Where this fits in the test plan

Pharmacological and Parenteral Therapies is about 15% of the items you will see. That percentage is worth taking literally when you plan revision time: a category at 15% deserves roughly 15% of your question practice, not equal time with everything else.

Medication Administration

Routes, rights and high-alert handling

Administration items test technique details that have safety consequences: which site, which needle, what to do before and after, and which forms must never be crushed or split.

Subtopics: Routes and absorption · Injection sites · Rights of administration · Special forms

Injection technique

Intradermal is 5 to 15 degrees with a 26 to 27 gauge needle. Subcutaneous is 45 to 90 degrees with a 25 to 27 gauge needle. Intramuscular is 90 degrees with a 20 to 23 gauge needle.

Intramuscular sites

Ventrogluteal is the safest adult site, being away from major nerves and vessels. Vastus lateralis is the preferred infant site. The deltoid takes small volumes only, generally up to 1 mL.

Never crush

Enteric-coated, extended-release, sustained-release and sublingual tablets are never crushed. Crushing an extended-release form delivers the whole dose at once.

Z-track

Used for irritating medications such as iron dextran. Pull the skin laterally, inject, wait ten seconds, withdraw and release the skin to seal the tract.

High-yield points

• Never administer a medication that another nurse drew up.
• Rotate insulin injection sites within one anatomical area to keep absorption consistent.
• Do not aspirate before a subcutaneous heparin or insulin injection, and do not massage afterwards.
• Ear drops in an adult: pull the pinna up and back. In a child under three: down and back.
• Eye drops go into the conjunctival sac, not onto the cornea; apply gentle pressure to the inner canthus afterwards.
• For multiple inhalers, give the bronchodilator first, wait, then the corticosteroid, then rinse.
• Check the client’s ability to swallow before giving oral medication after a stroke.

Dosage Calculation

Formulas that cover almost every item

Calculation items on the exam are usually fill-in-the-blank. Three formulas cover almost all of them, and the marks come from setting up the units correctly and rounding as instructed.

Subtopics: Basic dose formula · IV flow rates · Weight-based dosing · Titration

The basic formula

Desired divided by Have, multiplied by the Quantity. If the order is 250 mg and the supply is 125 mg in 5 mL, then 250 over 125 times 5 mL equals 10 mL.

IV flow rate in mL per hour

Total volume divided by total hours. 1000 mL over 8 hours equals 125 mL per hour.

Drops per minute

Volume in mL multiplied by the drop factor, divided by the time in minutes. 1000 mL with a drop factor of 15 over 480 minutes gives about 31 drops per minute.

Weight-based dosing

Convert pounds to kilograms by dividing by 2.2. Then multiply by the ordered dose per kilogram, and compare against the safe range.

High-yield points

• Always convert to the same unit before calculating: 1 g equals 1000 mg, 1 mg equals 1000 mcg, 1 kg equals 2.2 lb, 1 L equals 1000 mL.
• Drops per minute are always rounded to a whole number, because you cannot give part of a drop.
• For a safe-dose check, calculate the range first, then compare the order to it, and hold and clarify if the order is outside the range.
• One teaspoon is 5 mL, one tablespoon is 15 mL, one ounce is 30 mL.
• Read the rounding instruction in the stem: ‘record your answer to one decimal place’ is part of the answer.
• Do not include the unit in the fill-in-the-blank box unless the item asks for it.

IV Therapy, Blood Products and TPN

Solutions, complications and transfusion safety

IV items divide into three groups: which fluid for which problem, which complication is developing, and what to do when a transfusion goes wrong. All three are high-frequency.

Subtopics: IV solution tonicity · Infiltration and phlebitis · Transfusion reactions · Total parenteral nutrition · Central lines

Tonicity

Isotonic solutions such as 0.9 percent sodium chloride and lactated Ringer expand the intravascular space. Hypotonic solutions such as 0.45 percent sodium chloride move fluid into cells. Hypertonic solutions such as 3 percent sodium chloride pull fluid out of cells.

Local complications

Infiltration is cool, pale and swollen. Phlebitis is warm, red and tender along the vein. Extravasation is infiltration of a vesicant and can cause tissue necrosis. Stop the infusion in all three.

Transfusion reaction response

Stop the blood, keep the line open with normal saline using new tubing, stay with the client, take vital signs, then notify the provider and blood bank. Return the bag and tubing.

