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RN Pharmacology for Nursing

REVIEW MODULE EDITION 8.0
Contributors
Honey C. Holman, MSN, RN
Debborah Williams, MSN, RN
Sheryl Sommer, PhD, RN, CNE

Consultants
Janean Johnson, MSN, RN, CNE
Tracey Bousquet, BSN, RN
Brenda S. Ball, MEd, BSN, RN
Penny Fauber, PhD, MS, BSN, RN
Cindy Morris, DNP, RN, IBCLC
Jenni L. Hoffman, DNP,
LaKeisha Wheless, MSN, RN FNP-C, CLNC, FAANP
Mendy G. McMichael, DNP, RN Jessica L. Johnson, DNP, MSN, BSN, RN
Pamela Roland, MSN, MBA, RN Lisa Kongable, MA, ARNP, PMHCNS, CNE
Peggy Leehy, MSN, RN Melanie P. Schrader, PhD, RN
Robin Hertel, EdS, MSN, RN, CMSRN Virginia Tufano, EdD, MSN, RN
INTELLECTUAL PROPERTY NOTICE

ATI Nursing is a division of Assessment Technologies Institute®, LLC.
Copyright © 2019 Assessment Technologies Institute, LLC. All rights reserved.
The reproduction of this work in any electronic, mechanical, or other means, now known or hereafter
invented, is forbidden without the written permission of Assessment Technologies Institute, LLC. All of the
content in this publication, including, for example, the cover, all of the page headers, images, illustrations,
graphics, and text, are subject to trademark, service mark, trade dress, copyright, and/or other intellectual
property rights or licenses held by Assessment Technologies Institute, LLC, one of its affiliates, or by
third parties who have licensed their materials to Assessment Technologies Institute, LLC.
RN PHARMACOLOGY FOR NURSING I

07/24/15 April 19, 2019 9:51 AM rm_rn_2019_pharm_FRONT-MATTER 07/24
Director of content review: Kristen Lawler
Director of development: Derek Prater
Project management: Tiffany Pavlik, Shannon Tierney
Coordination of content review: Honey C. Holman, Debborah Williams
Copy editing: Kelly Von Lunen, Bethany Phillips, Kya Rodgers, Joshua Hoeven
Layout: Spring Lenox, Maureen Bradshaw, Bethany Phillips
Illustrations: Randi Hardy
Online media: Brant Stacy, Ron Hanson, Britney Fuller, Barry Wilson
Cover design: Jason Buck
Interior book design: Spring Lenox
IMPORTANT NOTICE TO THE READER

Assessment Technologies Institute, LLC, is the publisher of this publication. The content of this publication is for
informational and educational purposes only and may be modified or updated by the publisher at any time. This
publication is not providing medical advice and is not intended to be a substitute for professional medical advice,
diagnosis, or treatment. The publisher has designed this publication to provide accurate information regarding the
subject matter covered; however, the publisher is not responsible for errors, omissions, or for any outcomes related to
the use of the contents of this book and makes no guarantee and assumes no responsibility or liability for the use of the
products and procedures described or the correctness, sufficiency, or completeness of stated information, opinions, or
recommendations. The publisher does not recommend or endorse any specific tests, providers, products, procedures,
processes, opinions, or other information that may be mentioned in this publication. Treatments and side effects described
in this book may not be applicable to all people; likewise, some people may require a dose or experience a side effect
that is not described herein. Drugs and medical devices are discussed that may have limited availability controlled by
the Food and Drug Administration (FDA) for use only in a research study or clinical trial. Research, clinical practice,
and government regulations often change the accepted standard in this field. When consideration is being given to use
of any drug in the clinical setting, the health care provider or reader is responsible for determining FDA status of the
drug, reading the package insert, and reviewing prescribing information for the most up-to-date recommendations
on dose, precautions, and contraindications and determining the appropriate usage for the product. Any references
in this book to procedures to be employed when rendering emergency care to the sick and injured are provided solely
as a general guide. Other or additional safety measures may be required under particular circumstances. This book
is not intended as a statement of the standards of care required in any particular situation, because circumstances
and a patient’s physical condition can vary widely from one emergency to another. Nor is it intended that this book
shall in any way advise personnel concerning legal authority to perform the activities or procedures discussed. Such
specific determination should be made only with the aid of legal counsel. Some images in this book feature models.
These models do not necessarily endorse, represent, or participate in the activities represented in the images. THE
PUBLISHER MAKES NO REPRESENTATIONS OR WARRANTIES OF ANY KIND, WHETHER EXPRESS OR IMPLIED, WITH
RESPECT TO THE CONTENT HEREIN. THIS PUBLICATION IS PROVIDED AS-IS, AND THE PUBLISHER AND ITS AFFILIATES
SHALL NOT BE LIABLE FOR ANY ACTUAL, INCIDENTAL, SPECIAL, CONSEQUENTIAL, PUNITIVE, OR EXEMPLARY
DAMAGES RESULTING, IN WHOLE OR IN PART, FROM THE READER’S USE OF, OR RELIANCE UPON, SUCH CONTENT.
II CONTENT MASTERY SERIES

User’s Guide
Welcome to the Assessment Technologies Institute® RN ACTIVE LEARNING SCENARIOS
Pharmacology for Nursing Review Module Edition 8.0. The AND APPLICATION EXERCISES
mission of ATI’s Content Mastery Series® Review Modules
Each chapter includes opportunities for you to test your
is to provide user-friendly compendiums of nursing
knowledge and to practice applying that knowledge. Active
knowledge that will:
Learning Scenario exercises pose a nursing scenario
● Help you locate important information quickly.
and then direct you to use an ATI Active Learning
● Assist in your learning efforts.
Template (included at the back of this book) to record

● Provide exercises for applying your nursing knowledge.
the important knowledge a nurse should apply to the
● Facilitate your entry into the nursing profession as a
scenario. An example is then provided to which you can
newly licensed nurse.
compare your completed Active Learning Template. The
This newest edition of the Review Modules has been Application Exercises include NCLEX-style questions, such
redesigned to optimize your learning experience. We’ve as multiple-choice and multiple-select items, providing
fit more content into less space and have done so in a you with opportunities to practice answering the kinds of
way that will make it even easier for you to find and questions you might expect to see on ATI assessments or
understand the information you need. the NCLEX. After the Application Exercises, an answer key
is provided, along with rationales.
ORGANIZATION NCLEX® CONNECTIONS

This Review Module is organized into units covering To prepare for the NCLEX-RN, it is important to
pharmacological principles (Unit 1) and medications understand how the content in this Review Module
affecting the body systems and physiological processes is connected to the NCLEX-RN test plan. You can find
(Units 2 to 13). Chapters within these units conform to one information on the detailed test plan at the National
of two organizing principles for presenting the content. Council of State Boards of Nursing’s website, www.ncsbn.
● Nursing concepts org. When reviewing content in this Review Module,
● Medications regularly ask yourself, “How does this content fit into
the test plan, and what types of questions related to this
Nursing concepts chapters begin with an overview
content should I expect?”
describing the central concept and its relevance to nursing.
Subordinate themes are covered in outline form to To help you in this process, we’ve included NCLEX
demonstrate relationships and present the information in Connections at the beginning of each unit and with each
a clear, succinct manner. question in the Application Exercises Answer Keys. The
NCLEX Connections at the beginning of each unit point
Medications chapters include an overview describing a
out areas of the detailed test plan that relate to the content
disorder or group of disorders. Medications used to treat
within that unit. The NCLEX Connections attached to the
these disorders are grouped according to classification.
Application Exercises Answer Keys demonstrate how each
A specific medication can be selected as a prototype or
exercise fits within the detailed content outline.
example of the characteristics of medications in this
These NCLEX Connections will help you understand how
classification. These sections include information about
the detailed content outline is organized, starting with
how the medication works and its therapeutic uses.
major client needs categories and subcategories and
Next, you will find information about complications,
followed by related content areas and tasks. The major
contraindications/precautions, and interactions, as well as
client needs categories are:
nursing interventions and client education to help prevent ● Safe and Effective Care Environment
and/or manage these issues. Finally, the chapter includes ◯ Management of Care
information on nursing administration of the medication ◯ Safety and Infection Control
and evaluation of the medication’s effectiveness. ● Health Promotion and Maintenance

● Psychosocial Integrity
● Physiological Integrity
◯ Basic Care and Comfort
◯ Pharmacological and Parenteral Therapies
◯ Reduction of Risk Potential
◯ Physiological Adaptation
An NCLEX Connection might, for example, alert you that

content within a unit is related to:
● Pharmacological and Parenteral Therapies
◯ Adverse Effects/Contraindications/Side Effects/
Interactions
■ Identify a contraindication to the administration of
a medication to the client.
RN PHARMACOLOGY FOR NURSING USER’S GUIDE III

QSEN COMPETENCIES ICONS

As you use the Review Modules, you will note the Icons are used throughout the Review Module to draw
integration of the Quality and Safety Education for your attention to particular areas. Keep an eye out for
Nurses (QSEN) competencies throughout the chapters. these icons.
These competencies are integral components of the
curriculum of many nursing programs in the United States This icon is used for NCLEX Connections.
and prepare you to provide safe, high-quality care as a
newly licensed nurse. Icons appear to draw your attention This icon indicates gerontological considerations,
to the six QSEN competencies. or knowledge specific to the care of older
adult clients.
Safety: The minimization of risk factors that could
cause injury or harm while promoting quality care This icon is used for content related to safety
and maintaining a secure environment for clients, self, and is a QSEN competency. When you see this
and others. icon, take note of safety concerns or steps that
nurses can take to ensure client safety and a
Patient-Centered Care: The provision of caring and
safe environment.
compassionate, culturally sensitive care that addresses
clients’ physiological, psychological, sociological, spiritual, This icon is a QSEN competency that indicates
and cultural needs, preferences, and values. the importance of a holistic approach to
providing care.
Evidence-Based Practice: The use of current knowledge
from research and other credible sources, on which to base This icon, a QSEN competency, points out the
clinical judgment and client care. integration of research into clinical practice.
Informatics: The use of information technology as a This icon is a QSEN competency and highlights
communication and information-gathering tool that the use of information technology to support
supports clinical decision-making and scientifically based nursing practice.
nursing practice.
This icon is used to focus on the QSEN
Quality Improvement: Care related and organizational competency of integrating planning processes to
processes that involve the development and meet clients’ needs.
implementation of a plan to improve health care services
This icon highlights the QSEN competency of care
and better meet clients’ needs.
delivery using an interprofessional approach.
Teamwork and Collaboration: The delivery of client care
This icon appears at the top-right of pages
in partnership with multidisciplinary members of the
and indicates availability of an online media
health care team to achieve continuity of care and positive
supplement, such as a graphic, animation, or
client outcomes.
video. If you have an electronic copy of the
Review Module, this icon will appear alongside
clickable links to media supplements. If you have
a hard copy version of the Review Module, visit
www.atitesting.com for details on how to access
these features.
FEEDBACK
ATI welcomes feedback regarding this Review Module.
Please provide comments to comments@atitesting.com.
As needed updates to the Review Modules are identified,

changes to the text are made for subsequent printings
of the book and for subsequent releases of the electronic
version. For the printed books, print runs are based
on when existing stock is depleted. For the electronic
versions, a number of factors influence the update
schedule. As such, ATI encourages faculty and students to
refer to the Review Module addendums for information on
what updates have been made. These addendums, which
are available in the Help/FAQs on the student site and the
Resources/eBooks & Active Learning on the faculty site,
are updated regularly and always include the most current
information on updates to the Review Modules.
IV USER’S GUIDE CONTENT MASTERY SERIES

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Table of Contents
NCLEX® Connections 1
UNIT 1 Pharmacological Principles 3

