adverse skin reactions by detecting sensitivities early.

Nitroglycerin ointment is a transdermal nitrate medication used for the prevention of chronic angina by promoting vasodilation and improved myocardial oxygenation. Because the drug is absorbed through the skin, it is essential for nurses to apply it using safe, standardized techniques to ensure accurate dosing and avoid unintended exposure. Wearing gloves is a critical step, as nitroglycerin can be absorbed through the caregiver’s skin and may lead to hypotension, dizziness, or headaches.

Rationale for correct answer:

2. Use a gloved hand to apply the medication:
Gloves are essential when applying nitroglycerin ointment to prevent accidental absorption through the nurse’s skin, which could cause hypotension, headache, or dizziness.

Rationale for incorrect answers:

1. Rub the ointment into the skin for absorption:
Vigorous rubbing is discouraged as it can increase systemic absorption unpredictably and cause skin irritation. Nitroglycerin should be spread in a thin layer using the applicator paper and left to absorb passively.

3. Apply to the same site daily for consistency:
Using the same site repeatedly may lead to skin irritation and altered absorption. It is best practice to rotate application sites to maintain skin integrity and consistent drug levels.

4. Avoid rotating sites to maintain drug levels:
Rotating sites does not negatively impact drug levels. On the contrary, it helps prevent localized skin irritation and supports optimal absorption.

Take-home points:

• Always wear gloves when applying nitroglycerin ointment to prevent nurse exposure.
• Do not rub the ointment into the skin; allow it to absorb as prescribed.
• Rotate application sites to prevent skin breakdown and maintain drug effectiveness.
• Document the site and dose to ensure safe, consistent administration.

Transdermal patches are designed to deliver medication slowly and consistently through the skin into the bloodstream, making them ideal for chronic conditions requiring steady plasma drug levels. To ensure both efficacy and safety, nurses must follow precise application guidelines that include choosing appropriate skin sites, monitoring for adverse effects, and maintaining accurate documentation. Recording the date, time, and location of the patch helps prevent errors such as overlapping applications, missed doses, or skin irritation from repeated site use.

Rationale for correct answer:

3. Document the date, time, and site of application:
Proper documentation helps ensure that the patch is changed at the correct time and applied to a new site, reducing the risk of medication buildup and skin breakdown. It also promotes accountability and continuity of care.

1. Cut the patch in half for dosage adjustment:
Cutting a transdermal patch compromises its integrity and may lead to uncontrolled medication release, increasing the risk of overdose or therapeutic failure. Most patches are not designed to be divided.

2. Apply over the same site as the previous patch:
Reusing the same site repeatedly can cause skin irritation, decreased absorption, and local tissue reactions. Rotating sites allows the skin to recover and ensures proper absorption.

4. Apply to broken or irritated skin for faster absorption:
Broken or inflamed skin can absorb medications unpredictably, potentially resulting in toxicity or adverse reactions. Patches should only be applied to intact, clean, and dry skin.

Take-home points:

• Always document date, time, and site when applying a transdermal patch to ensure consistent care.
• Never cut or divide transdermal patches unless specified by the manufacturer.
• Apply patches to intact, hairless skin and rotate sites to prevent irritation and maintain drug effectiveness.

Administering eardrops safely and effectively in pediatric patients requires knowledge of anatomical differences and age-appropriate techniques. In children under 3 years old, the ear canal is shorter and more horizontal than in adults, which affects how the medication is delivered. To ensure the drops reach the inner ear canal properly in a 2-year-old, the nurse should gently pull the earlobe down and back.

Rationale for correct answer:

3. Pull the earlobe down and back:
This is the appropriate technique for children under 3 years old. It straightens the horizontal ear canal, ensuring the drops flow inward effectively without causing pain or resistance.

Rationale for incorrect answers:

1. Pull the auricle up and back:
This method is used for older children and adults (typically over age 3) to straighten the more vertical ear canal. For toddlers, this direction may misalign the canal and reduce the effectiveness of the drops.

2. Warm the drops in a microwave before use:
Microwaving eardrops is unsafe and may cause the solution to overheat, risking burns to the delicate ear tissues. Drops should be warmed in the hands or placed in warm water to reach body temperature before administration.

4. Instill the drops with the patient seated upright:
The child should ideally be lying on their side with the affected ear facing up to allow the drops to remain in place and prevent spillage. Afterward, keeping the position for a few minutes enhances absorption.

Take-home points:

• For children under 3, gently pull the earlobe down and back when administering eardrops.
• Avoid microwaving eardrops; instead, warm them safely by hand.
• Positioning the child on their side helps retain the drops and ensures full therapeutic effect.

Inhaled corticosteroids are essential in managing chronic respiratory conditions such as asthma and COPD due to their anti-inflammatory effects. However, because corticosteroids suppress local immune responses in the mouth and throat, they can increase the risk of oropharyngeal candidiasis (thrush). To minimize this risk, it is critical for the nurse to instruct patients to rinse the mouth thoroughly with water and spit it out after each use.

Rationale for correct answer:

2. Rinse the mouth thoroughly:
Rinsing after inhalation removes leftover steroid particles from the oral mucosa, helping prevent oral thrush and irritation. This is a key component of inhaler education and safe medication use.

1. Blow the nose:
This is more relevant for nasal sprays than for inhaled corticosteroids. It does not aid in removing medication from the mouth or throat, where the risk of fungal infection exists.

3. Take another puff within 30 seconds:
When a second puff is prescribed, waiting 1–2 minutes between doses is ideal for bronchodilators, not corticosteroids. Corticosteroids are usually not taken in rapid succession.

