Free NCLEX-RN Pharmacology questions
22 original Pharmacology questions on adverse effects, contraindications, interactions, blood and blood products, central venous access devices, dosage calculations, medication administration, pharmacological pain management, total parenteral nutrition, in Next Generation NCLEX formats.
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NCLEX-RN Pharmacology questions
- 22 questions
- Pharmacology
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A client is prescribed amoxicillin 375 mg by mouth every 8 hours. The pharmacy supplies amoxicillin oral suspension 250 mg/5 mL. How many mL will the nurse give for one dose? Round to the nearest tenth if needed.
Correct answer: 7.5
Set up with dimensional analysis, starting from the goal unit (mL): 5 mL / 250 mg x 375 mg = 1,875 / 250 = 7.5 mL. Check: 7.5 mL contains 1.5 times 250 mg, which is 375 mg. Starting with the label fraction keeps mg in the denominator so it cancels with the ordered mg.
Learn this topic: How to calculate oral, liquid, weight-based and IV doses 5-minute lesson
Source: Open RN Nursing Skills 2e, 5.9 Liquid Concentrations · Open RN Nursing Skills 2e, 5.5 Rounding ·
A client who weighs 150 lb is prescribed gentamicin 1.5 mg/kg IV. The vial is labeled 40 mg/mL. How many mL will the nurse draw up? Do not round until the final answer, then round to the nearest tenth.
Correct answer: 2.6
Convert pounds to kilograms by dividing by 2.2: 150 / 2.2 = 68.18 kg. Dose: 1.5 mg/kg x 68.18 kg = 102.27 mg. Volume: 1 mL / 40 mg x 102.27 mg = 2.557 mL, which rounds to 2.6 mL. In one chain: 1 mL/40 mg x 1.5 mg/kg x 1 kg/2.2 lb x 150 lb = 2.6 mL.
Learn this topic: How to calculate oral, liquid, weight-based and IV doses 5-minute lesson
Source: Open RN Nursing Skills 2e, 5.11 Weight-Based Calculations · Open RN Nursing Skills 2e, 5.5 Rounding ·
A client is prescribed 1,000 mL of 0.9% sodium chloride IV over 8 hours. If an infusion pump is used, the nurse programs it at . If the pump fails and the nurse runs the fluid by gravity using tubing with a drop factor of 15 gtt/mL, the nurse regulates the drip at .
Choose the best option from each list to complete the sentence.
Correct answer: 125 mL/hr; 31 gtt/min
A pump is set in mL/hr: 1,000 mL / 8 hr = 125 mL/hr. A gravity drip is set in gtt/min: 125 mL/hr x 15 gtt/mL / 60 min = 31.25, rounded to 31 gtt/min because drops are counted as whole numbers. Always check which unit the device needs before you calculate.
- 1,000 mL divided by 8 hours is 125 mL/hr; 83 mL/hr would be a 12-hour rate, 8 mL/hr confuses the number of hours with the rate, and 62.5 mL/hr would take 16 hours.
- 125 mL/hr x 15 gtt/mL / 60 min = 31.25, so 31 gtt/min; 125 gtt/min assumes 60 gtt/mL microdrip tubing, 8 gtt/min divides 125 by 15, and 1,875 gtt/min forgets to divide by 60 minutes.
Learn this topic: How to calculate oral, liquid, weight-based and IV doses 5-minute lesson
Source: Open RN Nursing Skills 2e, 5.15 IV Infusion by Pump · Open RN Nursing Skills 2e, 5.14 IV Infusion by Gravity · Open RN Nursing Skills 2e, 5.5 Rounding ·
A client with type 2 diabetes is scheduled to receive insulin lispro 6 units subcutaneously with breakfast. At 0730 the client is sweaty and shaky but alert and able to swallow. Point-of-care blood glucose is 62 mg/dL (fasting 70–99 mg/dL). Which action should the nurse take first?
Correct answer: C
A glucose below 70 mg/dL with shakiness and sweating is hypoglycemia, and a client who can swallow is treated right away with 15 g of fast-acting carbohydrate per the agency protocol. Treating the immediate physiological threat comes before notifying the provider, which is still done to discuss the cause and insulin changes. Giving the scheduled rapid-acting insulin now would push the glucose even lower.
- A Giving rapid-acting insulin to a client whose glucose is already 62 mg/dL would drive it lower and could cause severe hypoglycemia.
- B Waiting 15 minutes delays treatment of symptomatic hypoglycemia; the recheck comes after the carbohydrate is given.