CHAPTER 1 Pharmacokinetics and Routes of Administration 3
CHAPTER 2 Safe Medication Administration and Error Reduction 11
CHAPTER 3 Dosage Calculation 19
CHAPTER 4 Intravenous Therapy 35
CHAPTER 5 Adverse Effects, Interactions, and Contraindications 39
CHAPTER 6 Individual Considerations of Medication Administration 45
UNIT 2 Medications Affecting the Nervous System 51

CHAPTER 7 Anxiety and Trauma- and Stressor-Related Disorders 51
CHAPTER 8 Depressive Disorders 57
CHAPTER 9 Bipolar Disorders 67
CHAPTER 10 Psychotic Disorders 73
CHAPTER 11 Medications for Children and Adolescents Who Have Mental Health Issues 81
CHAPTER 12 Substance Use Disorders 91
CHAPTER 13 Chronic Neurologic Disorders 97
CHAPTER 14 Eye and Ear Disorders 109
Eye disorders 109
Ear disorders 113
CHAPTER 15 Miscellaneous Central Nervous System Medications 117
CHAPTER 16 Sedative-Hypnotics 123
RN PHARMACOLOGY FOR NURSING TABLE OF CONTENTS V

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UNIT 3 Medications Affecting the Respiratory

System 131
CHAPTER 17 Airflow Disorders 131
CHAPTER 18 Upper Respiratory Disorders 139
UNIT 4 Medications Affecting the Cardiovascular

System 147
CHAPTER 19 Medications Affecting Urinary Output 147
CHAPTER 20 Medications Affecting Blood Pressure 155
CHAPTER 21 Cardiac Glycosides and Heart Failure 167
CHAPTER 22 Angina 173
CHAPTER 23 Medications Affecting Cardiac Rhythm 177
CHAPTER 24 Antilipemic Agents 185
UNIT 5 Medications Affecting the Hematologic

System 193
CHAPTER 25 Medications Affecting Coagulation 193
CHAPTER 26 Growth Factors 205
CHAPTER 27 Blood and Blood Products 211
VI TABLE OF CONTENTS CONTENT MASTERY SERIES

UNIT 6 Medications Affecting the Gastrointestinal

System and Nutrition 219
CHAPTER 28 Peptic Ulcer Disease 219
CHAPTER 29 Gastrointestinal Disorders 225
CHAPTER 30 Vitamins and Minerals 235
UNIT 7 Medications Affecting the Reproductive

System 245
CHAPTER 31 Medications Affecting the Reproductive Tract 245
CHAPTER 32 Medications Affecting Labor and Delivery 255
UNIT 8 Medications for Joint and Bone

Conditions 265
CHAPTER 33 Connective Tissue Disorders 265
CHAPTER 34 Bone Disorders 275
UNIT 9 Medications for Pain and Inflammation 283

CHAPTER 35 Non-Opioid Analgesics 283
CHAPTER 36 Opioid Agonists and Antagonists 287
CHAPTER 37 Adjuvant Medications for Pain 293
CHAPTER 38 Miscellaneous Pain Medications 299
RN PHARMACOLOGY FOR NURSING TABLE OF CONTENTS VII

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UNIT 10 Medications Affecting the Endocrine

System 309
CHAPTER 39 Diabetes Mellitus 309
CHAPTER 40 Endocrine Disorders 319
UNIT 11 Medications Affecting the Immune System 331

CHAPTER 41 Immunizations 331
CHAPTER 42 Chemotherapy Agents 337
Cytotoxic chemotherapy agents 337
Noncytotoxic chemotherapy agents 347
UNIT 12 Medications for Infection 357

CHAPTER 43 Principles of Antimicrobial Therapy 357
CHAPTER 44 Antibiotics Affecting the Bacterial Cell Wall 361
CHAPTER 45 Antibiotics Affecting Protein Synthesis 367
CHAPTER 46 Urinary Tract Infections 373
CHAPTER 47 Mycobacterial, Fungal, and Parasitic Infections 379
CHAPTER 48 Viral Infections, HIV, and AIDS 385
VIII TABLE OF CONTENTS CONTENT MASTERY SERIES

UNIT 13 Other Medications 395

CHAPTER 49 Complementary, Alternative, and Integrative Therapies 395
References 401
Active Learning Templates A1

Basic Concept A1
Diagnostic Procedure A3
Growth and Development A5
Medication A7
Nursing Skill A9
System Disorder A11
Therapeutic Procedure A13
Concept Analysis A15
RN PHARMACOLOGY FOR NURSING TABLE OF CONTENTS IX

X TABLE OF CONTENTS CONTENT MASTERY SERIES

07/24/15 April 19, 2019 9:51 AM rm_rn_2019_pharm_unit1
NCLEX® Connections
When reviewing the following chapters, keep in mind the
relevant topics and tasks of the NCLEX outline, in particular:
Management of Care
CLIENT RIGHTS: Recognize the client’s right
to refuse treatment/procedures.
Pharmacological and Parenteral Therapies

ADVERSE EFFECTS/CONTRAINDICATIONS/
SIDE EFFECTS/INTERACTIONS
Identify a contraindication to the administration
of a medication to the client.
Notify the primary health care provider of side effects, adverse effects
and contraindications of medications and parenteral therapy.
DOSAGE CALCULATION
Perform calculations needed for medication administration.
Use clinical decision making/critical thinking when calculating dosages.
MEDICATION ADMINISTRATION
Prepare and administer medications, using
rights of medication administration.
Evaluate appropriateness and accuracy of medication order for client.
Administer and document medications given
by common routes (e.g., oral, topical).
PARENTERAL/INTRAVENOUS THERAPIES: Apply knowledge and

concepts of mathematics/nursing procedures/psychomotor skills when
caring for a client receiving intravenous and parenteral therapy.
RN PHARMACOLOGY FOR NURSING NCLEX® CONNECTIONS 1

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2 NCLEX® CONNECTIONS CONTENT MASTERY SERIES

07/24/15 April 15, 2019 3:31 PM rm_rn_2019_pharm_chp1
CHAPTER 1
UNIT 1 PHARMACOLOGICAL PRINCIPLES Inhalation via mouth, nose
CHAPTER 1 Pharmacokinetics BARRIERS TO ABSORPTION: Inspiratory effort
and Routes of ABSORPTION PATTERN: Rapid absorption through alveolar

capillary networks
Administration Intradermal, topical

BARRIERS TO ABSORPTION: Close proximity of
Pharmacokinetics refers to how medications epidermal cells
travel through the body. They undergo a variety ABSORPTION PATTERN

Slow, gradual absorption
of biochemical processes that result in absorption,
●
● Effects primarily local, but systemic as well, especially

distribution, metabolism, and excretion. with lipid-soluble medications passing through
subcutaneous fatty tissue
PHASES OF PHARMACOKINETICS Subcutaneous, intramuscular

BARRIERS TO ABSORPTION: Capillary walls have
ABSORPTION large spaces between cells. Therefore, there is no
significant barrier.
Absorption is the transmission of medications from the
location of administration (gastrointestinal [GI] tract, ABSORPTION PATTERN
muscle, skin, mucous membranes, or subcutaneous ● Solubility of the medication in water: Highly soluble
tissue) to the bloodstream. The most common routes of medications have rapid absorption (10 to 30 min); poorly
administration are enteral (through the GI tract) and soluble medications have slow absorption.
parenteral (by injection). Each of these routes has a unique ● Blood perfusion at the site of injection: sites with high
pattern of absorption. blood perfusion have rapid absorption; sites with low
● The rate of medication absorption determines how soon blood perfusion have slow absorption.
the medication will take effect.
● The amount of medication the body absorbs determines Intravenous
the intensity of its effects.
BARRIERS TO ABSORPTION: No barriers
● The route of administration affects the rate and amount
of absorption. ABSORPTION PATTERN
● Immediate: enters directly into the blood
Oral ● Complete: reaches the blood in its entirety
BARRIERS TO ABSORPTION: Medications must pass

through the layer of epithelial cells that line the GI tract. DISTRIBUTION
ABSORPTION PATTERN: Varies greatly due to: Distribution is the transportation of medications to sites
● Stability and solubility of the medication of action by bodily fluids. Factors influencing distribution
● GI pH and emptying time include the following.
● Presence of food in the stomach or intestines
Circulation: Conditions that inhibit blood flow or
● Other concurrent medications
perfusion, such as peripheral vascular or cardiac disease,
● Forms of medications (enteric-coated pills, liquids)
can delay medication distribution.
Sublingual, buccal Permeability of the cell membrane: The medication must

be able to pass through tissues and membranes to reach
BARRIERS TO ABSORPTION: Swallowing before dissolution
its target area. Medications that are lipid-soluble or have
allows gastric pH to inactivate the medication.
a transport system can cross the blood-brain barrier and
ABSORPTION PATTERN: Quick absorption systemically the placenta.
through highly vascular mucous membranes
Plasma protein binding: Medications compete for protein
binding sites within the bloodstream, primarily albumin.
Other mucous membranes (rectal, vaginal)
The ability of a medication to bind to a protein can affect
BARRIERS TO ABSORPTION: Presence of stool in the how much of the medication will leave and travel to
rectum or infectious material in the vagina limits target tissues. Two medications can compete for the same
tissue contact. binding sites, resulting in toxicity.
ABSORPTION PATTERN: Easy absorption with both local

and systemic effects
RN PHARMACOLOGY FOR NURSING CHAPTER 1 PHARMACOKINETICS AND ROUTES OF ADMINISTRATION 3

07/24/15 April 15, 2019 3:31 PM rm_rn_2019_pharm_chp1 07/24
METABOLISM THERAPEUTIC INDEX

Metabolism (biotransformation) changes medications into Medications with a high therapeutic index (TI) have a
less active or inactive forms by the action of enzymes. wide safety margin. Therefore, there is no need for routine
This occurs primarily in the liver, but it also takes place in blood medication-level monitoring. Medications with
the kidneys, lungs, intestines, and blood. a low TI require close monitoring of medication levels.
Nurses should consider the route of administration when
FACTORS INFLUENCING THE RATE OF MEDICATION
monitoring for peak levels (highest plasma level when
METABOLISM
elimination = absorption). For example, an oral medication
● Age: Infants have a limited medication-metabolizing
can peak from 1 to 3 hr after administration. If the route
capacity. The aging process also can influence medication
is IV, the peak time might occur within 10 min. (Refer to
metabolism, but varies with the individual. In general,
a drug reference or a pharmacist for specific medication
hepatic medication metabolism tends to decline with age.
peak times.) For trough levels, obtain a blood sample
Older adults require smaller doses of medications due to
immediately before the next medication dose, regardless
the possibility of accumulation in the body.
of the route of administration. A plateau is a medication’s
● Increase in some medication-metabolizing enzymes:
concentration in plasma during a series of doses.
This can metabolize a particular medication sooner,
requiring an increase in dosage of that medication to
maintain a therapeutic level. It can also cause an increase
HALF-LIFE
in the metabolism of other concurrent-use medications. Half-life (t½) refers to the time for the medication in
● First‑pass effect: The liver inactivates some the body to drop by 50%. Liver and kidney function
medications on their first pass through the liver, and affect half-life. It usually takes four half-lives to
thus they require a nonenteral route (sublingual, IV) achieve a steady blood concentration (medication
because of their high first-pass effect. intake = medication metabolism and excretion).
● Similar metabolic pathways: When the same
SHORT HALF-LIFE
pathway metabolizes two medications, it can alter the ● Medications leave the body quickly (4 to 8 hr).
metabolism of one or both of them. In this way, the ● Short-dosing interval or MEC drops between doses.
rate of metabolism can decrease for one or both of the
medications, leading to medication accumulation. LONG HALF-LIFE
● Nutritional status: Clients who are malnourished can ● Medications leave the body more slowly: over more than
be deficient in the factors that are necessary to produce 24 hr, with a greater risk for medication accumulation
specific medication-metabolizing enzymes, thus and toxicity.
impairing medication metabolism. ● Medications can be given at longer intervals without
loss of therapeutic effects.
OUTCOMES OF METABOLISM ● Medications take a longer time to reach a steady state.
● Increased renal excretion of medication
● Inactivation of medications
● Increased therapeutic effect PHARMACODYNAMICS
● Activation of pro-medications (also called pro-drugs)
Pharmacodynamics describes the interactions between
into active forms
medications and target cells, body systems, and organs
● Decreased toxicity when active forms of medications
to produce effects. These interactions result in functional
become inactive forms
changes that are the mechanism of action of the
● Increased toxicity when inactive forms of medications
medication. Medications interact with cells in one of two
become active forms
ways or in both ways.
Agonists are medications that bind to or mimic the