4. Drink water before each dose:
Drinking water before administration does not prevent side effects and does not replace the need for rinsing the mouth afterward. The priority is removing residual corticosteroid from the oropharynx post-use.

Take-home points:

• Always instruct patients to rinse their mouth and spit after using an inhaled corticosteroid.
• This practice significantly reduces the risk of oropharyngeal candidiasis.
• It should become a routine part of inhaler technique education.

Vaginal suppositories are used to deliver medications directly to the vaginal mucosa, often for infections, hormone therapy, or local conditions. For maximum absorption and therapeutic effect, the medication must remain in contact with the vaginal walls long enough to dissolve. Nurses play a vital role in educating clients about post-insertion care, especially the need to remain lying down to prevent premature expulsion of the suppository.

Rationale for correct answer:

3. Remain lying down for 15 minutes:
Staying in a lying position allows the suppository to fully dissolve and be absorbed by the vaginal mucosa. This step supports maximum drug effect and is a standard nursing instruction.

Rationale for incorrect answers:

1. Resume ambulation immediately:
Walking or sitting up too soon after insertion can cause the suppository to leak before it's fully dissolved, reducing therapeutic effectiveness. Remaining supine helps retain the medication in the vaginal canal.

2. Avoid use of a sanitary pad:
While tampons should be avoided, sanitary pads can help manage minor leakage without affecting absorption. Advising against their use isn't necessary unless it interferes with comfort or hygiene.

4. Douche within 1 hour to enhance absorption:
Douching is not recommended after suppository use. It may flush out the medication and irritate the mucosa, interfering with absorption and increasing infection risk.

Take-home points:

• Instruct clients to lie down for at least 15 minutes after vaginal suppository insertion.
• Early movement can reduce absorption and should be avoided.
• Douching is contraindicated as it disrupts effectiveness and mucosal health.

Some oral medications are formulated to release their active ingredients slowly over time to maintain therapeutic levels in the bloodstream. These sustained-release (SR), extended-release (ER), or controlled-release (CR) medications must never be crushed, as altering their form can cause rapid drug release, leading to toxicity or reduced efficacy.

Rationale for correct answer:

2. Sustained-release capsules:
These are formulated to release the drug gradually. Crushing or opening the capsule can result in dose dumping, where too much medication is absorbed at once, increasing the risk of side effects or toxicity.

Rationale for incorrect answers:

1. Chewable tablets:
These are specifically designed to be chewed before swallowing. Crushing is not harmful and may even be appropriate if the patient has difficulty chewing or swallowing, depending on the situation.

3. Regular coated tablets:
Although coated to improve taste or ease swallowing, regular coated tablets typically do not have a time-release mechanism. While not ideal, they may be crushed if the patient cannot swallow them, and the drug itself is safe to crush.

4. Sublingual tablets:
Sublingual tablets are designed to dissolve under the tongue for rapid absorption into the bloodstream. Crushing would alter the route of absorption and reduce the drug's intended rapid effect, but they are not typically classified as sustained-release formulations.

Take-home points:

• Never crush sustained-release, extended-release, or controlled-release medications, as this can lead to toxicity.
• Know the difference between drug formulations—sublingual, chewable, and regular coated tablets may be altered only if safe and appropriate.
• Always verify with a pharmacist or drug guide before altering any oral medication.

Preventing aspiration is a key nursing responsibility during medication administration, especially in patients who may have swallowing difficulties or impaired gag reflexes. When giving oral liquid medications to adults, using proper techniques such as positioning and delivery method can reduce the risk of aspiration and ensure the medication reaches the digestive tract safely and effectively.

Rationale for correct answer:

4. Administering into the cheek using an oral syringe:
Directing the liquid medication into the buccal area (cheek) allows the patient to swallow more slowly and safely. This method gives greater control over the flow of liquid and minimizes the risk of aspiration, particularly in patients with impaired swallowing.

Rationale for incorrect answers:

1. Administering medication while the patient is supine:
The supine position increases the risk of aspiration because gravity does not aid in swallowing. Instead, patients should be upright or in a high Fowler's position during oral medication administration.

2. Mixing with a full glass of water:
Although water may aid in swallowing, a full glass may overwhelm patients with impaired swallowing. This method does not directly control the flow of liquid or prevent aspiration in those at risk.

3. Placing the liquid toward the back of the throat:
Placing medication at the back of the throat can trigger the gag reflex or cause choking, especially in patients with difficulty swallowing, making this approach unsafe.

Take-home points:

• Always position patients upright during oral medication administration to reduce aspiration risk.
• Administer liquid medications slowly into the cheek to allow controlled swallowing and prevent choking.
• Avoid placing medications directly at the back of the throat or using excessive volumes of fluid in at-risk patients.

Administering medication through a percutaneous endoscopic gastrostomy (PEG) tube requires careful adherence to safety protocols to prevent complications such as aspiration, infection, or mis-delivery of the drug. The most important nursing action before giving any medication through a PEG tube is confirming the tube's placement to ensure it is correctly situated in the stomach and not displaced.

Rationale for correct answer:

2. Confirm tube placement:
Ensuring that the PEG tube is correctly positioned is the top priority to prevent administering medication into the peritoneal cavity or lungs in case of displacement. This is essential to protect the patient from serious harm such as peritonitis or aspiration.

Rationale for incorrect answers:

1. Warm the medication:
Warming medications is not a priority and may alter the drug’s stability. Medications should be given at room temperature unless otherwise directed, but this does not take precedence over verifying safe placement of the PEG tube.

