💊 Lesson 3: Medication Administration & Safety

Introduction

Master medication administration and dosage calculations with free flashcards and spaced repetition quizzes designed specifically for NCLEX-PN preparation. This lesson covers the six rights of medication administration, safe medication practices, basic dosage calculations, common drug classifications, and the LPN/LVN role in medication management—all critical concepts for passing your practical nursing licensure exam and ensuring patient safety in clinical practice.

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🎯 Welcome to Medication Administration

Welcome to one of the most heavily tested areas on the NCLEX-PN! Medication administration is a core responsibility for LPN/LVNs, and exam questions frequently test your ability to calculate doses accurately, identify unsafe orders, and follow proper protocols. This lesson builds on your foundational nursing knowledge by diving into the practical, hands-on skills you'll use daily in practice.

Why This Matters: Medication errors are among the most common causes of patient harm in healthcare settings. As an LPN/LVN, you are often the last line of defense between an incorrect order and patient injury. Your vigilance, calculation accuracy, and adherence to safety protocols can literally save lives.

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📋 Core Concepts: The Six Rights of Medication Administration

The foundation of safe medication administration rests on the Six Rights. These are non-negotiable checkpoints that must be verified before administering any medication:

💡 Memory Device - "PMDRTD": Patient, Medication, Dose, Route, Time, Documentation. Think: "Please Make Double Really Thorough Documentation!"

Additional Safety Checks

Beyond the Six Rights, professional practice includes:

• Right to refuse: Patients can decline medications; document refusal and notify prescriber
• Right reason: Understand WHY the medication is ordered (indication)
• Right assessment: Check vital signs, allergies, lab values, and contraindications BEFORE administering
• Right education: Teach patient about medication purpose, side effects, and special instructions

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🧮 Dosage Calculations: Essential Formulas

Dosage calculation questions appear frequently on NCLEX-PN. You must demonstrate competency in basic mathematical conversions and medication math.

Formula Method (Most Universal)

The Desired over Have formula works for most calculations:

Dose to give = (Desired dose ÷ Dose on Hand) × Vehicle

Where:
- Desired = What the doctor ordered
- Have = What's available (drug strength)
- Vehicle = Form it comes in (tablets, mL)

Example: Order reads "Give acetaminophen 650 mg PO." You have 325 mg tablets available.

Step	Calculation	Result
1. Identify values	Desired = 650 mg Have = 325 mg Vehicle = 1 tablet	-
2. Apply formula	(650 mg ÷ 325 mg) × 1 tablet	2 tablets
3. Verify reasonableness	650 is double 325	✓ Makes sense

IV Flow Rate Calculations

Intravenous medication administration requires calculating drops per minute (gtt/min) or milliliters per hour (mL/hr).

Formula for gtt/min:

gtt/min = (Total volume in mL × Drop factor) ÷ Time in minutes

Example: Infuse 1000 mL over 8 hours using tubing with drop factor of 15 gtt/mL.

Step	Calculation	Result
1. Convert time	8 hours × 60 min/hr	480 minutes
2. Apply formula	(1000 mL × 15 gtt/mL) ÷ 480 min	31.25 gtt/min
3. Round appropriately	Round to whole number	31 gtt/min

💡 Common Drop Factors:

• Macrodrip: 10, 15, or 20 gtt/mL (standard IV tubing)
• Microdrip: 60 gtt/mL (pediatric or precise delivery)

Dimensional Analysis Method

Some nurses prefer dimensional analysis (factor-label method) because it reduces errors through systematic conversion:

Example: Give heparin 8000 units SubQ. Available: 10,000 units/mL.

8000 units × (1 mL / 10,000 units) = 0.8 mL

Units cancel out, leaving mL

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💊 Common Drug Classifications

As an LPN/LVN, you need to recognize major drug categories, their purposes, common examples, and key nursing considerations.