EXCRETION receptor activity that endogenous compounds regulate. For
Excretion is the elimination of medications from the body, example, morphine is an agonist because it activates the
primarily through the kidneys. Elimination also takes receptors that produce analgesia, sedation, constipation,
place through the liver, lungs, intestines, and exocrine and other effects. (Receptors are the medication’s target
glands (such as in breast milk). Kidney dysfunction can sites on or within the cells.)
lead to an increase in the duration and intensity of a
Antagonists are medications that can block the usual
medication’s response, so it is important to monitor BUN
receptor activity that endogenous compounds regulate or
and creatinine levels.
the receptor activity of other medications. For example,
losartan, an angiotensin II receptor blocker, is an
MEDICATION RESPONSES antagonist. It works by blocking angiotensin II receptors
on blood vessels, which prevents vasoconstriction.
Medication dosing attempts to regulate medication
responses to maintain plasma levels between the minimum Partial agonists act as agonists and antagonists, with
effective concentration (MEC) and the toxic concentration. limited affinity to receptor sites. For example, nalbuphine
A plasma medication level is in the therapeutic range when acts as an antagonist at mu receptors and an agonist
it is effective and not toxic. Nurses use therapeutic levels of at kappa receptors, causing analgesia with minimal
many medications to monitor clients’ responses. respiratory depression at low doses.
4 CHAPTER 1 PHARMACOKINETICS AND ROUTES OF ADMINISTRATION CONTENT MASTERY SERIES

Routes of administration TOPICAL

Medications directly applied to the mucous membranes or
skin. Includes powders, sprays, creams, ointments, pastes,
ORAL OR ENTERAL oil-and suspension-based lotions.
● Painless
Tablets, capsules, liquids, ● Limited adverse effects
suspensions, elixirs, lozenges
NURSING ACTIONS
Most common route ● Apply with a glove, tongue blade, or cotton-tipped applicator.
● Do not apply with a bare hand.
NURSING ACTIONS ● For skin applications, wash the skin with soap and
● Contraindications for oral medication administration
water. Pat dry before application.
include vomiting, decreased GI motility, absence of a ● Use surgical asepsis to apply topical medications to
gag reflex, difficulty swallowing, and a decreased level
open wounds.
of consciousness.
Have clients sit upright at a 90° angle to
Transdermal
●
facilitate swallowing.
● Administer irritating medications, such as analgesics, Medication in a skin patch for absorption through the
with small amounts of food. skin, producing systemic effects
● Do not mix with large amounts of food or beverages in
CLIENT EDUCATION
case clients cannot consume the entire quantity. ● Apply patches to ensure proper dosing.
● Avoid administration with interacting foods or ● Wash the skin with soap and water, and dry it
beverages, such as grapefruit juice.
thoroughly before applying a new patch.
● Administer oral medications as prescribed, and follow ● Place the patch on a hairless area, and rotate sites daily
directions for whether medication is to be taken on an
to prevent skin irritation.
empty stomach (30 min to 1 hr before meals, 2 hr after
meals) or with food.
Eye
● Follow the manufacturer’s directions for crushing,
cutting, and diluting medications. Break or cut scored ● Have clients sit upright or lie supine, tilt their head
tablets only. (See the Institute for Safe Medication slightly, and look up at the ceiling.
Practices website.) ● Rest your dominant hand on the clients’ forehead, hold the
● Make sure clients swallow enteric-coated or dropper above the conjunctival sac about 1 to 2 cm, drop
time-release medications whole. the medication into the sac, avoid placing it directly on the
● Use a liquid form of the medication to facilitate cornea, and have them close the eye gently. If they blink
swallowing whenever possible. during instillation, repeat the procedure.
● For liquids, including suspension and elixirs, follow ● Apply gentle pressure with your finger and a clean facial
directions for dilution and shaking. To prepare the tissue on the nasolacrimal duct for 30 to 60 seconds to
medication, place a medicine cup on a flat surface before prevent systemic absorption of the medication.
pouring, and ensure the base of the meniscus (lowest ● If instilling more than one medication in the same eye,
fluid line) is at the level of the dose. wait at least 5 min between them.
● For eye ointment, apply a thin ribbon to the edge of the
ADVANTAGES
lower eyelid from the inner to the outer canthus.
● Safe
Inexpensive
Ear
●
● Easy and convenient

● Have clients sit upright or lie on their side.
DISADVANTAGES ● Straighten the ear canal by pulling the auricle upward and
● Oral medications have highly variable absorption.
outward for adults or down and back for children less than
● Inactivation can occur in the GI tract or by
3 years of age. Hold the dropper 1 cm above the ear canal,
first-pass effect.
instill the medication, and then gently apply pressure with
● Clients must be cooperative and conscious.
your finger to the tragus of the ear unless it is too painful.
Do not press a cotton ball deep into the ear canal. If
Sublingual and buccal
●
necessary, gently place it into the outermost part of the

Sublingual: under the tongue ear canal.
● Have clients remain in the side-lying position if
Buccal: between the cheek and the gum
possible for 2 to 3 min after instilling ear drops.
Directly enters the bloodstream and bypasses the liver
CLIENT EDUCATION
● Keep the medication in place until complete
absorption occurs.
● Do not eat or drink while the tablet is in place or until it
has completely dissolved.

Nose ● Hold your breath for 10 seconds to allow the medication

to deposit in your airways.
● Use medical aseptic technique when administering ● Take the inhaler out of your mouth and slowly exhale
medications into the nose.
through pursed lips.
● Have clients lie supine with their head positioned to allow ● Resume normal breathing.
the medication to enter the appropriate nasal passage. ● A spacer keeps the medication in the device longer,
● Use your dominant hand to instill nasal drops,
thereby increasing the amount of medication the device
supporting the head with your nondominant hand.
delivers to the lungs and decreasing the amount of
● Instruct clients to breathe through the mouth, stay in a
medication in the oropharynx.
supine position, and not blow their nose for 5 min after ● If using a spacer:
drop instillation. ◯ Remove the covers from the mouthpieces of the
● For nasal spray, prime the spray if indicated, insert tip into
inhaler and of the spacer.
nare, and point nozzle away from the center of the nose. ◯ Insert the MDI into the end of the spacer.
● Spray into nose while the client inhales. Instruct the ◯ Shake the inhaler five or six times.
client not to blow their nose for several minutes. ◯ Exhale completely, and then close your mouth around
the spacer’s mouthpiece. Continue as with an MDI.

Rectal suppositories
● Position clients in the left lateral position or DPI
Sims’ position.
CLIENT EDUCATION
● Insert the suppository just beyond the internal sphincter. ● Do not shake the device.
● Instruct clients to remain flat or in the left lateral ● Take the cover off the mouthpiece.
position for at least 5 min after insertion to retain the ● Follow the manufacturer’s directions for preparing the
suppository. Absorption times vary with the medication.
medication, such as turning the wheel of the inhaler or
loading a medication pellet.
Vaginal ● Exhale completely.
● Position clients supine with their knees bent and their ● Place the mouthpiece between your lips and take a deep
feet flat on the bed and close to their hips (modified inhalation breath through your mouth.
lithotomy or dorsal recumbent position). ● Hold your breath for 5 to 10 seconds.
● Provide perineal care, if needed. ● Take the inhaler out of your mouth and slowly exhale
● Lubricate the suppository or fill the applicator, through pursed lips.
depending on the formulation. ● Resume normal breathing.
● Insert the medication along the posterior wall of ● If more than one puff is needed, wait the length of time
the vagina (7.5 to 10 cm [3 to 4 in] for suppositories; the provider specifies before self-administering the
5 to 7.6 cm [2 to 3 in] for creams, jellies or foams) or second puff.
instill irrigation as indicated. ● Rinse the mouth out with water or brush the teeth
● Instruct clients to remain supine for at least 5 min after if using a corticosteroid inhaler to reduce the risk of
insertion to retain the suppository. fungal infections of the mouth.
● If using a reusable applicator, wash it with soap and ● Remove the canister and rinse the inhaler, cap, and
water. (If it is disposable, discard it.) spacer once a day with warm running water and dry
them completely before using the inhaler again.
INHALATION Nasogastric and gastrostomy tubes

Administered through metered dose inhalers (MDI) or ● Use liquid forms of medications; if not available, consider
dry-powder inhalers (DPI)
crushing medications if appropriate guidelines allow.
MDI ● Do not administer sublingual medications through the NG
tube (can give sublingual medications under the tongue).
CLIENT EDUCATION ● Do not crush specifically-prepared oral medications
● Remove the cap from the inhaler’s mouthpiece.
(extended/time-release, fluid-filled, enteric-coated).
● Shake the inhaler vigorously five or six times. ● Administer each medication separately.
● Hold the inhaler with the mouthpiece at the bottom. ● Do not mix medications with enteral feedings.
● Hold the inhaler with your thumb near the mouthpiece ● Completely dissolve crushed tablets and capsule contents
and your index and middle fingers at the top.
in 15 to 30 mL of sterile water prior to administration.
● Hold the inhaler about 2 to 4 cm (1 to 2 in) away from
the front of your mouth or close your mouth around the NURSING ACTIONS
mouthpiece of the inhaler with the opening pointing ● Verify proper tube placement.
toward the back of your throat. ● Use a syringe and allow the medication to flow in by
● Take a deep breath and then exhale. gravity or push it in with the plunger of the syringe.
● Tilt your head back slightly, press the inhaler, and, at ● To prevent clogging, flush the tubing before and after
the same time, begin a slow, deep inhalation breath. each medication with 15 to 30 mL of sterile water.
Continue to breathe in slowly and deeply for 3 to ● Flush with another 15 to 30 mL of warm sterile water
5 seconds to facilitate delivery to the air passages. after instilling all the medications.