3. Flush with 5 mL of air:
Flushing with air does not reliably confirm placement and may lead to inaccurate assessments. Tube placement must be verified using institutional protocols such as checking for residuals or aspirating stomach contents.

4. Check respiratory rate:
Although respiratory rate monitoring is important in general care, it does not help determine if a PEG tube is properly positioned for medication administration and is therefore not the most immediate priority.

Take-home points:

• Always confirm PEG tube placement before administering medications to prevent misplacement-related complications.
• Do not rely solely on air flushes or external observation to verify correct tube location.
• Patient safety depends on confirming that the tube ends in the stomach, not the lungs or elsewhere.

When administering medications through a gastrostomy tube, nurses must be aware of which drug formulations are safe to alter and which must remain intact. Some medications are specially designed with coatings or release mechanisms that can be destroyed if crushed or dissolved, leading to reduced efficacy or increased risk of side effects. Enteric-coated drugs are one such formulation.

Rationale for correct answer:

3. Enteric-coated aspirin:
Enteric-coated aspirin should never be crushed or administered via a gastrostomy tube. The coating is designed to prevent the drug from dissolving in the stomach, reducing the risk of gastric irritation. Administering it through a tube bypasses this protection, possibly leading to gastric ulcers or reduced drug effectiveness.

Rationale for incorrect answers:

1. Crushed tablets in sterile water:
Tablets that are safe to crush can be mixed with sterile water and administered through the gastrostomy tube. This method is commonly used for drugs that do not have extended-release or special coatings.

2. Liquid acetaminophen:
Liquid forms are preferred for tube administration because they are already in a form that allows for quick absorption and are unlikely to clog the tube. Acetaminophen in liquid form is well tolerated and easy to deliver.

4. Reconstituted antibiotic suspensions:
These are commonly used for patients with feeding tubes. When properly mixed, they are easy to administer and generally well absorbed through the gastrointestinal tract via a gastrostomy tube.

Take-home points:

• Avoid crushing or administering enteric-coated medications through gastrostomy tubes, as this alters drug action and may cause gastric irritation.
• Use liquid formulations or crushable tablets when administering via gastrostomy tubes.
• Consult with pharmacy before administering medications through enteral tubes to ensure safety and efficacy.

Administering medications via a nasogastric (NG) tube requires strict adherence to safe and evidence-based practices to maintain tube patency and ensure proper medication delivery. One of the most essential follow-up steps is flushing the tube after medication administration to prevent blockage, promote full drug delivery, and preserve tube function.

Rationale for correct answer:

2. Flush the tube with 15–30 mL of water:
Flushing with water immediately after medication administration helps clear the tubing of any residual medication, preventing interactions between drugs and reducing the risk of clogging. This step also ensures the entire dose reaches the stomach.

Rationale for incorrect answers:

1. Clamp the tube for 1 hour:
Clamping may be necessary in some cases, such as to enhance drug absorption, but it is not the universal or most essential follow-up step. The priority after giving medications is to ensure the tube remains clear and functional, which is achieved by flushing.

3. Administer all medications together in one mixture:
Combining all medications in one container is not recommended. Each medication should be administered separately with water flushes in between to avoid drug incompatibility, tube blockage, or altered therapeutic effects.

4. Keep patient supine for comfort:
The patient should be kept in a semi-Fowler’s or upright position (30–45°) during and for at least 30–60 minutes after administration to reduce the risk of aspiration. Supine positioning can increase this risk and is not advised.

Take-home points:

• Always flush an NG tube with 15–30 mL of water after administering medications to prevent clogging and ensure full delivery.
• Administer medications individually with flushes between each to avoid drug interactions and maintain tube patency.
• Maintain the patient in an upright position after administration to reduce aspiration risk.

When administering a rectal suppository to an adult, correct insertion depth is critical to ensure proper placement for optimal absorption. The suppository must be inserted beyond the internal anal sphincter into the rectal vault, where it can dissolve and be absorbed effectively by the rectal mucosa.

Rationale for correct answer:

3. 2–3 inches:
This is the appropriate depth for adult clients, ensuring the suppository is inserted well past the internal sphincter into the rectal cavity for reliable absorption and retention. It promotes proper drug effectiveness.

Rationale for incorrect answers:

1. 1 inch:
Inserting a suppository only 1 inch is insufficient for adults, as it may not pass the internal anal sphincter. This could result in the suppository being expelled before absorption occurs.

2. 2 inches:
Although better than 1 inch, 2 inches might still place the suppository too close to the sphincter, risking expulsion. It's important to ensure it reaches the rectal vault.

4. 4–5 inches:
Inserting a suppository this far could cause discomfort or trauma to the rectal mucosa. It exceeds the recommended insertion depth for adults and is unnecessary for effective absorption.

Take-home points:

• For adults, rectal suppositories should be inserted 2–3 inches to ensure retention and effective absorption.
• Too shallow an insertion increases the risk of expulsion, while too deep may cause trauma.
• Proper technique also includes lubrication and gentle insertion to minimize discomfort.

Rectal medication administration is often used when oral routes are impractical due to conditions like vomiting, unconsciousness, or swallowing difficulties. This route allows for systemic or local absorption without relying on the gastrointestinal tract’s upper segments. In cases of persistent nausea and vomiting, rectal delivery ensures the medication remains in the body long enough to be effective.

Rationale for correct answer:

2. Nausea and vomiting with inability to retain oral meds:
When a patient cannot keep down oral medications due to vomiting, the rectal route offers a reliable alternative for systemic absorption. This ensures therapeutic levels are reached without relying on the oral or gastric pathway.