Classification	Purpose	Examples	Key Nursing Actions
Analgesics	Pain relief	Morphine, acetaminophen, ibuprofen	Assess pain level before/after; monitor respiratory rate with opioids; teach non-pharmacological methods
Antibiotics	Fight bacterial infections	Penicillin, cephalosporins, vancomycin	Check allergies; administer on time; monitor for allergic reactions; teach to complete full course
Antihypertensives	Lower blood pressure	Lisinopril, metoprolol, amlodipine	Check BP before giving; hold if systolic <100 mmHg (or per facility policy); teach orthostatic precautions
Anticoagulants	Prevent blood clots	Warfarin, heparin, enoxaparin	Monitor for bleeding; check PT/INR (warfarin) or aPTT (heparin); teach bleeding precautions
Antidiabetics	Control blood glucose	Insulin, metformin, glyburide	Check blood glucose before giving; know onset/peak/duration; have glucose source available for hypoglycemia
Diuretics	Increase urine output, reduce fluid	Furosemide, hydrochlorothiazide	Monitor I&O, weight, electrolytes (especially potassium); administer early in day to avoid nocturia

🔍 Medication Name Types

Understanding medication naming prevents confusion:

• Generic name (lowercase): The official drug name (e.g., acetaminophen, ibuprofen)
• Brand/Trade name (capitalized): Manufacturer's marketing name (e.g., Tylenol, Advil)
• Chemical name: Scientific molecular structure (rarely used clinically)

⚠️ NCLEX Tip: The exam typically uses generic names. Always learn both generic and common brand names.

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🚨 Medication Safety Protocols

High-Alert Medications

Certain medications carry higher risk of causing significant patient harm if used incorrectly. The Institute for Safe Medication Practices (ISMP) designates these as high-alert:

┌─────────────────────────────────────────────┐
│     ⚠️ HIGH-ALERT MEDICATIONS ⚠️           │
├─────────────────────────────────────────────┤
│                                             │
│  💉 Insulin and oral hypoglycemics          │
│  🩸 Anticoagulants (heparin, warfarin)     │
│  💊 Opioids and sedatives                   │
│  💧 IV potassium chloride                   │
│  💉 Chemotherapy agents                     │
│  🧪 Neuromuscular blockers                  │
│                                             │
│  ➜ Require double-check verification       │
│  ➜ Independent calculation by 2 nurses     │
│  ➜ Special storage/labeling                │
│                                             │
└─────────────────────────────────────────────┘

Look-Alike, Sound-Alike (LASA) Medications

Drug names that appear or sound similar create confusion:

• HydrOXYzine (antihistamine) vs. HydrALAzine (antihypertensive)
• CeleBREX (pain reliever) vs. CelEXA (antidepressant)
• GlyBURide (diabetes) vs. GlipiZIDE (diabetes)—both similar actions but different dosing

💡 Strategy: Use Tall Man lettering (capitalizing differing letters) and always verify indication matches the drug.

Medication Error Prevention

MEDICATION SAFETY WORKFLOW

    📋 Receive Order
         |
         ↓
    🔍 Verify Complete Order (includes dose, route, frequency)
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         ↓
    ⚠️ Check for Contraindications (allergies, interactions)
         |
         ↓
    🧮 Calculate Dose (double-check if needed)
         |
         ↓
    🔒 Three Checks (label vs MAR: selecting, preparing, giving)
         |
         ↓
    👤 Two Patient Identifiers
         |
         ↓
    💊 Administer at Bedside (never leave unattended)
         |
         ↓
    ✍️ Document Immediately
         |
         ↓
    👁️ Monitor Patient Response

⚠️ Never leave medications at bedside unless specifically ordered (e.g., nitroglycerin, insulin for self-administration). Watch patient swallow oral medications.

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📝 Detailed Examples with Explanations

Example 1: Applying the Six Rights

Scenario: You are preparing to administer medications at 0900. Your MAR shows: "John Smith, DOB 3/15/1960, MRN 123456: Metoprolol 50 mg PO daily at 0900."

You retrieve a medication labeled "Metoprolol 25 mg tablets" from the automated dispensing cabinet.