PARENTERAL ADVANTAGES
● Use for poorly soluble medications.
NURSING ACTIONS ● Use for administering medications that have
● The vastus lateralis is best for infants 1 year
slow absorption for an extended period of time
and younger.
(depot preparations).
● The ventrogluteal site is preferable for IM injections and
for injecting volumes exceeding 2 mL. DISADVANTAGES
● The deltoid site has a smaller muscle mass and can only ● Injections are more costly.
accommodate up to 1 mL of fluid. ● Injections are inconvenient.
● Use a needle size and length appropriate for the type ● There can be pain with the risk for local tissue damage
of injection and the client’s size. Syringe size should and nerve damage.
approximate the volume of medication. ● There is a risk for infection at the injection site.
● Use a tuberculin syringe for solution volumes smaller
than 0.5 mL.
● Rotate injection sites to enhance medication absorption,
INTRAVENOUS
and document each site. NURSING ACTIONS
● Do not use injection sites that are edematous, inflamed, ● Use for administering medications, fluid, and
or have moles, birthmarks, or scars. blood products.
● For IV administration, immediately monitor clients for ● Vascular access devices can be for short-term use
therapeutic and adverse effects. (catheters) or long-term use (infusion ports). Use
● Discard all sharps (broken ampule bottles, needles) in 16-gauge devices for clients who have trauma, 18-gauge
leak- and puncture-proof containers. during surgery and for blood administration, and
22- to 24-gauge for children, older adults, and clients
who have medical issues or are stable postoperatively.
INTRADERMAL ● Peripheral veins in the arm or hand are preferable. Ask
NURSING ACTIONS clients which site they prefer. For newborns, use veins
● Use for tuberculin testing or checking for medication or in the head, lower legs, and feet. After administration,
allergy sensitivities. immediately monitor for therapeutic and adverse effects.
● Use small amounts of solution (0.01 to 0.1 mL) in ● Use the Z-track technique for IM injections of
a tuberculin syringe with a fine-gauge needle irritating fluids or fluids that can stain the skin (iron
(26- to 27-gauge) in lightly pigmented, thin-skinned, preparations). This method prevents medication from
hairless sites (the inner surface of the mid-forearm or leaking back into subcutaneous tissue.
scapular area of the back) at a 10° to 15° angle.
ADVANTAGES
● Insert the needle with the bevel up. A small bleb ● Onset is rapid, and absorption into the blood is
should appear.
immediate, which provides an immediate response.
● Do not massage the site after injection. ● This route allows control over the precise amount of
medication to administer.
SUBCUTANEOUS AND INTRAMUSCULAR ● It allows for administration of large volumes of fluid.
● It dilutes irritating medications in free-flowing IV fluid.
NURSING ACTIONS
DISADVANTAGES
Subcutaneous ● IV injections are even more costly.
● Use for small doses of nonirritating, water-soluble ● IV injections are inconvenient.
medications, such as insulin and heparin. ● Absorption of the medication into the blood is
● Use a 3/8- to 5/8-inch, 25- to 27-gauge needle or a
immediate. This is potentially dangerous if giving the
28- to 31-gauge insulin syringe. Inject no more than
wrong dosage or the wrong medication.
1.5 mL of solution. ● There is an increased risk for infection or embolism
● Select sites that have an adequate fat-pad size (abdomen,
with IV injections.
upper hips, lateral upper arms, thighs). ● Poor circulation can inhibit the medication’s distribution.
● For average-size clients, pinch up the skin and inject
at a 45° to 90° angle. For clients who are obese, use
a 90° angle. EPIDURAL
Intramuscular NURSING ACTIONS
● Use for irritating medications, solutions in oils, and ● Use for IV opioid analgesia (morphine or fentanyl).
aqueous suspensions. ● The clinician advances the catheter through the needle
● The most common sites are ventrogluteal, deltoid, and into the epidural space at the level of the fourth or
vastus lateralis (pediatric). The dorsogluteal is no longer fifth vertebra.
recommended as a common injection site due to its ● Use an infusion pump to administer medication.
close proximity to the sciatic nerve.
● Use a needle size 18- to 27-gauge (usually
22- to 25-gauge), 1- to 1.5-inch long, and inject at a 90°
angle. Solution volume is usually 1 to 3 mL. Divide larger
volumes into two syringes and use two different sites.

Application Exercises Active Learning Scenario
1. A provider prescribes phenobarbital for a client who A nurse is showing a client how to use a metered-dose
has a seizure disorder. The medication has a long inhaler (MDI) with a spacer. What should the nurse
half-life of 4 days. How many times per day should include in the instructions? Use the ATI Active Learning
the nurse expect to administer this medication? Template: Therapeutic Procedure to complete this item.
A. One INDICATIONS: Identify the medication absorption

B. Two pattern and a barrier to absorption.
C. Three CLIENT EDUCATION: Describe the steps to
D. Four follow when using an MDI with a spacer.
2. A nurse educator is reviewing medication

metabolism at an in-service presentation.
Which of the following factors should the
educator include as a reason to administer lower
medication dosages? (Select all that apply.)
A. Increased renal excretion
B. Increased medication-metabolizing enzymes
C. Liver failure
D. Peripheral vascular disease
E. Concurrent use of medication the
same pathway metabolizes
3. A nurse is preparing to administer eye drops to

a client. Which of the following actions should
the nurse take? (Select all that apply.)
A. Have the client lie on one side.
B. Ask the client to look up at the ceiling.
C. Tell the client to blink when the drops enter the eye.
D. Drop the medication into the
client’s conjunctival sac.
E. Instruct the client to close the eye
gently after instillation.
4. A nurse is teaching a client about transdermal patches.

Which of the following statements should the nurse
identify as an indication that the client understands?
A. “I will clean the site with an alcohol
swab before I apply the patch.”
B. “I will rotate the application sites weekly.”
C. “I will apply the patch to an area
of skin with no hair.”
D. “I will place the new patch on
the site of the old patch.”
5. A nurse reviewing a client’s medical record

notes a new prescription for verifying the trough
level of the client’s medication. Which of the
following actions should the nurse take?
A. Obtain a blood specimen immediately prior to
administering the next dose of medication.
B. Verify that the client has been taking
the medication for 24 hr before
obtaining a blood specimen.
C. Ask the client to provide a urine specimen
after the next dose of medication.
D. Administer the medication, and obtain
a blood specimen 30 min later.

Application Exercises Key Active Learning Scenario Key

1. A. CORRECT: Medications with long half-lives remain Using the ATI Active Learning Template: Therapeutic Procedure
at their therapeutic levels between doses for INDICATIONS
long periods of time. The nurse should expect to ●
Medication Absorption Pattern: rapid absorption through
administer this medication once a day.
the alveolar capillary network. A spacer keeps the
B. Medications with long half-lives remain at their therapeutic
medication in the device longer, thereby increasing the
levels between doses for long periods of time. A
amount of medication the device delivers to the lungs and
medication the nurse administers twice a day would
decreasing the amount of medication in the oropharynx.
have a shorter half-life. An example is vancomycin.
C. Medications with long half-lives remain at their therapeutic
●
Barrier to Absorption: Inadequate respiratory effort
levels between doses for long periods of time. A CLIENT EDUCATION
medication the nurse administers three times a day would ●
Remove the covers from the mouthpieces
have a shorter half-life. An example is zidovudine. of the inhaler and of the spacer.
D. Medications with long half-lives remain at their therapeutic ●
Insert the MDI into the end of the spacer.
levels between doses for long periods of time. A ●
Shake the inhaler five or six times.
medication the nurse administers four times a day would
have a shorter half-life. An example is ibuprofen.
●
Exhale completely, and then close your mouth
around the spacer’s mouthpiece.
NCLEX Connection: Pharmacological and Parenteral Therapies,
®
●
Take a deep breath and then exhale.
Medication Administration ●
Tilt your head back slightly, press the inhaler, and, at
the same time, begin a slow, deep inhalation breath.
2. A. Increased renal excretion decreases the concentration of Continue to breathe in slowly and deeply for 3 to 5 seconds
the medication, requiring an increased dosage. to facilitate delivery to the air passages.
B. Increased medication-metabolizing enzymes
●
Hold your breath for 10 seconds to allow the
decrease the concentration of the medication, medication to deposit in your airways.
requiring an increased dosage. ●
Take the mouthpiece out of your mouth and
C. CORRECT: Liver failure decreases metabolism and slowly exhale through pursed lips.
thus increases the concentration of a medication. ●
Resume normal breathing.
This requires decreasing the dosage.
NCLEX® Connection: Pharmacological and Parenteral Therapies,
D. Peripheral vascular disease impairs distribution,
Medication Administration
requiring an increased dosage.
E. CORRECT: When the same pathway metabolizes two
medications, they compete for metabolism, thereby
increasing the concentration of one or both medications. This
requires decreasing the dosage of one or both medications.
Adverse Effects/Contraindications/Side Effects/Interactions
3. A. The client should be sitting or in a supine position

to facilitate the instillation of eye drops.
B. CORRECT: The client should look upward to keep
the drops from falling onto the cornea.
C. Ideally, the client should not blink so that they do not eject
the eye drops. If they do blink, repeat the instillation.
D. CORRECT: Drop the medication into the
conjunctival sac to promote distribution.
E. CORRECT: The client should close the eye gently
to promote distribution of the medication.
4. A. The client should wash their skin with soap and water and
dry it thoroughly before applying a transdermal patch.
B. The client should rotate application sites
daily to prevent skin irritation.
C. CORRECT: The client should apply the patch to a hairless
area of skin to promote absorption of the medication.
D. The client should rotate application sites
daily to prevent skin irritation.
5. A. CORRECT: To verify trough levels of a medication, the

nurse should obtain a blood specimen immediately before
administering the next dose of medication.
B. The length of time the client has been taking the
medication does not affect trough levels.
C. Trough levels are measured from the blood, not urine.
D. Trough levels reflect the least concentration of the
medication in the client’s blood. It will be higher
after administration of the medication.
Parenteral/Intravenous Therapies


CHAPTER 2
UNIT 1 PHARMACOLOGICAL PRINCIPLES MEDICATION CATEGORY
CHAPTER 2 Safe Medication AND CLASSIFICATION
Administration and NOMENCLATURE

Error Reduction Chemical name is the name of the medication that
reflects its chemical composition and molecular structure
(isobutylphenylpropanoic acid).
The providers who can legally write prescriptions Generic name is the official or nonproprietary name the
United States Adopted Names Council gives a medication.
in the United States include physicians, advanced
Each medication has only one generic name (ibuprofen).
practice nurses, dentists, and physician
Trade name is the brand or proprietary name the company
assistants. These providers are responsible for that manufactures the medication gives it. One medication
can have multiple trade names (Advil, Motrin).
obtaining clients’ medical history, performing a
physical examination, diagnosing, prescribing CONSIDERATIONS
medications, monitoring response to therapy, Nurses administer prescription medications under the
and modifying prescriptions as necessary. supervision of providers. Some medications can be
habit-forming, or have potential harmful effects and
Nurses are responsible for having knowledge require more stringent supervision.
of federal, state (nurse practice act), and local Uncontrolled substances require monitoring by a provider,
but do not generally pose risks of misuse and addiction.
laws, and facilities’ policies that govern Antibiotics are an example of uncontrolled prescription
prescribing and dispensing medications; medications.
preparing and administering medications; and Controlled substances have a potential for misuse and
dependence and have a “Schedule” classification. Heroin is
evaluating clients’ responses to medications.
in Schedule I and has no medical use in the United States.
Nurses should develop and maintain an Medications in Schedules II through V have legitimate
applications. Each subsequent level has a decreasing risk
up-to-date knowledge base of medications they
of misuse and dependence. For example, morphine is a
administer, including uses, mechanisms of action, Schedule II medication that has a greater risk for misuse
and dependence than phenobarbital, which is a Schedule
routes of administration, safe dosage range,
IV medication.
adverse effects, precautions, contraindications,
and interactions. Nurses can help reduce adverse FDA REGULATIONS
events related to medications by determining the ● New drugs in development undergo the rigorous testing
procedures of the U.S. Food and Drug Administration
accuracy of medication prescriptions, reporting (FDA) to determine both effectiveness and safety before
all medication errors, safeguarding and storing approval. However, new drugs can have unidentified or
unreported adverse effects. Nurses observing these can
medications, following legal mandates when report them to MedWatch on the FDA’s website.
administering controlled substances, calculating ● The FDA’s Pregnancy Risk Categories (A, B, C, D, X)
have previously classified medications according to
medication doses accurately, and understanding their potential harm during pregnancy, with Category
the responsibilities of other members of the A being the safest and Category X the most dangerous.
Teratogenesis from unsafe medications is most likely to
health care team regarding medications. occur during the first trimester. Before administering
any medication to a client who is pregnant or could
be pregnant, determine whether it is safe for use
during pregnancy.
● FDA labeling requirements implemented in 2015 require
medication manufacturers to include guidance for
administration to clients who are pregnant, lactating, or
of reproductive potential.
RN PHARMACOLOGY FOR NURSING CHAPTER 2 SAFE MEDICATION ADMINISTRATION AND ERROR REDUCTION 11
MEDICATION PRESCRIPTIONS Components of a medication prescription
Each facility has written policies for medication ● Client’s full name
prescriptions, including which providers can write, receive, ● Date and time of the prescription
and transcribe medication prescriptions. ● Name of the medication (generic or brand)
● Strength and dosage of the medication
Use verbal prescriptions only for emergencies, and follow ● Route of administration
the facility’s protocol for telephone prescriptions. Nursing ● Time and frequency of administration: exact times or
students cannot accept verbal or telephone orders.
number of times per day (according to the facility’s
policy or the specific qualities of the medication)
Types of medication prescriptions ● Quantity to dispense and the number of refills
Routine or standing prescriptions ● Signature of the prescribing provider
Single or one-time prescriptions