Rationale for incorrect answers:

1. Constipation with abdominal cramping:
Although rectal medications such as suppositories or enemas may relieve constipation, abdominal cramping might signal a potential bowel obstruction, in which case rectal administration could be contraindicated or harmful.

3. Dysphagia after stroke:
While swallowing difficulties limit oral medication use, rectal administration isn’t typically the first alternative. Safer and more common alternatives include enteral (e.g., PEG tube) or parenteral routes for long-term use.

4. Frequent urination due to UTI:
Rectal administration is not appropriate for managing urinary tract infections. Oral or IV antibiotics are the standard routes for treating UTIs, as rectal administration doesn’t effectively target the urinary tract.

Take-home points:

• Rectal medications are especially useful when oral routes are not viable, such as during vomiting or severe nausea.
• This route enables drug delivery without relying on upper GI absorption.
• Conditions involving GI obstruction or local rectal issues may limit use of this route.

The “Six Rights” of medication administration form the foundation of safe nursing practice and reduce the risk of medication errors. These include: right patient, right drug, right dose, right route, right time, and right documentation. Nurses must consistently apply all six components to protect patient safety and comply with legal and professional standards.

Rationale for correct answer:

3. Giving the correct drug, dose, route, and documenting administration:
This reflects multiple components of the “Six Rights”—drug, dose, route, and documentation. While it does not list every right explicitly, it implies proper adherence when combined with correct timing and patient verification.

Rationale for incorrect answers:

1. Giving the drug on time but without documenting:
Timely administration is part of the “right time,” but omitting documentation violates the “right documentation.” This can lead to duplication, missed doses, or legal liability.

2. Administering the correct dose to the wrong patient:
Even if the medication and dose are correct, giving it to the wrong person breaches the “right patient” principle. This error can cause harm and is a major safety violation.

4. Adjusting the dose based on nurse judgment:
Altering the medication dose without a provider’s order violates scope of practice and the “right dose.” Nurses must administer only what is prescribed unless authorized changes are made by the provider.

Take-home points:

• The “Six Rights” of medication administration are non-negotiable elements for patient safety.
• Complete adherence, including correct patient, drug, dose, route, time, and documentation, is essential.
• Nurses cannot alter doses independently and must always document administration accurately.

Nurses are expected to safely apply topical medications such as creams, lotions, powders, and ointments, which are absorbed through the skin. Proper technique includes wearing gloves to prevent unintentional absorption and cross-contamination. The nurse should gently smooth these medications over the skin, ensuring even distribution and therapeutic effectiveness while minimizing skin irritation or damage.

Rationale for correct answer:

Creams

Gently Smooth Over the Skin When Applying: Creams are semi-solid emulsions that are applied directly to the skin for localized effect; they require gentle spreading to ensure proper coverage and absorption.

Can Be Removed by Water: Most creams are water-based and can be rinsed off easily with soap and water.

Necessary to Use Gloves: Gloves prevent absorption through the nurse’s skin and reduce the risk of cross-contamination.

Lotions

Shake Container First: Lotions often separate upon standing; shaking ensures the active ingredients are evenly distributed.

Gently Smooth Over the Skin When Applying: Lotions are thinner than creams and are applied to large or hairy areas; gentle application ensures even absorption.

Can Be Removed by Water: Being primarily water-based, lotions wash off easily.

Necessary to Use Gloves: Wearing gloves protects the nurse from unintended exposure to medicated substances.

Powders

Necessary to Use Gloves: Powders can aerosolize and be unintentionally inhaled or absorbed through the skin, so gloves are important for nurse safety. They are typically dusted, not rubbed into the skin.

Ointments

Gently Smooth Over the Skin When Applying: Ointments are thick and greasy, requiring smoothing to stay in place and deliver medication effectively over time.

Necessary to Use Gloves: Gloves prevent greasy residue and protect the nurse from systemic absorption of the medication.

Take-home points:

• Always wear gloves when applying topical medications like creams, lotions, ointments, and powders to prevent nurse exposure and cross-contamination.
• Shake lotions before application to ensure proper distribution of active ingredients, as separation can occur.
• Creams and lotions can be removed with water, while ointments are thicker and adhere longer, requiring thorough smoothing during application.

A patch test for allergens is used to identify substances that may cause delayed allergic reactions in a client. The procedure includes asking about recent antihistamine or anti-inflammatory use, preparing the skin with alcohol, and applying designated allergen patches. It is crucial to have emergency equipment available in case of a severe reaction and to monitor the skin for the formation of a wheal, which indicates a positive response to an allergen.

Rationale for correct answer:

5. Ask the client if they have taken any antihistamines or anti-inflammatory agents
Antihistamines or corticosteroids can suppress allergic reactions and may cause false-negative results. It’s critical to verify that the client hasn’t taken such medications before testing.

1. Have emergency equipment available in case of an anaphylactic response
Even though patch tests are usually low risk, systemic allergic reactions are possible. Emergency equipment (e.g., epinephrine, oxygen) must be nearby to ensure client safety.

4. Cleanse the area for testing with alcohol
Cleansing removes oils, dirt, or lotions that may interfere with absorption of the allergen or patch adhesion. A clean surface ensures accurate test results.

2. Apply the designated patches to the skin
Once the area is prepped, the patches containing the suspected allergens are applied to the back or arm. They must be secured properly and left in place for the recommended time.

3. Recognize when a wheal has formed
After 48–72 hours, the nurse checks the site for a wheal, redness, or swelling. The formation of a wheal indicates a localized allergic reaction and helps identify specific allergens.