Total parenteral nutrition

Given through a central line because of its high osmolality. Monitor glucose closely, never stop abruptly, and never speed up or slow down to catch up. If a bag is unavailable, hang 10 percent dextrose.

High-yield points

• Blood is administered with 0.9 percent sodium chloride only; dextrose causes haemolysis.
• Start a transfusion slowly and stay with the client for the first 15 minutes.
• A unit of blood must be infused within four hours.
• Air embolism: clamp the line, place the client left side down with head lowered, give oxygen and call for help.
• Have the client perform the Valsalva manoeuvre during central line tubing changes to prevent air entry.
• A femoral or non-tunnelled central line site that is red and draining needs immediate reporting.
• Lactated Ringer is avoided in liver failure because the liver cannot convert lactate.

Cardiovascular Medications

Digoxin, beta blockers, ACE inhibitors and nitrates

Cardiac drug items nearly always ask what to check before giving, or which finding means toxicity. Learn the parameter and the toxic picture for each class.

Subtopics: Digoxin · Beta blockers · ACE inhibitors and ARBs · Nitrates · Antidysrhythmics

Digoxin

Apical pulse for a full minute, hold under 60 in an adult. Toxicity brings nausea, anorexia, visual halos and dysrhythmias, and low potassium makes it far more likely.

Beta blockers

Hold for a heart rate under 60 or systolic under 100. Never stop abruptly. In diabetes they mask the adrenergic warning signs of hypoglycaemia except sweating.

ACE inhibitors

Dry cough is common and expected. Angioedema is an emergency and permanently contraindicates the class. Watch potassium and renal function.

Nitrates

Sublingual every five minutes for up to three doses. Headache is expected. Contraindicated with phosphodiesterase inhibitors for erectile dysfunction because of profound hypotension.

High-yield points

• Check potassium before giving digoxin, because hypokalaemia potentiates toxicity.
• Amiodarone requires baseline and periodic chest imaging, thyroid studies and eye examination.
• Adenosine is pushed over one to two seconds followed by a rapid flush, and a brief pause on the monitor is expected.
• Statins: report unexplained muscle pain with dark urine, which suggests rhabdomyolysis.
• Teach clients on antihypertensives to change position slowly and to report dizziness.
• Store nitroglycerin in its original dark container and replace it as directed; a tingling sensation is not a reliable potency test.

Anti-Infective Therapy

Antibiotics, antifungals, antivirals and antitubercular drugs

Anti-infective items focus on the toxicity profile and the teaching point. Two rules cover a surprising number of them: obtain cultures before the first dose, and finish the full course.

Subtopics: Antibiotic classes · Culture before antibiotic · Tuberculosis regimens · Antifungal and antiviral agents

Culture first

Obtain culture specimens before starting antibiotics whenever the client’s condition allows, because prior antibiotic exposure can produce a false negative.

Aminoglycosides and vancomycin

Both are nephrotoxic and ototoxic. Monitor trough levels, creatinine and hearing, and ensure good hydration.

Fluoroquinolones

Tendon rupture, QT prolongation and photosensitivity. Separate from antacids, calcium, iron and dairy by at least two hours.

Tuberculosis therapy

Multiple drugs for months. Isoniazid causes peripheral neuropathy, prevented with pyridoxine. Rifampin turns body fluids orange and reduces oral contraceptive effectiveness. Ethambutol affects vision.

High-yield points

• Finish the entire prescribed course even after symptoms resolve.
• Vancomycin infused too quickly causes a flushing reaction; slow the infusion to at least 60 minutes.
• New watery diarrhoea during or after antibiotic therapy suggests C. difficile.
• Report a sore throat, fever or unusual bruising during anti-infective therapy.
• Antifungal azoles interact with many drugs and can be hepatotoxic.
• Antiretroviral adherence must be near-perfect to prevent resistance.

Pain Management and Sedation

Opioids, adjuncts and monitoring

Pain is what the client says it is. The exam consistently rewards believing the client’s report and monitoring respiratory status rather than withholding analgesia out of fear of dependence.

Subtopics: Pain assessment · Opioid safety · PCA pumps · Non-pharmacological measures

Assessment

Self-report is the gold standard. Use a numeric or faces scale for verbal clients, and a behavioural scale such as FLACC for infants or non-verbal clients.