Medication reconciliation
Stat prescriptions
The Joint Commission requires policies and procedures for
PRN prescriptions medication reconciliation. Nurses compile a list of each
client’s current medications, including all medications
with their dosages and frequency. They compare the list
with new medication prescriptions and reconcile it with
the provider to resolve any discrepancies. This process
should take place at admission, when transferring clients
between units or facilities, and at discharge.
2.1 Knowledge required prior to medication administration
Medication category/class Toxic effects Precautions/

Medications have a pharmacological Medications can have specific risks and Contraindications
action, therapeutic use, body system manifestations of toxicity. They develop These are conditions (diseases, age,
target, chemical makeup, and after taking a medication for a lengthy pregnancy, lactation) that make it
classification for use during pregnancy. period of time or when toxic amounts build risky or completely unsafe for clients
For example, lisinopril is an ACE up due to faulty metabolism or excretion. to take specific medications.
inhibitor (pharmacological action) and For example, nurses monitor clients For example, tetracyclines can stain
an antihypertensive (therapeutic use). taking digoxin for dysrhythmias, developing teeth. Therefore, children
a manifestation of cardiotoxicity.
Mechanism of action Hypokalemia places these clients at
younger than 8 years should not take these
medications. Another example is that
greater risk for digoxin toxicity. myasthenia gravis is a contraindication
This is how medications produce
their therapeutic effect.
Medication interactions for fentanyl, an opioid analgesic.
For example, glipizide is an oral Some medications require caution
hypoglycemic agent that lowers blood Medications can interact with each other, with some conditions.
glucose levels primarily by stimulating resulting in beneficial or harmful effects.
For example, the kidneys excrete
pancreatic islet cells to release insulin. For example, giving the beta blocker vancomycin without changing it. Therefore,
atenolol concurrently with the renal impairment requires caution
Therapeutic effect calcium channel blocker nifedipine when administering this medication.
helps prevent reflex tachycardia.
This is the expected effect (physiological
response) for which the nurse An example of an undesirable interaction Preparation, dosage,
administers a medication to a specific is giving omeprazole, a proton pump
inhibitor, concurrently with phenytoin,
administration
client. One medication can have
more than one therapeutic effect. an anticonvulsant. This can increase It is important to know any specific
the blood level of phenytoin. considerations for preparation, safe
One client might take diphenhydramine dosages, dosage calculations, and
to relieve allergies while another Obtain a complete medication
history, and be knowledgeable of how to administer the medication.
takes it to induce sleep.
clinically significant interactions. For example, morphine is available in many
Adverse effects Be aware that medications can also formulations. Oral doses of morphine are
generally higher than parenteral doses
These are undesirable and potentially interact beneficially or harmfully with food
and with herbal and dietary supplements. due to extensive first-pass effect. Clients
dangerous responses to a medication. who have chronic, severe pain (cancer)
For example, the antibiotic gentamicin generally take oral doses of morphine.
can cause hearing loss. Adverse effects
can be inadvertent or predictable. Some Nursing implications
adverse effects are immediate and others
take weeks or months to develop. Know how to monitor therapeutic
effects and adverse effects, prevent
and treat adverse effects, provide
comfort, and instruct clients about
the safe use of medications.
12 CHAPTER 2 SAFE MEDICATION ADMINISTRATION AND ERROR REDUCTION CONTENT MASTERY SERIES
RIGHTS OF SAFE MEDICATION Right route
ADMINISTRATION The most common routes of administration are oral,
topical, subcutaneous, IM, and IV. Additional routes
Right client
include sublingual, buccal, intradermal, transdermal,
Verify clients’ identification before each medication epidural, inhalation, nasal, ophthalmic, otic, rectal,
administration. The Joint Commission requires two vaginal, intraosseous, and via enteral tubes.
client identifiers. ● Select the correct preparation for the route the provider
● Acceptable identifiers include the client’s name, an prescribed (otic versus ophthalmic topical ointment
assigned identification number, telephone number, birth or drops).
date, or another person-specific identifier (a photo ● Always use different syringes for enteral and parenteral
identification card). medication administration.

● Check identification bands for name and ● Know how to administer medication safely and correctly.
identification number.
● Check for allergies by asking clients, looking for an Right documentation
allergy bracelet or medal, and reviewing the MAR. ● Immediately record the medication, dose, route, time,
● Use barcode scanners to identify clients.
and any pertinent information, including the client’s
response to the medication. Document the medication
Right medication
after administration, not before.
Correctly interpret medication prescriptions, verifying ● For some medications, in particular those to alleviate
completeness and clarity. pain, evaluate the client’s response and document it
● Read medication labels and compare them with the later, perhaps after 30 min.
MAR three times: before removing the container, when
removing the amount of medication from the container, Right client education
and in the presence of the client before administering ● Inform clients about the medication: its purpose, what
the medication.
to expect, how to take it, and what to report.
● Leave unit-dose medication in its package ● To individualize the teaching, determine what the clients
until administration.
already know about the medication, need to know about
● When using automated medication dispensing systems,
the medication, and want to know about the medication.
perform the same checks and adapt them as necessary.
Right to refuse
Right dose
● Respect clients’ right to refuse any medication.
● Use a unit-dose system to decrease errors. If not ● Explain the consequences, inform the provider, and
available, calculate the correct medication dose.
document the refusal.
● Check a drug reference to ensure the dose is within the
usual range.
Right assessment
● When performing medication calculations or
conversions, have another qualified nurse check the Collect any essential data before and after administering
calculated dose. any medication. For example, measure apical heart rate
● Prepare medication dosages using standard before giving digoxin.
measurement devices (graduated cups or syringes).
Some medication dosages require a second verifier Right evaluation
or witness (some cytotoxic medications). Automated
Follow up with clients to verify therapeutic effects as well
medication dispensing systems use a machine to control
as adverse effects.
the dispensing of medications.
Right time
MEDICATION ERROR PREVENTION
Administer medication on time to maintain a consistent
therapeutic blood level.
● Administer time-critical medications 30 min before
COMMON MEDICATION ERRORS
or after the prescribed time. Facilities define which ● Wrong medication or IV fluid
medications are time-critical; usually this includes ● Incorrect dose or IV rate
medications that require a consistent blood level ● Wrong client, route, or time
(antibiotics). ● Administration of an allergy-inducing medication
● Administer non-time-critical medications prescribed ● Omission of a dose or administration of extra doses
once daily, weekly, or monthly within 2 hr of the ● Incorrect discontinuation of a medication or IV fluid
prescribed time. ● Inaccurate prescribing
● Administer non-time-critical medications prescribed ● Inadvertently giving a medication that has a
more than once daily (but not more than every 4 hr) similar name
within 1 hr of the prescribed time.
Online Video: Look-Alike, Sound-Alike Medications
USING THE NURSING PROCESS TO ● Interpret the medication prescription accurately. The
PREVENT MEDICATION ERRORS Institute for Safe Medication Practices (ISMP) is a
nonprofit organization working to educate health
Assessment care providers and consumers about safe medication
practices. The ISMP and the FDA identify the
● Be knowledgeable about the medications administered.
most common medical abbreviations that result in
Use appropriate resources.
misinterpretation, mistakes, and injury. For a complete
◯ Providers, including nurses, physicians,
list, go to the ISMP website.

and pharmacists ◯ Error-Prone Abbreviation List: abbreviations that
◯ Poison control: 1-800-222-1222 (24/7)
have caused a high number of medication errors

◯ Sales representatives from drug companies
◯ Confused Medication Name List: sound-alike and
◯ Nursing pharmacology textbooks and drug handbooks
look-alike medication names

◯ Physicians’ Desk Reference
◯ High-Alert Medication List: medications that, if a
◯ Professional journals
nurse administers them in error, have a high risk for

◯ Professional websites
resulting in significant harm to clients. Strategies

● Obtain information about medical diagnoses and
to prevent errors include limiting access; using
conditions that affect medication administration (ability
auxiliary labels and automated alerts; standardizing
to swallow; allergies; heart, liver, and kidney disorders).
the prescription, preparation, and administration; and
● Obtain necessary preadministration data (heart
using automated or independent double checks.
rate, blood pressure, blood levels) to assess the ● Question the provider if the prescription is unclear or
appropriateness of the medication and to obtain
seems inappropriate for the client. Refuse to administer
baseline data for evaluating the effectiveness
a medication if it seems unsafe, and notify the charge
of medications.
nurse or supervisor.
● Omit or delay doses as necessary due to clients’ status. ● Providers usually make dosage changes gradually.
● Determine whether the medication prescription
Question them about abrupt and excessive changes.
is complete.
Planning
● Identify client outcomes for medication administration.
● Set priorities (which medications to give first or before
specific treatments or procedures).
2.2 Confused medication name list

Sound-alike and look-alike medication names ESTABLISHED NAME RECOMMENDED NAME
ESTABLISHED NAME RECOMMENDED NAME hydralazine hydrALAZINE
acetohexamide acetoHEXAMIDE hydromorphone hYDROmorphone
acetazolamide acetaZOLAMIDE hydroxyzine hydrOXYzine
bupropion buPROPion medroxyprogesterone medroxyPROGESTERone
buspirone busPIRone methylprednisolone methylPREDNISolone
methyltestosterone methylTESTOSTERone
chlorpromazine chlorproMAZINE
mitoxantrone mitoXANTRONE
chlorpropamide chlorproPAMIDE
nicardipine niCARdipine
clomiphene clomiPHENE
nifedipine NIFEdipine
clomipramine clomiPRAMINE
prednisone predniSONE
cyclosporine cycloSPORINE
prednisolone prednisoLONE
cycloserine cycloSERINE
risperidone risperiDONE
daunorubicin DAUNOrubicin
ropinirole ROPINIRole
doxorubicin DOXOrubicin
sulfadiazine sulfADIAZINE
dimenhydrinate dimenhyDRINATE
sulfisoxazole sulfiSOXAZOLE
diphenhydramine diphenhydrAMINE
tolazamide TOLAZamide
dobutamine DOBUTamine
tolbutamide TOLBUTamide
dopamine DOPamine
vinblastine vinBLAStine
glipizide glipiZIDE
vincristine vinCRIStine
glyburide glyBURIDE
Implementation Evaluation
● Avoid distractions during medication preparation (poor ● Evaluate clients’ responses to medications, and
lighting, ringing phones). Interruptions can increase the document and report them.
risk of error. ● Use knowledge of the therapeutic effect and common
● Prepare medications for one client at a time. adverse effects of medications to compare expected
● Check the labels for the medication’s name outcomes with actual findings.
and concentration. ● Identify adverse effects, and document and report them.
● Measure doses accurately, and double-check dosages ● Notify the provider of all errors, and implement
of high-alert medications (insulin and heparin) with a corrective measures immediately.
colleague. Check the medication’s expiration date. ◯ Complete an incident report within the time frame
● Doses are usually one to two tablets or one single-dose the facility specifies, usually 24 hr. This report
vial. Question multiple tablets or vials for a single dose. should include
● Follow the rights of medication administration ■ Client’s identification
consistently and carefully. Take the MAR to the bedside. ■ Name and dose of the medication
● Do not administer medications that someone else prepared. ■ Time and place of the incident
● Encourage clients to become part of the safety net, ■ Accurate and objective account of the event
teaching them about medications and the importance of ■ Who you notified
proper identification before medication administration. ■ What actions you took
Omit or delay a dose when clients question the size of a ■ Your signature (or that of the person who completed
dose or the appearance of a medication. the report)