Take-home points:

• Verify that the client has not taken antihistamines or corticosteroids before performing a patch test to prevent false-negative results.
• Always have emergency equipment available when conducting allergy testing in case of an anaphylactic reaction.
• Monitor for a wheal or localized skin response after applying patches to identify a positive allergic reaction.

When a nurse assesses the effectiveness of percutaneous nitroglycerin, it is important to evaluate for relief of anginal pain, blood pressure changes, and proper patch placement. These findings help determine whether the medication is being absorbed correctly and achieving its intended vasodilatory effect. Documentation of these outcomes ensures appropriate clinical monitoring and continuity of care.

Rationale for correct answers:

2. Blood pressure:

Nitroglycerin is a vasodilator that lowers blood pressure by relaxing vascular smooth muscle. Monitoring blood pressure helps assess for therapeutic effects like reduced preload and afterload, as well as potential hypotension, a known side effect.

4. Location of patch:

The location must be checked to ensure the patch is correctly placed on a clean, hairless area and not reused on the same site consecutively. Proper application supports consistent drug absorption and thus effectiveness.

5. Anginal pain relief:

Relief from chest pain is the primary therapeutic goal of nitroglycerin. Documenting the client's report of reduced or resolved angina is a direct measure of medication effectiveness.

Rationale for incorrect answers:

1. Temperature:

Body temperature is not directly affected by nitroglycerin, nor is it a key indicator of the drug’s effectiveness. Monitoring temperature would be more appropriate for evaluating infection or inflammatory responses rather than angina management.

3. Urine output:

While urine output is an important measure of kidney perfusion and fluid balance, it is not directly impacted by nitroglycerin. It is not used as a primary indicator of the drug’s effectiveness in relieving anginal symptoms.

Take-home points:

• Blood pressure and anginal pain relief are critical indicators of nitroglycerin's therapeutic effect as a vasodilator.
• Proper patch placement ensures consistent absorption and effectiveness of percutaneous nitroglycerin.
• Temperature and urine output are not relevant assessments for evaluating nitroglycerin’s efficacy.

Fentanyl transdermal patches are a form of long-acting opioid analgesia used for managing chronic pain. It is essential for nurses to understand that these patches typically take about 24 hours to reach therapeutic blood levels. This delayed onset highlights the importance of timing, patient education, and supplemental pain control during the initial application phase.

Rationale for correct answer:

4. 24 hours

Transdermal fentanyl reaches therapeutic plasma levels approximately 24 hours after application. During this initial period, supplemental short-acting opioids are often used to manage pain until the patch becomes fully effective.

Rationale for incorrect answers:

1. 6 hours

Fentanyl patches do begin to release medication soon after application, but therapeutic blood levels are typically not reached this early. Using 6 hours as a reference point underestimates the delayed onset of transdermal fentanyl.

2. 12 hours

Although some absorption may occur within 12 hours, this time frame is still too short for achieving steady-state plasma concentrations. Pain relief is usually inadequate until the drug accumulates sufficiently in the bloodstream.

3. 18 hours

This option is closer to the correct timeframe, but peak therapeutic levels are generally not reliably achieved until around 24 hours after the initial application of the patch.

Take-home points:

• Fentanyl patches require approximately 24 hours to reach therapeutic blood levels and provide effective pain relief.
• Short-acting opioids may be needed during the initial 24 hours for breakthrough or baseline pain management.
• Patient education is essential to prevent premature expectations of pain relief and ensure proper opioid safety.

The buccal route involves placing a medication between the cheek and gum, allowing it to be absorbed directly into the mucous membranes and bypass the gastrointestinal tract. This route is often used for drugs requiring rapid absorption or when swallowing is difficult. Nurses must instruct clients not to chew or swallow buccal medications to ensure proper absorption and therapeutic effect.

Rationale for correct answer:

1. Place the medication inside the pouch between the client’s lower molar and the cheek:

This is the correct method for administering medication via the buccal route, which allows the drug to dissolve and absorb directly into the bloodstream through the oral mucosa. This route bypasses the gastrointestinal system and avoids first-pass liver metabolism, allowing for faster systemic absorption.

Rationale for incorrect answers:

2. Crush the medication before administration:

Crushing buccal tablets can alter their intended formulation and absorption, potentially reducing efficacy or increasing the risk of adverse effects. Buccal medications are specifically designed to dissolve slowly in the cheek pouch.

3. Offer the client a glass of water or juice after administration:

Offering fluids immediately after buccal administration may cause the client to swallow the medication, which would defeat the purpose of buccal absorption and reduce its therapeutic effect.

4. Use sterile technique to administer the medication:

Sterile technique is not required for buccal medications, as they are administered in the non-sterile oral cavity. Clean technique and hand hygiene are sufficient for safe administration via this route

Take-home points:

• Buccal medications should be placed between the cheek and gum to allow direct absorption through the oral mucosa.
• Do not crush or chew buccal tablets, as this interferes with proper absorption and effectiveness.
• Avoid food or fluids immediately after administration to prevent swallowing the medication and reducing its therapeutic benefit.

When teaching a client how to use an inhaler prescribed for asthma, it is important to emphasize correct technique for medication delivery to ensure optimal airway deposition. The client should be instructed to exhale fully, then inhale slowly and deeply while activating the inhaler, followed by holding the breath for about 10 seconds to allow the medication to settle in the lungs. Proper inhaler use improves symptom control, reduces exacerbations, and enhances treatment effectiveness.