Step-by-Step Application:

1. Right Patient: Approach patient, scan wristband showing "John Smith, 3/15/1960, MRN 123456." Ask patient to state name and birth date. ✓

2. Right Medication: Compare MAR to medication label (First check when selecting). Label reads "Metoprolol." ✓

3. Right Dose: Order = 50 mg. Available = 25 mg tablets. Calculate: (50 mg ÷ 25 mg) × 1 tablet = 2 tablets. Prepare 2 tablets (Second check while preparing). ✓

4. Right Route: Order specifies "PO" (by mouth). Tablets are appropriate for oral route. ✓

5. Right Time: Current time is 0855. Order states 0900. Within acceptable 30-minute window. ✓

6. Right Documentation: After patient swallows tablets with water, immediately document in MAR: "Metoprolol 50 mg (2 tablets) given PO at 0900." ✓

Additional Safety Step: Before administering, you check the patient's blood pressure: 128/76 mmHg. Since metoprolol is an antihypertensive and BP is adequate, safe to proceed. You also verify no allergy band present.

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Example 2: Dosage Calculation with Conversion

Scenario: Order reads "Amoxicillin 500 mg PO q8h." Pharmacy supplies amoxicillin suspension 250 mg/5 mL.

Calculation Process:

Step	Action	Result
1	Identify Desired dose	500 mg
2	Identify Have (concentration)	250 mg per 5 mL
3	Set up formula: (Desired ÷ Have) × Vehicle	(500 mg ÷ 250 mg) × 5 mL
4	Calculate	2 × 5 mL = 10 mL
5	Verify reasonableness	500 is double 250, so need double the volume ✓

Administration: Measure 10 mL using oral syringe or medication cup. Instruct patient to shake suspension well before measuring each dose to ensure even distribution of medication.

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Example 3: IV Flow Rate Calculation

Scenario: Provider orders "1000 mL Normal Saline IV over 10 hours." You're using an IV pump (mL/hr).

Simple pump calculation:

mL/hr = Total volume ÷ Time in hours
mL/hr = 1000 mL ÷ 10 hours = 100 mL/hr

Set pump to 100 mL/hr.

But what if using gravity drip tubing with 15 gtt/mL drop factor?

Step	Calculation	Result
1	Convert hours to minutes	10 hrs × 60 = 600 min
2	Apply gtt/min formula: (Volume × Drop factor) ÷ Time	(1000 mL × 15 gtt/mL) ÷ 600 min
3	Calculate	15,000 ÷ 600 = 25 gtt/min
4	Set roller clamp and count drops	Adjust to 25 drops per minute

💡 Nursing Tip: With gravity drip, recheck flow rate hourly—patient movement, IV site position, and tubing kinks affect flow.

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Example 4: Recognizing an Unsafe Order

Scenario: New order received: "Digoxin 2.5 mg PO daily."

Your patient's current vital signs: HR 58 bpm (regular), BP 118/72 mmHg.

Critical Thinking Process:

1. Know the drug: Digoxin is a cardiac glycoside that slows heart rate and strengthens contractions. Used for heart failure and atrial fibrillation.

2. Know typical dosing: Normal digoxin maintenance dose is 0.125-0.25 mg daily (note: MICROGRAMS often used: 125-250 mcg).

3. Recognize the error: 2.5 mg is 10 times the normal dose—likely a decimal point error or mg/mcg confusion.

4. Check parameters: Heart rate is already 58 bpm. Digoxin would further decrease it, risking bradycardia.

5. Action: DO NOT ADMINISTER. Contact prescriber immediately to clarify order. Document the discrepancy and conversation.

⚠️ NCLEX Priority: When you identify an unsafe order, your FIRST action is to contact the prescriber for clarification. Never administer a questionable medication.

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⚠️ Common Mistakes in Medication Administration

1. Calculation Errors

Mistake: Misplacing decimal points or using wrong conversion factors.

Example: Confusing 0.5 mg with 5 mg, or failing to convert micrograms to milligrams (1 mg = 1000 mcg).