● Follow correct procedures for all routes of administration. ◯ Do not reference or include the incident report in the
● Follow all laws and regulations for preparing and client’s medical record.
administering controlled substances. Keep them in a ◯ Medication errors relate to systems, procedures,
secure area. Have another nurse witness the discarding product design, or practice patterns. Report all errors
of controlled substances. to help the facility’s risk managers determine how
● Do not leave medications at the bedside. Some facilities’ errors occur and what changes to make to avoid
policies allow exceptions (for topical medications). similar errors in the future.
● Educate the client and anyone who will be assisting in
the client’s care regarding medications. Provide verbal
and written instructions.
2.3 High-alert medication list

The following medications and medication categories from the ISMP’s list require specific safeguards to reduce
the risk of errors. Strategies include limiting access; using auxiliary labels and automated alerts; standardizing
the prescription, preparation, and administration; and using automated or independent double checks.
Class or category of medications Specific medications

●
Adrenergic agonists, IV (epinephrine) ●
Epinephrine, subcutaneous
●
Adrenergic antagonists, IV (propranolol) ●
Epoprostenol, IV
●
Anesthetic agents, general, inhaled and IV (propofol) ●
Heparin, low molecular weight, injection
●
Cardioplegic solutions ●
Heparin, unfractionated, IV
●
Chemotherapeutic agents, parenteral and oral ●
Insulin, subcutaneous and IV
●
Dextrose, hypertonic, 20% or greater ●
Lidocaine, IV
●
Dialysis solutions, peritoneal and hemodialysis ●
Magnesium sulfate injection
●
Epidural or intrathecal medications ●
Methotrexate, oral, nononcologic use
●
Glycoprotein IIb/IIIa inhibitors (eptifibatide) ●
Opium tincture
●
Hypoglycemics, oral ●
Oxytocin, IV
●
Inotropic medications, IV (digoxin, milrinone) ●
Nitroprusside for injection
●
Liposomal forms of drugs (liposomal amphotericin B) ●
Potassium chloride for injection concentrate
●
Moderate sedation agents, IV (midazolam) ●
Potassium phosphates injection
●
Moderate sedation agents, oral, for children (chloral hydrate) ●
Promethazine, IV
●
Narcotics/opiates, IV and oral (including liquid ●
Vasopressin, IV or intraosseous
concentrates, immediate- and sustained-release) ●
Warfarin
●
Neuromuscular blocking agents (succinylcholine)
●
Radiocontrast agents, IV
●
Sodium chloride injection, hypertonic,
more than 0.9% concentration
●
Thrombolytics/fibrinolytics, IV (tenecteplase)
●
Total parenteral nutrition solutions
Application Exercises Active Learning Scenario
1. A nurse is preparing a client’s medications. Which of A staff educator is reviewing the prevention of medication
the following actions should the nurse take in following errors with a group of newly licensed nurses. What should
legal practice guidelines? (Select all that apply.) the educator include about using the nursing process to
prevent medication errors? Use the ATI Active Learning
A. Teach the client about the medication. Template: Basic Concept to complete this item.
B. Determine the dosage.
C. Monitor for adverse effects. NURSING INTERVENTIONS: Using the nursing process
D. Lock compartments for controlled substances. to prevent medication errors, list the following.
E. Determine the client’s insurance status. ●
Three assessment actions
●
One planning action
2. Four implementation actions

●
A nurse is preparing to administer digoxin to

a client who states, “I don’t want to take that ●
Three evaluation actions
medication. I do not want one more pill.” Which of
the following responses should the nurse make?
A. “Your physician prescribed it for you,
so you really should take it.”
B. “Well, let’s just get it over quickly then.”
C. “Okay, I’ll just give you your other medications.”
D. “Tell me your concerns about
taking this medication.”
3. A nurse is reviewing a client’s prescribed medications.

Which of the following situations represents a
contraindication to medication administration?
A. The client drank grapefruit juice, which could
reduce a medication’s effectiveness.
B. The medication has orthostatic
hypotension as an adverse effect.
C. A medication is approved for ages 12 and
older, and the client is 8 years old.
D. An antianxiety medication that has an
adverse effect of drowsiness is prescribed
as a preoperative sedative.
4. A nurse is assessing a client before administering

medications. Which of the following data should
the nurse obtain? (Select all that apply.)
A. Use of herbal products
B. Daily fluid intake
C. Ability to swallow
D. Previous surgical history
E. Allergies
5. A nurse is working with a newly licensed nurse

who is administering medications to clients.
Which of the following actions should the nurse
identify as an indication that the newly hired nurse
understands medication error prevention?
A. Taking all medications out of the unit-dose
wrappers before entering the client’s room
B. Checking the prescription when a single dose
requires administration of multiple tablets
C. Administering a medication, then
looking up the usual dosage range
D. Relying on another nurse to clarify
a medication prescription
Application Exercises Key Active Learning Scenario Key
1. A. CORRECT: Teach the medication as part of the Using the ATI Active Learning Template: Basic Concept
rights of medication administration. NURSING INTERVENTIONS
B. Determining the medication’s dosage is
the provider’s responsibility. Assessment
C. CORRECT: Monitor for adverse effects as part of ●
Be knowledgeable about the medication to
the rights of medication administration. administer. Use appropriate resources.
D. CORRECT: Lock controlled substances in a drawer, ●
Obtain information about medical diagnoses and
cart, or other compartment to prevent misuse. conditions that affect medication administration.
E. The client’s insurance status does not relate to legal ●
Determine whether the medication prescription is complete.
medication administration requirements. ●
Interpret the medication prescription accurately.
NCLEX® Connection: Safety and Infection Control, ●
Question the provider if the prescription is unclear
Accident/Error/Injury Prevention or seems inappropriate for the client.
●
Question the provider about abrupt and excessive changes in dosage.
2. A. This response dismisses the client’s concerns. Planning
B. This response is dismissing the client’s concerns ●
Identify clients’ outcomes for medication administration.
about taking the medication by continuing ●
Set priorities (which medications to give first or
with medication administration. before specific treatments or procedures).
C. Although clients have the right to refuse a medication,
provide information about the risk of refusal instead Implementation
of proceeding with medication administration.
●
Avoid distractions and interruptions during medication preparation.
D. CORRECT: Although clients have the right to refuse a ●
Prepare medications for one client at a time.
medication, this response is correct in determining the ●
Check the labels for the medication’s name and concentration.
reason for refusal by asking about the client’s concerns. Then ●
Question multiple tablets or vials for a single dose.
information can be provided about the risk of refusal and ●
Follow the rights of medication administration
facilitate an informed decision. At that point, if the client consistently and carefully.
still exercises their right to refuse a medication, notify the ●
Do not administer medications that someone else prepared.
provider and document the refusal and the actions taken. ●
Encourage clients to become part of the safety net.
NCLEX Connection: Pharmacological and Parenteral Therapies,
®
●
Follow correct procedures for all routes of administration.
Medication Administration ●
Communicate clearly both verbally and in writing.
●
Use verbal prescriptions only for emergencies, and follow
3. A. This represents a medication interaction; the client could take the facility’s protocol for telephone prescriptions.
a larger dose of medication or take it at a later time.
●
Follow all laws and regulations for preparing and
B. Give this medication and monitor the client administering controlled substances.
blood pressure more closely. ●
Do not leave medications at the bedside.
C. CORRECT: Age is one factor that can be a contraindication ●
Follow the principles of client and family education for medications.
to medication administration. Contraindications are
Evaluation
findings that indicate the client should not receive a
medication and are different from instances where an
●
Evaluate clients’ responses to medications,
undesirable effect or more monitoring are needed. and document and report them.
D. This is an example of a medication that
●
Use knowledge of the therapeutic effect and common
has multiple therapeutic effects. side and adverse effects of medications to compare
expected outcomes with actual findings.
NCLEX® Connection: Safety and Infection Control, ●
Identify side and adverse effects, and document and report them.
Accident/Error/Injury Prevention ●
Report all errors, and implement corrective measures immediately.
NCLEX® Connection: Safety and Infection Control,
4. A. CORRECT: Inquire about the client’s use of herbal Reporting of Incident/Event/Irregular Occurrence Variance
products, which often contain caffeine, prior to
medication administration because caffeine can
affect medication biotransformation.
B. Daily fluid intake is important for ensuring adequate
hydration, but it is not part of the preassessment the
nurse completes prior to medication administration.
C. CORRECT: Determine the client’s ability to
swallow to see what route or formulation of
the medication the client requires.
D. Surgical history is important for determining any
risks or alterations in the client’s health status,
but it is not part of the preassessment the nurse
completes prior to medication administration.
E. CORRECT: Inquire about food allergies
during the preassessment to identify any
potential reactions or interactions.
NCLEX® Connection: Safety and Infection Control,
Accident/Error/Injury Prevention
5. A. To prevent errors, do not take unit-dose medications out

of wrappers until at the bedside when performing the third
check of medication administration. Encourage clients’
involvement and provide teaching at this time.
B. CORRECT: If a single dose requires multiple
tablets, it is possible that an error has occurred in
the prescription or transcription of the medication.
This action could prevent a medication error.
C. Reviewing the usual dosage range prior to administration
can help identify an inaccurate dosage.
D. If the prescription is unclear, contact the provider,
not another nurse, for clarification.
Adverse Effects/Contraindications/Side Effects/Interactions
CHAPTER 3
UNIT 1 PHARMACOLOGICAL PRINCIPLES For dosages greater than 1.0: Round to the nearest tenth.
Dosage Calculation
● For example (rounding up): 1.38 = 1.4. The calculated
CHAPTER 3 dose is 1.38 mg. Look at the number in the hundredths
place (8). Eight is greater than 5. To round to the tenth,
add 1 to the 3 in the tenth place and drop the 8. The
Basic medication dose conversion and rounded dose is 1.4 mg.
Or (rounding down): 1.34 mL = 1.3 mL. The calculated
calculation skills are essential for providing safe
●
dose is 1.34 mL. Look at the number in the hundredths