Rationale for correct answer:

2. “I will take a slow deep breath and let it out quickly.”

This statement shows a misunderstanding. After inhaling the medication slowly and deeply, the client should hold the breath for 5–10 seconds to allow the medication to reach deep into the airways. Breathing out quickly reduces medication retention and limits its effectiveness.

Rationale for incorrect answers:

1. “I will hold my breath for 10 seconds before breathing out.”

Holding the breath for about 10 seconds after inhaling helps the medication settle in the lungs, enhancing absorption and therapeutic effectiveness. This is a recommended step in inhaler use.

3. “I will check the number on the dose counter window to see how many more puffs I have left.”

Monitoring the dose counter ensures that the inhaler still contains medication and prevents accidental underdosing or treatment interruptions. This demonstrates proper inhaler use.

4. “I will notify my primary healthcare provider if I notice that I am coughing a lot more than usual.”

Reporting increased coughing can help detect medication side effects, worsening asthma control, or improper inhaler use. It reflects good patient awareness and safety.

Take-home points:

• After inhaling from an inhaler, clients should hold their breath for 5–10 seconds to allow medication to reach the lungs.
• Exhaling immediately after inhaling limits drug absorption and reduces the effectiveness of asthma treatment.
• Monitoring the dose counter and reporting new symptoms like increased coughing are important aspects of responsible inhaler use and asthma management.

When administering vaginal medications, the nurse must prioritize client comfort, privacy, and correct positioning to ensure effective delivery and absorption of the drug. The appropriate position for this procedure is the lithotomy position, where the client lies on her back with knees bent and hips rotated outward. This position allows for optimal access to the vaginal canal, promoting accurate placement of the medication and reducing the risk of contamination or improper absorption.

Rationale for correct answer:

3. Lithotomy position

This position involves the client lying on the back with knees flexed and feet placed in stirrups. It provides the best access to the vaginal canal, making it ideal for accurate and comfortable insertion of vaginal medications or devices.

Rationale for incorrect answers:

1. Left lateral recumbent position

This position is commonly used for rectal suppositories and enemas, not for vaginal medication administration. It allows easy access to the rectum but does not provide optimal exposure of the vaginal canal.

2. Trendelenburg position

In this position, the body is laid flat with the feet elevated higher than the head. It is used in specific medical scenarios like promoting venous return or certain surgical procedures, but it is not appropriate for administering vaginal medications.

4. Prone position

The prone position involves the client lying on the abdomen, which obstructs access to the vaginal area and is unsuitable for vaginal medication administration.

Take-home points:

• The lithotomy position provides optimal access to the vaginal canal and is the recommended position for administering vaginal medications.
• The left lateral, Trendelenburg, and prone positions do not provide proper access and are not appropriate for this procedure.
• Correct positioning enhances medication absorption and patient safety during vaginal administration.

When administering medications via the enteral routes the nurse uses the gastrointestinal or oral route, and the nurse may have to crush the tablets or caplets dosage forms for easier delivery.

When administering medications via enteral routes, the nurse may need to crush tablets or caplets to ensure safe and effective delivery, especially through feeding tubes. However, it is essential to verify whether the medication is safe to crush, as some forms—such as enteric-coated or extended-release tablets—should never be altered due to the risk of dose dumping or reduced efficacy.

Rationale for correct answer:

Options for 1 – Route:

Gastrointestinal and oral are appropriate enteral routes. The term enteral specifically refers to medication administration involving the gastrointestinal (GI) tract, which includes the oral, gastric, and rectal routes.

Intravenous is a parenteral route, not enteral.

Rectal is enteral but less commonly used for general medication administration than oral.

Therefore, gastrointestinal and oral are the most broadly correct and inclusive for enteral routes.

Options for 2 – Dosage forms:

Tablets and caplets can usually be crushed (unless they are extended-release or enteric-coated), which is common practice for clients with feeding tubes or swallowing difficulties.

Timed-release capsules should not be crushed because doing so destroys the extended-release mechanism, potentially causing overdose.

Lozenges are meant to dissolve slowly in the mouth and are not suitable for crushing or enteral tube administration.

Take-home points:

• Enteral routes include the gastrointestinal and oral pathways, which are commonly used for administering medications through the GI tract.
• Tablets and caplets may be crushed for easier delivery, especially when using feeding tubes, but only if they are not extended- or enteric-coated.
• Timed-release capsules and lozenges should not be crushed, as this can alter drug absorption, reduce effectiveness, or increase the risk of adverse effects.

In medication administration, nurses must be familiar with different systems used to store and dispense medications, including the unit-dose system and the computer-controlled system. The unit-dose system provides individually packaged doses for each patient, promoting accuracy and minimizing waste. In contrast, the computer-controlled system uses automated dispensing cabinets with security access codes and barcode scanning to track medications, ensure patient safety, and maintain detailed administration records.

Rationale for correct answer:

Compares the label with the client profile – X (Both)
This is a universal safety step followed in both systems to verify the medication matches the prescription and patient details.

Uses bar code scanner – X (Computer-Controlled System only)
Computer-controlled dispensing units (like Pyxis or Omnicell) often use barcode scanning to verify the "Five Rights" and link administration data to the electronic health record.

Checks expiration date on label – X (Both)
Nurses are required to check expiration dates before giving any medication, regardless of the system used, to ensure safety.

Uses security access code – X (Computer-Controlled System only)
These systems are computerized and require a login or biometric scan to access medications, enhancing accountability and reducing diversion.