- C Correct: an alert client who can swallow receives 15 g of rapidly absorbed carbohydrate immediately per the hypoglycemia protocol.
- D The provider should be notified, but treating the low glucose comes first because the client is symptomatic now.
Learn this topic: How to give insulin, heparin and warfarin safely 5-minute lesson
Source: Open RN Nursing Pharmacology, 9.4 Antidiabetics · MedlinePlus: Blood sugar test ·
The nurse reviews laboratory results for five clients receiving anticoagulants. For each result, indicate whether it is expected for the client's therapy or requires follow-up.
Expected Requires follow-up Continuous IV heparin: aPTT 62 seconds (normal 25–35 seconds; facility protocol target 46–70 seconds) Warfarin for atrial fibrillation: INR 4.8 (normal 0.8–1.1; prescribed target 2.0–3.0) Continuous IV heparin, day 6: platelets 96,000/mm³ (normal 150,000–400,000/mm³; baseline 220,000/mm³) Warfarin for atrial fibrillation: INR 2.6 (normal 0.8–1.1; prescribed target 2.0–3.0) Continuous IV heparin: aPTT 30 seconds (normal 25–35 seconds; facility protocol target 46–70 seconds) Select one option in each row.
Correct answer: Continuous IV heparin: aPTT 62 seconds (normal 25–35 seconds; facility protocol target 46–70 seconds): Expected; Warfarin for atrial fibrillation: INR 4.8 (normal 0.8–1.1; prescribed target 2.0–3.0): Requires follow-up; Continuous IV heparin, day 6: platelets 96,000/mm³ (normal 150,000–400,000/mm³; baseline 220,000/mm³): Requires follow-up; Warfarin for atrial fibrillation: INR 2.6 (normal 0.8–1.1; prescribed target 2.0–3.0): Expected; Continuous IV heparin: aPTT 30 seconds (normal 25–35 seconds; facility protocol target 46–70 seconds): Requires follow-up
On IV heparin the aPTT is meant to be prolonged, roughly 1.5 to 2 times normal, inside the target set by the facility protocol in the order. On warfarin the INR is meant to sit inside the prescribed target, usually 2.0 to 3.0. Results above the target raise bleeding risk, results below it mean the drug is not protecting the client, and a platelet drop of 30% or more on heparin suggests heparin-induced thrombocytopenia.
- Continuous IV heparin: aPTT 62 seconds (normal 25–35 seconds; facility protocol target 46–70 seconds) Expected: an aPTT of 62 seconds is prolonged on purpose and falls inside the protocol target of 46–70 seconds.
- Warfarin for atrial fibrillation: INR 4.8 (normal 0.8–1.1; prescribed target 2.0–3.0) Requires follow-up: an INR of 4.8 is well above the 2.0–3.0 target and puts the client at high risk for bleeding.
- Continuous IV heparin, day 6: platelets 96,000/mm³ (normal 150,000–400,000/mm³; baseline 220,000/mm³) Requires follow-up: platelets fell by more than half from baseline (a drop of 30% or more suggests heparin-induced thrombocytopenia) and are below 100,000/mm³, the level at which the heparin label calls for stopping heparin and evaluating for HIT.
- Warfarin for atrial fibrillation: INR 2.6 (normal 0.8–1.1; prescribed target 2.0–3.0) Expected: an INR of 2.6 is inside the prescribed 2.0–3.0 target for warfarin therapy.
- Continuous IV heparin: aPTT 30 seconds (normal 25–35 seconds; facility protocol target 46–70 seconds) Requires follow-up: an aPTT of 30 seconds is in the normal range, so the heparin is below the protocol target and the dose needs adjustment per protocol.
Learn this topic: How to give insulin, heparin and warfarin safely 5-minute lesson
Source: Open RN Nursing Pharmacology, 6.12 Blood Coagulation Modifiers · DailyMed: Heparin Sodium in Dextrose Injection label · MedlinePlus: Partial thromboplastin time (PTT) · MedlinePlus: Prothrombin time (PT) · MedlinePlus: Platelet count ·
The nurse is preparing insulin and heparin for several clients. Which actions reflect safe practice for these high-alert medications? Select all that apply.
Select all that apply.
Correct answer: A, C, F
ISMP lists all insulin and the anticoagulants as high-alert medications, so their use is built around redundant checks. Before subcutaneous insulin the nurse reviews the current glucose and tells the client the product, dose and purpose. Heparin comes in many strengths, so the label is checked against the order every time.