nursing care. place (4). Four is less than 5. To round to the tenth, drop
the 4 and leave the 3 as is. The rounded dose is 1.3 mL.
Nurses are responsible for administering the
correct amount of medication by calculating the
precise amount of medication to give. Nurses Solid dosage
Example: A nurse is preparing to administer
can use three different methods for dosage phenytoin 0.2 g PO every 8 hr. The amount available
calculation: ratio and proportion, formula is phenytoin 100 mg/capsule. How many capsules
should the nurse administer per dose? (Round the
(desired over have), and dimensional analysis. answer to the nearest whole number. Use a leading
zero if it applies. Do not use a trailing zero.)
TYPES OF CALCULATIONS
● Solid oral medication USING RATIO AND PROPORTION
● Liquid oral medication
STEP 1: What is the unit of measurement the nurse
● Injectable medication
should calculate?
● Correct doses by weight
● IV infusion rates capsules
STEP 2: What is the dose the nurse should administer?
STANDARD CONVERSION FACTORS Dose to administer = Desired
● 1 mg = 1,000 mcg 0.2 g
● 1 g = 1,000 mg
STEP 3: What is the dose available? Dose available = Have
● 1 kg = 1,000 g
● 1 oz = 30 mL 100 mg
● 1 L = 1,000 mL
STEP 4: Should the nurse convert the units of measurement?
● 1 tsp = 5 mL
Yes (g ≠ mg)
● 1 tbsp = 15 mL
Set up an equation.
● 1 tbsp = 3 tsp
● 1 kg = 2.2 lb 1g 0.2 g
1 gr = 60 mg =
1,000 mg X mg
●
Solve for X.
GENERAL ROUNDING GUIDELINES
X mg = 200 mg
ROUNDING UP: If the number to the right is equal to
or greater than 5, round up by adding 1 to the number Or you can use your knowledge of equivalents.
on the left.
1 g = 1,000 mg (1 × 1,000)
ROUNDING DOWN: If the number to the right is less
than 5, round down by dropping the number, leaving the 0.2 g = 200 mg (0.2 × 1,000)
number to the left as is.
STEP 5: What is the quantity of the dose available? = Quantity
For dosages less than 1.0: Round to the nearest hundredth.
1 capsule
● For example (rounding up): 0.746 mL = 0.75 mL. The
calculated dose is 0.746 mL. Look at the number in the STEP 6: Set up the equation and solve for X.
thousandths place (6). Six is greater than 5. To round to
Have Desired
hundredths, add 1 to the 4 in the hundredths place and =
Quantity X
drop the 6. The rounded dose is 0.75 mL.
● Or (rounding down): 0.743 mL = 0.74 mL. The 100 mg 200 mg
calculated dose is 0.743 mL. Look at the number in the 1 capsule =
X capsule(s)
thousandths place (3). Three is less than 5. To round
to the hundredth, drop the 3 and leave the 4 as is. The X capsule(s) = 2 capsules
rounded dose is 0.74 mL.
STEP 7: Round, if necessary.
RN PHARMACOLOGY FOR NURSING CHAPTER 3 DOSAGE CALCULATION 19

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DOUBLE PATENT PENS, No. 2, in Boxes, containing three

dozen, six dozen, or twelve dozen each, with Fine, Medium,
or Extra Fine Points.
CURVE-CUT PENS, in Boxes, containing three dozen, six

dozen, or twelve dozen each, with Fine or Medium Points.
Pens on Cards.
DOUBLE PATENT LARGE BARREL PENS, with Fine or Medium Points.—

Nine Pens with Holder.
DOUBLE PATENT SMALL BARREL PENS ”
CURVE-CUT PENS ”
Pens in Cases containing a Quarter Hundred, with Holder.
DOUBLE PATENT PENS, No. 2, with Fine or Medium Points

RAVEN BLACK PENS No. 2, ”
BRONZE PENS No. 2, ”
The Following Sorts of the Perryian Pens, manufactured by James Perry &
Co., are Sold on Cards as Usual.
s. d.
RAVEN BLACK PENS, with Fine or Medium Points per Card 1 0
NATIONAL PENS, Nos. 1, 2, 3, & 4, with Fine or Medium Points ditto 1 0
OFFICE PENS ditto 1 0
FINE OFFICE PENS ditto 1 0
NATIONAL PENS, Nos. 7 and 8, with Fine or Medium Points ditto 1 6
DOUBLE PATENT PENS, with Fine, Medium, Broad, or Extra ditto 2 0
Fine Points
UNDER SPRING PENS ditto ditto 2 0
FLAT SPRING PENS ditto ditto 2 0
SIDE SPRING PENS ditto ditto 2 0
THREE-POINTED PENS ditto 2 0
ELASTIC FOUNTAIN PENS, with Fine, Medium, Broad, or ditto 2 6
Extra Fine Points
INDIA-RUBBER SPRING PENS, ditto ditto 2 6
REGULATING SPRING PENS ditto ditto 2 6
ELASTIC HOLDER, with appropriate Pens ditto ditto 2 6
FOUNTAIN PENS ditto ditto 3 0
SCHOOL PENS, for Large, Round, or Small Hand, per Packet 2 0
N.B.—Each Card and Packet contains NINE PENS, with suitable Holder.
DRAWING and MAPPING PENS, per Card of Six Pens, with Holder 3 6
LITHOGRAPHIC PENS ditto 3 6
PATENT PERRYIAN ELASTIC HOLDER.

The Elastic Holder is so constructed as to impart an agreeable softness and
flexibility to the Pen, rendering it so unconstrained in its action as not to fatigue
the hand. This Holder facilitates the progress of the Pen over every description
of paper. It may be had with the Perryian Pens, at an advance of Threepence
per Card; or separately, at Threepence each. Each Holder is stamped with the
words “Patent, Perry, London.”
PERRYIAN LIMPID INK.

This Ink has a flowing property peculiar to itself, and does not corrode Metallic
Pens as other Inks.—In Bottles, 6d., 1s., and 2s. each.
BLACK INK POWDER, 6d. and 1s. per Packet.
LIMPIDUM, for neutralising the ill effects of the usual Inks, when used with
Metallic Pens, Sixpence per Packet.
Writing Paper; Silver, Albata, and other Pen-Holders and Pencil-Pen Cases,
adapted to the Perryian Pens, at the usual Prices.
⁂ £20 Reward will be given, on
conviction, for information of any
Person or Persons infringing any of
the Proprietors Patent Rights.
☞ Sold by all Stationers and
Dealers in Metallic Pens, and at the Manufactory, 37 Red Lion Square, London.
DOUBLE PATENT PERRYIAN FILTER

INKSTAND.
JAMES PERRY and Co., Manufacturers to Her Majesty and H. R. H. Prince
Albert,
Having effected considerable improvement in their FILTER INKSTAND, have
now the pleasure to announce that a Second Patent has been granted to them
for such improvement, which they have united with their First Patent, under the
title of “DOUBLE PATENT PERRYIAN FILTER INKSTAND.” The eulogy
bestowed on the Patent Filter Inkstand by the public journals, and the
preference obtained for them over the common Inkstands, were almost
unprecedented. The present novel and scientific method of supplying Clear Ink
to the Dipping Cup, and returning it into the reservoir, is exceedingly simple, the
action being now performed by merely lifting up the lid to obtain a supply, and
shutting it down to withdraw it; in this state it is protected from dust or other
injury in any place or climate. When the Inkstand is filled, it is always ready for
use, and the writer will have a regular and daily supply of Clear Ink for four or six
months.
No. 1. No. 2. No. 3. No. 4.
No. 5. No. 6. No. 7. No. 4½.
TESTIMONIALS.
It possesses the advantage, from being air-tight, of preserving Ink for almost
any period of time.—Times.
One of the most useful inventions of the present day that has come under our
observation.—Morning Herald.
It is really most ingenious, and not in the slightest degree liable to get out of
order.—John Bull.
Very ingeniously constructed to keep the surface of the Ink at a uniform level,
where it is presented to the dip of the Pen.—Morning Post.
We have tested the PERRYIAN INKSTAND, and have every reason to be
perfectly satisfied with the trial.—Atlas.
PATENT PERRYIAN GRAVITATING

INKSTAND.
As Cheap as the Common Inkstand.
This neat and novel invention is exceedingly well adopted for general use; it
preserves the Ink in great perfection for months together, without the trouble of
refilling; it excludes dust, &c., and at any moment the writer is supplied with Ink
in the most perfect state.
The Patentees strongly recommend it to the notice of Bankers, Merchants,
Solicitors, Government Offices, Public Companies, Shops, Schools, &c., as a
great improvement over the ordinary Inkstand, both as regards convenience,
and considerable saving of Ink. This Inkstand will be found invaluable in keeping
the Ink always clear and fit for use in every climate. It is of a cylindrical form,
with a gravitating action, adjusted so as to supply the Dipping Cup with Ink,
which can be returned into the Cylinder when not in use. Economy, cleanliness,
and usefulness are secured by it, and it cannot get out of order.
No. 1. No. 3. No. 2.
☞ Sold by all Stationers and Dealers in Metallic Pens, and at the Manufactory,
37, Red Lion Square, London.
“THE BUILDER.”
THE BUILDER.—This Journal will be exclusively devoted to the
interests of Builders, by which term must be understood all that
numerous and wealthy portion of persons connected directly or
indirectly with Building. It will partake of the character of a Trade
Journal or Magazine, and also fulfil the objects of a Weekly
Newspaper, by giving a faithful and impartial abstract of the News of
the Week. The Conductors will not discuss the question of general
Politics, nor will they enter upon Political disquisition at all, unless
any measure should be proposed affecting the class whose interests
they will always support and defend. Upon such occasions, and
upon such occasions only, will their paper be political. It will be of no
party, unless, indeed, the advocating the true interests of all classes
connected with the Building Business, from the Labourer to the
Architect, can be so considered. A portion of
“THE BUILDER”
will be occupied by Essays on the Building and Furnishing Arts in all
their various and numerous branches. It will contain the designs of
Ancient Buildings and Works, and of those of our own day—not
mere pictures or views from which nothing is to be learnt, but plans,
sections, &c., which, while they will be rendered perfectly intelligible
to workmen of ordinary information, it is hoped will not be below the
notice of the Architect and the Amateur.
When we consider how numerous and important is the class to
whose interests this Journal is dedicated; a class of British Artisans
numbering at least half a million; a class whose trade-education
distinguishes them in intellect, knowledge, and wealth, it can only
form matter of surprise, that while the Clerical, Medical, Legal,
Military, and Naval, the Artists and Literati, and other classes have
their public organs of opinion and information; while the Gardeners
and Agriculturists, Railway and Commercial and Banking Companies
have each their mouth-piece and record; the religious sects, and all
Politicians their special advocates that this most numerous, most
intelligent, and most wealthy, should have so long remained without
this bond of the Press; to instruct and inform, to disseminate
knowledge as to discoveries and inventions, to advertise wants, and
form for it a general nucleus of strength, light, and union.
Amongst the Tradesmen, Manufacturers, &c. who are particularly
interested in
“THE BUILDER,”
both as a medium for obtaining information, and for Advertising their
own productions and requirements, we may enumerate the following:
—
Architectural Authors and Publishers

Asphalte Companies
Artificial Stone Manufacturers
Auctioneers and Agents for Buildings, Land, Timber Sales, &c.
Bath, Portland, Granite, Yorkshire, and other Stone Merchants
Brass Fender, Rods, Plate, &c. Manufacturers
Brass Founders
Blind Makers, Venetian and others
Booksellers
Bent Timber Manufacturers
Brokers, Consignments, Sales, &c.
Bronzists
Builders’ Cards and Advertisements
Building Material Dealers
Carpet Warehouses
Carvers
Cabinet Makers
Chimney-piece Manufacturers
Cement Manufacturers
Carriers, Canals, and Vans
Clerks of Works and their Employers
Clock Makers and Bell Founders
Coppersmiths and Braziers
Contractors and Contracts
Drawing Schools, Academies, and Schools of Design
Engineers and Workmen
Estate and House Agents
Fender Makers
Founders and Furnishing Ironmongers
Fire-proof Materials
Fencing,—Iron, Wood, or Stone
Foremen wanted
Glass and Lead Merchants
” Manufacturers, Plate and Stained
Gas Fitters, &c.
Grindstones, &c.
Houses of Call
Insurance Companies
Iron and Steel Merchants
Iron and Tin Plate Workers
Iron Bedstead Makers, Safes, &c.
Land Jobbers, and Sales for Building, &c.
Lamp Manufacturers
Lath Renders
Lead Merchants
Lime Merchants and Burners
Locksmiths and Bellhangers
Lock Manufacturers
Loan Societies
Mathematical Instrument Makers
Machine Makers, Engines, &c.
Metallic Sash Makers—Springs, &c.
Mechanics’ Institutions
Mechanical Instrument Makers
Millwrights and Millstones
Modellers and Carvers
Marble Workers—Chimney-piece Manufacturers
Nail Merchants
Oven Builders
Paint and Colour Merchants
Papier Maché Manufacturers
Paviours
Picture Frame and Gilt Moulding Makers
Patents—Patent Agencies, &c.
Plasterers and Plaster of Paris
Pump Makers, &c.
Pencil Makers
Prices Current—Timber, Lead, Iron, &c.
Publishers, Printers, &c.
Railway Companies
Registration of Designs
Roman Cement Makers
Sales—Timber, Land, Houses, &c.
Scagliola Manufacturers
Saw Mills, Sawing, Saw Makers
Stone Quarries and Merchants
Slate do. do.
Staffordshire Tiles, Bricks, Pipes, &c.
Ships—Imports, Exports, Emigration, &c.
Steam Engines, and Boiler Makers
Stove Grate Makers
Tool Makers
Turners
Ventilating and Warming Buildings
Upholsterers
Wire Drawers and Workers
Water Closet Makers
Wood Paving Companies
Wood Letters
Window Blind Makers—Transparent, &c.
Workmen wanted
Zinc Manufacturers, and Door-plate Makers
Zincography and Artists
The following presents a list, taken from the census of 1831, of the
building and connected classes in Great Britain only, and of these
only the male adults of 20 years old and upwards:—
Architects and Engineers—No number given.