Obtains medications from cart with drawer assigned to client – X (Unit-Dose System only)
Unit-dose carts have individual drawers per client, prefilled with a 24-hour supply of medications. This design simplifies administration and reduces error risk.

Take-home points:

• Both unit-dose and computer-controlled systems require label verification and expiration date checks before medication administration.
• Computer-controlled systems enhance safety through security access codes and barcode scanning to match the right medication to the right patient.
• The unit-dose system uses client-specific drawers with prepackaged doses to minimize medication errors and improve efficiency.

When preparing to administer guaifenesin syrup to a 5-year-old, the nurse must follow specific steps to ensure accurate dosing and child safety. This includes reviewing the medication order, verifying the dose and concentration, and measuring the liquid accurately at eye level using a medicine cup. The nurse should protect the medication label, use two identifiers to confirm the child's identity, and document administration promptly.

Rationale for correct answer:

Review the order for the number of milligrams of medicine or the volume the liquid to be administered.
Understanding the exact dose prescribed is the starting point for safe administration. It ensures the correct drug and dose is given, especially important in pediatrics where dosing is often weight-based.

Check the expiration date on the medicine.
Verifying the expiration date ensures the medication is still effective and safe for administration. Giving expired medication can reduce therapeutic efficacy or introduce risk.

Review the label to assure correct medicine and appropriate concentration of the liquid (e.g., number of mg per mL) and calculate the volume to be poured into the cup.
This step ensures the right drug and dose are being prepared. Pediatric medications often come in different concentrations, so careful review is essential.

Hold the bottle containing the liquid so the label is covered with the palm of the hand.
Covering the label prevents dripping liquid from smudging or damaging it. This maintains legibility and allows continued verification in future uses.

Pour the correct volume of liquid in a medicine cup reading the meniscus at eye level.
Measuring at eye level ensures dosing accuracy. The lowest curve of the liquid (meniscus) must align with the dosage mark to avoid under- or overdosing.

Identify the client through two identifiers and hand the medication to the client for ingestion.
Confirming the client's identity using two identifiers (e.g., name and birthdate) ensures the medication is given to the correct person, a key part of the "Right Patient" principle.

Document the administration of the medicine in the client’s chart.
Timely documentation verifies the medication was given and provides a legal record. It also supports communication among the healthcare team and prevents duplicate dosing.

Take-home points:

• Always verify the medication order, check the expiration date, and calculate the dose based on concentration before preparing any pediatric medication.
• Use proper technique when pouring liquid medications, including covering the label and measuring at eye level for accuracy.
• Confirm the client's identity using two identifiers before administration, and document promptly to ensure safe and complete care.

When preparing to administer medications via a gastrointestinal (GI) tube, the nurse’s first priority is to verify tube placement. Ensuring that the tube is correctly positioned in the stomach or intestines helps prevent aspiration, injury, or ineffective medication delivery. This safety check must be done before any medication or feeding is introduced, using methods such as pH testing or confirming placement as per facility policy.

Rationale for correct answer:

4. Check for the placement of the tube:
Verifying correct tube placement is the priority to ensure the medications are delivered into the gastrointestinal tract and not the lungs, which would cause serious harm. This safety step must be completed before any medication is administered.

Rationale for incorrect answers:

1. Add the medication to the tube feeding being given:
Mixing medications directly into enteral feeding formulas can alter drug effectiveness and increase the risk of tube blockage. Medications should be administered separately from feedings and flushed between drugs.

2. Crush all tablets and capsules before administration:
Not all medications can be crushed (e.g., enteric-coated or extended-release formulations), as doing so may alter their effectiveness or increase the risk of side effects. Each medication must be evaluated individually before crushing.

3. Administer all of the medications mixed together:
Combining medications in a single syringe can lead to drug incompatibilities, altered absorption, and increased risk of adverse reactions. Each drug should be administered separately with proper flushing to prevent interactions.

Take-home points:

• Always verify GI tube placement before administering any medications to prevent aspiration and ensure proper drug delivery.
• Administer medications separately with flushing in between to avoid drug interactions and tube obstruction.
• Do not crush medications without confirming their suitability, as some formulations are unsafe to alter.

When administering an intermittent enteral feeding to an adult client, the nurse must always assess the gastric residual before proceeding. If the residual aspirate appears “coffee-ground” in color, it may indicate gastrointestinal bleeding, often due to irritation or ulceration of the gastric mucosa. This finding requires immediate notification of the healthcare provider, as continuing the feeding could worsen the condition and lead to complications such as aspiration or hemodynamic instability.

Rationale for correct answer:

3. Notify the healthcare provider:
A coffee-ground appearance in gastric aspirate is an abnormal and potentially serious sign of gastrointestinal bleeding. Immediate notification of the provider is essential for further diagnostic evaluation and appropriate intervention to prevent complications.

Rationale for incorrect answers:

1. Administer the next scheduled feeding:
Continuing the feeding without addressing abnormal findings could lead to worsening complications. A coffee-ground appearance in aspirate often indicates upper gastrointestinal bleeding, which requires prompt evaluation before proceeding.

2. Stop feeding the client for 30 minutes:
Temporarily pausing the feeding is not sufficient when the aspirate suggests possible GI bleeding. This response delays necessary medical intervention and fails to address the seriousness of the finding.

4. Re-instill the aspirate and start a new feeding:
Reinstilling potentially blood-tinged or altered gastric contents could reintroduce harmful substances into the stomach. Additionally, starting a new feeding without clarifying the cause of the abnormal aspirate could compromise the client’s safety.