Opioid monitoring

Assess respiratory rate and sedation level before and after. A sedation score that is rising is an earlier warning than a falling respiratory rate.

Patient-controlled analgesia

Only the client presses the button. Family pressing it is a serious safety event and is addressed with immediate teaching.

Constipation never resolves

Tolerance develops to sedation and nausea but not to constipation, so a bowel regimen starts with the opioid.

High-yield points

• Do not withhold opioids from a client in genuine pain because of concern about addiction.
• Naloxone has a shorter half-life than most opioids, so keep monitoring for re-sedation.
• Cap acetaminophen at 4 g in 24 hours for a healthy adult, less with liver disease or alcohol use.
• Check combination analgesics for hidden acetaminophen before adding another dose.
• Give analgesia around the clock for constant pain rather than only on request.
• Non-pharmacological measures such as positioning, heat, cold, distraction and relaxation are adjuncts, not substitutes.

Psychotropic Medications

Antidepressants, mood stabilisers and antipsychotics

Psychotropic items are dominated by three emergencies: serotonin syndrome, hypertensive crisis on an MAO inhibitor, and neuroleptic malignant syndrome. Everything else is teaching.

Subtopics: SSRIs and serotonin syndrome · MAO inhibitors and tyramine · Lithium · Antipsychotic adverse effects

Serotonin syndrome

Agitation, hyperthermia, tremor, diaphoresis, hyperreflexia and diarrhoea, usually after adding a second serotonergic agent. Stop the drugs and support the client.

MAO inhibitors

A tyramine-containing food causes a hypertensive crisis with severe occipital headache. Avoid aged cheese, cured and smoked meats, tap beer, soy sauce, fermented foods and overripe fruit.

Lithium

Therapeutic range 0.6 to 1.2 mEq/L. Dehydration, sodium loss, NSAIDs and thiazides raise the level. Early toxicity brings nausea, coarse tremor and diarrhoea.

Antipsychotic emergencies

Acute dystonia is treated with an anticholinergic. Neuroleptic malignant syndrome requires stopping the drug immediately.

High-yield points

• Antidepressants take four to six weeks for full effect; teach the client not to stop early.
• The risk of suicide can rise as energy returns before mood lifts.
• Clozapine requires ongoing neutrophil monitoring.
• Do not combine an SSRI with an MAO inhibitor; a washout period is required.
• Keep fluid and salt intake steady on lithium and hold the dose for vomiting, diarrhoea or heavy sweating until advised.
• Benzodiazepines are tapered, never stopped abruptly, because withdrawal can cause seizures.

Anticoagulants and Antiplatelets

Monitoring, antidotes and bleeding precautions

This topic is almost pure pattern recognition: match the drug to the laboratory test and to the antidote, then apply bleeding precautions.

Subtopics: Heparin · Warfarin · Direct oral anticoagulants · Bleeding precautions

The pairs

Heparin goes with aPTT and protamine sulfate. Warfarin goes with PT and INR and vitamin K. Enoxaparin needs no routine monitoring.

Heparin-induced thrombocytopenia

A drop in platelets of about 50 percent from baseline during heparin therapy. Stop all heparin, including flushes, and use an alternative anticoagulant.

Warfarin diet

Consistency, not avoidance. A sudden increase in leafy greens lowers the INR; a sudden decrease raises it.

Bleeding precautions

Soft toothbrush, electric razor, no rectal temperatures or suppositories, fall precautions, hold pressure longer after venipuncture.

High-yield points

• Target INR is generally 2 to 3, and 2.5 to 3.5 for a mechanical valve.
• Do not expel the air bubble in a prefilled enoxaparin syringe.
• Give subcutaneous heparin in the abdomen at least five centimetres from the umbilicus, and do not aspirate or massage.
• Report black tarry stools, blood in urine, unusual bruising or a severe headache.
• Many antibiotics and antifungals raise the INR; herbal products such as ginkgo and garlic increase bleeding risk.
• Aspirin and clopidogrel are antiplatelets, not anticoagulants, and do not change the INR.

More NCLEX practice and review

Everything on this site tagged NCLEX lives in the NCLEX category.

Sources

• NCSBN — NCLEX Test Plans (official blueprint and category weights)
• NCSBN — The NCLEX examination (official candidate information)
• DailyMed (US National Library of Medicine) — current drug labelling