Prevention:

• Always include units in calculations
• Estimate expected answer first ("Should I give more or less than what's on hand?")
• Use a calculator for complex math
• Have another nurse verify high-alert medication calculations

2. Skipping the Three Checks

Mistake: Checking medication label only once, or not at all if "familiar" with the drug.

Reality: Even experienced nurses make errors. Distractions, similar packaging, and fatigue contribute to mistakes.

Prevention: Make the three checks a habit—EVERY TIME, NO EXCEPTIONS:

• Check 1: When selecting/retrieving from storage
• Check 2: When preparing/pouring/drawing up
• Check 3: Before returning container to storage or at bedside before giving

3. Inadequate Patient Assessment

Mistake: Administering medications without checking relevant vital signs or lab values.

Examples:

• Giving antihypertensive without checking blood pressure
• Administering digoxin without checking heart rate (hold if <60 bpm)
• Giving potassium supplement without checking potassium level
• Administering warfarin without checking INR

Prevention: Know your drug categories and required assessments. Make checking parameters part of your pre-administration routine.

4. Crushing Medications That Shouldn't Be Crushed

Mistake: Crushing extended-release, enteric-coated, or sublingual medications.

Why it's dangerous:

• Extended-release (ER, SR, XL, CR): Crushing releases entire dose at once, causing toxicity
• Enteric-coated: Crushing removes protective coating meant to prevent stomach irritation
• Sublingual/buccal: Meant to absorb through mucous membranes, not swallowed

Prevention: Check drug reference before crushing. If patient cannot swallow, contact prescriber for alternative form (liquid, dissolvable, transdermal).

5. Documentation Errors

Mistake: Documenting before administration ("pre-charting") or forgetting to document.

Legal principle: "If it isn't documented, it wasn't done."

Prevention:

• Document immediately after giving medication
• Never document for another nurse
• If medication wasn't given, document why (patient refused, NPO for procedure, held per parameters) and notify prescriber

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🎯 LPN/LVN Scope: Medication Administration

What LPNs/LVNs CAN Do:

✅ Administer oral, topical, subcutaneous, and intramuscular medications (after proper training) ✅ Administer some IV medications via established IV line (varies by state—check your state's Nurse Practice Act) ✅ Monitor patient response to medications and report findings to RN/provider ✅ Reinforce medication teaching provided by RN ✅ Document medication administration accurately ✅ Recognize adverse effects and contraindications ✅ Calculate medication dosages ✅ Maintain medication security and proper storage

What LPNs/LVNs CANNOT Do (or have restrictions):

❌ Administer IV push medications (in most states) ❌ Administer blood or blood products (in most states—RN responsibility) ❌ Initiate IV therapy (in many states—varies) ❌ Administer chemotherapy or experimental drugs ❌ Initial patient teaching for new medications (RN does initial teaching; LPN reinforces) ❌ Make independent decisions to hold or change medication orders without RN/provider consultation

⚠️ State Variability: LPN/LVN scope for IV therapy varies significantly by state. Some states allow LPNs to perform IV therapy after certification; others restrict it entirely. Always practice within your state's Nurse Practice Act.

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💡 Key Takeaways

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📚 Further Study

Deepen your medication administration knowledge with these trusted resources:

1. Institute for Safe Medication Practices (ISMP) - https://www.ismp.org/ - Lists of high-alert medications, LASA drugs, and error prevention strategies

2. Drugs.com Drug Information - https://www.drugs.com/ - Comprehensive database with dosing, interactions, and patient teaching information for thousands of medications

3. CDC Injection Safety - https://www.cdc.gov/injection-safety/ - Evidence-based guidelines for safe injection practices and infection prevention during medication administration

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📋 Quick Reference Card: Medication Administration

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Congratulations! You've completed Lesson 3 on Medication Administration & Safety. This knowledge forms the backbone of safe nursing practice. As you move forward, continue practicing calculations daily, stay current on new medications in your clinical area, and always maintain a questioning attitude when something doesn't seem right. Your vigilance protects your patients.

🎯 Next Steps: Practice dosage calculation problems daily, review drug cards for common medications in your clinical setting, and observe experienced nurses' medication administration techniques during clinical rotations.