Take-home points:

• “Coffee-ground” gastric aspirate may indicate gastrointestinal bleeding and must be reported immediately.
• Do not continue feedings when abnormal aspirate is observed—feeding could worsen the client’s condition.
• Re-instilling suspicious aspirate is unsafe; withhold feeding and consult the healthcare provider first.

When preparing to administer a rectal suppository, the nurse must follow both correct technique and use appropriate equipment to ensure safe and effective medication delivery. This includes using clean gloves, applying a water-soluble lubricant, and gently inserting the suppository past the internal anal sphincter while the client is positioned on their left side.

Rationale for correct answer:

Correct Technique

Gently insert suppository past the internal sphincter
Inserting the suppository beyond the internal sphincter ensures that the medication stays in place and is not expelled immediately. This allows for optimal absorption in the rectal mucosa.

Position the client on their left side
The left lateral (Sims') position takes advantage of the natural anatomy of the rectum and colon, making insertion easier and more comfortable for the client, and aiding the suppository in remaining in place.

Ask the client to remain on their side for 20 minutes
Staying in this position helps prevent the suppository from being expelled prematurely. It also allows the medication time to dissolve and begin absorption through the rectal wall.

Explain the procedure and educate the client on the drug being administered
Providing education reduces anxiety, ensures informed consent, and promotes client cooperation during the procedure, all of which contribute to safe and effective administration.

Correct Equipment:

Obtain a water-soluble lubricant
Lubrication is necessary to reduce friction and prevent trauma or discomfort during insertion. Water-soluble lubricants are preferred because they are easily absorbed and safe for mucosal tissues.

Remove suppository from unit-dose wrapper
Suppositories are typically packaged in a protective wrapper. Removing the wrapper is essential to prepare the medication for use and to avoid inserting packaging material.

Obtain clean gloves
Gloves provide a barrier that protects both the nurse and the client from transmission of microorganisms. Clean gloves are part of standard precautions for any procedure involving mucous membranes.

Take-home points:

• Position the client in the left lateral (Sims’) position to facilitate smooth insertion and reduce discomfort during rectal suppository administration.
• Always use clean gloves and water-soluble lubricant to maintain aseptic technique and minimize tissue trauma.
• Insert the suppository past the internal sphincter and instruct the client to remain on their side for 20 minutes to ensure optimal retention and absorption of the medication.

Crushing long-acting medications can significantly alter their intended pharmacological effect. These formulations are designed to release the drug slowly over time. When crushed, the entire dose is released immediately, increasing the risk of toxicity or overdose. Nurses must recognize which medications are extended-, sustained-, or controlled-release and avoid crushing them to preserve therapeutic safety and efficacy.

Rationale for correct answer:

2. Medications that are crushed release the drug immediately, stopping the long-acting effect, potentially causing an overdose:
Crushing long-acting (extended-release) medications disrupts their time-release mechanism, causing rapid absorption of the entire dose at once. This can lead to dangerously high serum drug levels and a risk of toxicity or overdose, defeating the purpose of sustained drug release.

Rationale for incorrect answers:

1. Medications that are crushed are harder to swallow, making it harder to activate the effect:
Crushing a medication actually makes swallowing easier, not harder. However, this choice misunderstands the pharmacological consequences of crushing long-acting drugs and does not address the safety risk.

3. Medications that are crushed will not be absorbed properly, inactivating the long-acting effect:
While crushing may alter absorption, the major concern is not poor absorption but too rapid absorption. The long-acting coating ensures gradual release, which is lost when the drug is crushed.

4. Medications that are crushed will become powder and lose all the effectiveness of the drug:
The medication does not become ineffective just because it's in powder form. The issue lies in how quickly the drug is absorbed, not whether the drug retains potency.

Take-home points:

• Never crush long-acting, extended-, or sustained-release medications because doing so destroys the time-release mechanism and leads to rapid drug release.
• Crushing long-acting medications increases the risk of overdose by delivering the full dose at once instead of over time.
• Always verify a drug’s formulation before crushing and consult a pharmacist if unsure whether a medication can be safely altered.

When checking for gastric tube placement, aspirating and assessing the contents helps confirm proper positioning. Gastric fluid is typically green with sediment and has an acidic pH around 1 to 5, most often close to pH 3. This assessment supports safe medication administration and feeding by ensuring the tube is in the stomach, not the respiratory tract or intestines.

Rationale for correct answer:

2. pH of 3, green with sediment:

Gastric fluid typically has a low pH (1–5), reflecting the acidity of stomach acid, and may appear green due to bile or food remnants, often with visible particles or sediment. This finding supports the correct placement of the tube in the stomach.

Rationale for incorrect answers:

1. pH of 8, clear colored:

A pH of 8 is too alkaline to be considered gastric fluid. This pH suggests intestinal or possibly respiratory secretions, not stomach contents. Clear fluid also indicates it likely originates from another part of the GI tract.

3. pH of 7, yellow colored:

A pH of 7 is neutral and not characteristic of gastric contents. Yellow fluid may be seen in the intestines, not the stomach, especially in the duodenum where bile is more common.

4. pH of 4, off-white colored:

Although a pH of 4 is still acidic and could represent gastric content, "off-white" fluid is not typically seen in the stomach. Gastric secretions are more commonly greenish or clear with food particles rather than off-white.

Take-home points:

• Gastric fluid is typically acidic (pH 1–5), most often around pH 3, and may appear green with sediment due to bile and food remnants.
• Aspirated gastric contents help verify correct placement of GI tubes before administering medications or feedings.
• Alkaline or neutral pH values (above 5) may indicate placement in the intestines or respiratory tract, not the stomach.