Agents—None given.
Auctioneers 2,823
Bricklayers 29,653
Brickmakers 10,184
Builders 5,204
Carpenters 103,238
Cabinet Makers 21,774
Carvers and Gilders 2,854
Chair Makers 802
Ironmongers and Ironfounders 10,411
Land Jobbers 651
Lime Burners 3,122
Masons or Wallers 49,159
Marble Cutters 1,732
Nailors 1,882
Painters 15,653
Plumbers and Glaziers 11,999
Plasterers 9,683
Sawyers 19,181
Slaters 4,539
Turners 5,905
Upholsterers 2,932
Undertakers 1,121
314,502
To which, if we add for Ireland, for apprentices and increase of

population, we shall have a number probably far exceeding half a
million!
That this description of paper has been long a desideratum, is
evinced by the history and character of the associations of years
past. The struggles on the part of masters and men, and the attitude
taken by the public towards both, required an interlocutor of this
nature to promote a good understanding, and to secure equity and
justice to all. With such an auxiliary, what waste of time and funds
had been avoided—what noble projects carried out—what petty
strife suppressed—what distractions kept down. Our dignity would
have been maintained, and our cause ennobled.
But more than this. How many of the claims of humble merit have
slept in this interval for the want of a friendly expositor, or a common
vehicle of publicity? And how many valuable inventions have
languished wanting encouragement, or died still-born in the obscurity
of their birth? How many toilsome wanderings of the artisan in
search of employment might have been avoided?—how many
common benefits have been withheld?—How frequently the hand of
brotherly charity undirected, and the worthy object frustrated of its
aid? In the glut of work in one quarter and its scarcity in another, how
promptly would
“THE BUILDER”
have adjusted the balance? Its columns at all times open to inquiries,
and the office for reference, would have solved many difficulties, and
facilitated many purposes of good.
But “better late than never.” The present effort will be under the
chief conduct of one who, from his experience and practice, has
derived means and opportunities of knowing the wants, and
understanding the interests, of the class to whom he has the honour
to belong. And it will be the object at all times to enlist in behalf of
this enterprise the talent and services of all superior minds and
zealous hearts in the various kindred professions.
The paper will be of a convenient size for being bound as a book,
and so that the essays and illustrations may be separated and
preserved. As before stated in respect of the political department,
the Editor will endeavour to steer clear of partizanship. But times
may arise when a fearless advocacy of trade interests will require
him to oppose or support the party in power; on such occasions he
will claim for himself the right to assert his views, and those of his
class, in a manly and temperate manner.
The illustrations will consist of views, plans, elevations, and
sections of ancient and modern buildings, and of parts of buildings,
so as effectually to describe their peculiar excellencies;—of working
drawings and diagrams for the carpenter, mason, cabinet-maker, &c.
&c.;—designs of manufactured articles and implements used in
building;—of improved associations and architectural arrangements,
whether in the cottage or the mansion, the villa or the palace, in the
farm, the village, and the city; in short, there will be no subject in art
or science connected with building and the furnishing of buildings
that will not be sought after to be introduced here.
As a medium of Advertisements, its merits will be obvious: the list
already given comprehends a large number of those to whom such a
paper as this offers always the only proper vehicle. But there are
many besides to whom it will be a welcome organ. In the matter of
contracts for building, of business to be disposed of or sought after,
of workmen wanted or seeking employment, and in all such
pertaining to the class of builders and cabinet makers, it will at once
form a perfect scheme of publicity, thereby encouraging many to
advertise, in the certainty of their advertisements being read, and
many to read in the same certainty of finding an answer to their
wants.
All communications to be addressed to the Editor of “The
Builder,” No. 2, York-street, Covent Garden.
TESSELLATED PAVEMENT.—WYATT, PARKER, and CO.

respectfully call the attention of the Public to their Specimens of
Tessellated Pavement which may be seen at Albion Wharf, Holland-
street, Surrey Foot of Blackfriars-bridge.
The Tesseræ for forming this Pavement or Flooring, being
composed of similar material to that used in the manufacture of
porcelain, and highly vitrified, are imperishable. They can be had of
any size and form, from cubes of a quarter of an inch, and with the
colours burnt throughout the entire body. If required, they may be gilt
similar to those on the tombs of Edward the Confessor and Henry
the Third. They are prepared to execute designs for these floors, or
to dispose of the small Quarries or Tesseræ by the gross, to such
persons as may wish to execute their own floors. These Tesseræ
may be united on the floor with Roman Cement, Lime, and
Pozzolano, Plaster of Paris, or most of the Cements now in use; or
prepared in slabs, and laid with the same facility as Portland Stone
paving.
ENCAUSTIC or INLAID ORNAMENTAL TILES, for paving churches,

halls, corridors, &c.—WYATT, PARKER, and Co. beg to acquaint the
public that they are now prepared to execute PAVEMENTS with
these beautiful tiles, manufactured in imitation of the best ancient
examples from the Chapterhouse, Westminster, Winchester
Cathedral, Romsey Church, Great Malvern, &c. Being made of the
famous red Staffordshire clay, they are of a less porous body than
the ancient tiles, consequently are more durable, and will bear the
roughest usage to which a foot-pavement can be subject, and are
therefore more economical than any of the marbles and stones now
in use for similar purposes. W. P., and Co. also have a great variety
of other tiles of various colours for flooring, and white glazed tiles for
the sides of stoves, dairies, baths, &c. Specimens may be seen at
Wyatt, Parker, and Co.’s wharf, Holland-street, Surrey Foot of
Blackfriars-bridge.
ARTISTS, PRINTSELLERS, and Others are respectfully informed

that C. F. Brelefeld has formed a large Collection of new and elegant
Designs for Picture Frames in the Improved Papier Maché. The
superiority of these Frames consists in their having all the effect of
old carved work; many patterns represent exactly the finest carvings
of the 17th century. The small parts are far less liable to injury than
putty work. Papier Maché being a remarkably tough and hard
substance, it never shrinks, and takes gilding very freely; the frames
do not weigh one quarter the weight of others, and the price is below
that usually charged.
Many specimens are now on view at C. F. Brelefeld’s Papier
Maché Works, No. 15, Wellington-street North, Strand, where also
Pattern Books may be had, price 14s., consisting of a variety of
Patterns of Picture and Glass Frames and Window Cornices, already
executed, and on sale.
“PICTURE FRAMES.—We direct the especial attention of all
persons interested in this subject to the frames for pictures
manufactured by Mr. Brelefeld; they are of Papier Maché, and the
advantages they possess over the ordinary composition frames are
so strong and so numerous, that they must inevitably be brought into
general use. They look exceedingly attractive, and are in reality as
much so as if they had passed through the hands of the carver, and
been produced at about ten times the expense. The gilding tells with
very brilliant effect; and no matter how elaborate the pattern may be,
they have a clearness and sharpness that we have seldom or never
seen obtained in composition.”—Art-Union.
TO CIVIL ENGINEERS, ARCHITECTS, BUILDERS, AND THE

PUBLIC.
THOMAS PEAKE’S TERRO-METALLIC MANUFACTORIES,
Tunstall, near Newcastle, Staffordshire. Depôt, Albion Wharf,
Holland-street, London, per Messrs. Wyatt, Parker, and Co.
The manufacturer and his late father have conducted the present
business since 1808, now thirty-four years. He begs to remark that,
during that period, the articles have supplanted other materials to a
considerable extent provincially; and experience leads him to believe
that they will be more generally adopted in the metropolis, as they
become known.
T. P. had the honour to supply roof tiles for lodges, villas, &c. at
Chatsworth, and he believes they are not excelled in efficiency or
appearance by any tiled roofs in the world.

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Debborah Williams, MSN, RN

Sheryl Sommer, PhD, RN, CNE

Peggy Leehy, MSN, RN Melanie P. Schrader, PhD, RN

INTELLECTUAL PROPERTY NOTICE

Copyright © 2019 Assessment Technologies Institute, LLC. All rights reserved.

RN PHARMACOLOGY FOR NURSING I

Director of content review: Kristen Lawler

Director of development: Derek Prater

Project management: Tiffany Pavlik, Shannon Tierney

Coordination of content review: Honey C. Holman, Debborah Williams

Layout: Spring Lenox, Maureen Bradshaw, Bethany Phillips

Illustrations: Randi Hardy

Cover design: Jason Buck

Interior book design: Spring Lenox

IMPORTANT NOTICE TO THE READER

II CONTENT MASTERY SERIES

Template (included at the back of this book) to record

ORGANIZATION NCLEX® CONNECTIONS

information on nursing administration of the medication ◯ Safety and Infection Control

and evaluation of the medication’s effectiveness. ● Health Promotion and Maintenance

◯ Pharmacological and Parenteral Therapies

◯ Reduction of Risk Potential

An NCLEX Connection might, for example, alert you that

a medication to the client.

RN PHARMACOLOGY FOR NURSING USER’S GUIDE III

QSEN COMPETENCIES ICONS

As needed updates to the Review Modules are identified,

IV USER’S GUIDE CONTENT MASTERY SERIES

UNIT 1 Pharmacological Principles 3

CHAPTER 2 Safe Medication Administration and Error Reduction 11

CHAPTER 3 Dosage Calculation 19

CHAPTER 4 Intravenous Therapy 35

CHAPTER 5 Adverse Effects, Interactions, and Contraindications 39

CHAPTER 6 Individual Considerations of Medication Administration 45

UNIT 2 Medications Affecting the Nervous System 51

CHAPTER 8 Depressive Disorders 57

CHAPTER 9 Bipolar Disorders 67

CHAPTER 10 Psychotic Disorders 73

CHAPTER 12 Substance Use Disorders 91

CHAPTER 13 Chronic Neurologic Disorders 97

CHAPTER 14 Eye and Ear Disorders 109

Eye disorders 109

Ear disorders 113

CHAPTER 15 Miscellaneous Central Nervous System Medications 117

CHAPTER 16 Sedative-Hypnotics 123

RN PHARMACOLOGY FOR NURSING TABLE OF CONTENTS V

NCLEX® Connections 129

UNIT 3 Medications Affecting the Respiratory

CHAPTER 18 Upper Respiratory Disorders 139

NCLEX® Connections 145

UNIT 4 Medications Affecting the Cardiovascular

CHAPTER 20 Medications Affecting Blood Pressure 155

CHAPTER 21 Cardiac Glycosides and Heart Failure 167