- A Correct: ISMP guidance has the nurse assess the most current blood glucose before subcutaneous insulin.
- B Incorrect: an insulin pen is never used for more than one client, even with a new needle, because of bloodborne pathogen exposure.
- C Correct: fatal heparin errors have come from choosing the wrong strength, so the product is checked against the order.
- D Incorrect: U-500 insulin is measured only with a U-500 syringe to avoid a dosing error.
- E Incorrect: a verbally reported glucose is never the only source of information for an insulin dose.
- F Correct: telling the client the product name, dose and intended action is part of ISMP's safe insulin practice and gives the client a chance to catch an error.
Learn this topic: How to give insulin, heparin and warfarin safely 5-minute lesson
Source: Open RN Nursing Pharmacology, 9.4 Antidiabetics · Open RN Nursing Pharmacology, 6.12 Blood Coagulation Modifiers · DailyMed: Heparin Sodium in Dextrose Injection label · ISMP List of High-Alert Medications in Acute Care Settings (2024) ·
A client with symptomatic anemia is prescribed 1 unit of packed red blood cells. Consent is signed and the crossmatch is complete. Before the nurse calls for the unit, the client's temperature is 101.0°F (38.3°C); it was 98.6°F (37.0°C) four hours ago. What is the best action by the nurse?
Correct answer: D
A pre-transfusion temperature above 100.4°F (37.8°C) is reported to the provider before the blood is picked up. A new fever would hide the main early sign of a transfusion reaction, and once a unit leaves the blood bank it must be started within about 30 minutes and can't be returned. Clarifying first is the safe choice when data change before a high-risk procedure.
- A Starting with a new fever means a reaction fever couldn't be told apart from the baseline fever, and the provider hasn't been told about the change.
- B Blood is never stored in a unit refrigerator; it must start within about 30 minutes of leaving the blood bank.
- C Acetaminophen has not been prescribed, and treating the fever without telling the provider skips the needed clarification.
- D Correct: a febrile client is reported to the provider before the unit is obtained, because blood can't go back to the bank once it is picked up.
Learn this topic: How nurses give blood safely and spot transfusion reactions 5-minute lesson
Source: Open RN Nursing Advanced Skills, 3.3 Applying the Nursing Process · Open RN Nursing Advanced Skills, 3.4 Checklist: Administer Blood Products ·
Four clients develop new findings while receiving packed red blood cells. For each client, indicate the transfusion reaction the findings are most consistent with.
Acute hemolytic Febrile non-hemolytic Mild allergic Circulatory overload (TACO) At 2 hours: crackles in both lung bases, dyspnea, distended neck veins, BP 172/96 mm Hg (baseline 134/80 mm Hg) At 10 minutes: chills, low back pain, pain along the IV vein, HR 124/min, BP 86/50 mm Hg At 90 minutes: itchy raised welts on the chest; vital signs and breathing unchanged from baseline At 2 hours: temperature 100.9°F (38.3°C) from a baseline of 98.8°F (37.1°C), chills, headache; BP and breathing unchanged Select one option in each row.
Correct answer: At 2 hours: crackles in both lung bases, dyspnea, distended neck veins, BP 172/96 mm Hg (baseline 134/80 mm Hg): Circulatory overload (TACO); At 10 minutes: chills, low back pain, pain along the IV vein, HR 124/min, BP 86/50 mm Hg: Acute hemolytic; At 90 minutes: itchy raised welts on the chest; vital signs and breathing unchanged from baseline: Mild allergic; At 2 hours: temperature 100.9°F (38.3°C) from a baseline of 98.8°F (37.1°C), chills, headache; BP and breathing unchanged: Febrile non-hemolytic
Timing and blood pressure separate these reactions. Acute hemolytic reactions from ABO or Rh mismatch begin within about 15 minutes with chills, back or flank pain, pain along the vein, tachycardia and hypotension. TACO brings crackles, jugular vein distension and hypertension; a febrile non-hemolytic reaction raises the temperature more than 1°C above baseline; a mild allergic reaction causes itching and hives with stable vital signs.
- At 2 hours: crackles in both lung bases, dyspnea, distended neck veins, BP 172/96 mm Hg (baseline 134/80 mm Hg) TACO: crackles, dyspnea, jugular vein distension and a rising blood pressure point to volume overload.
- At 10 minutes: chills, low back pain, pain along the IV vein, HR 124/min, BP 86/50 mm Hg Acute hemolytic: back pain, pain along the vein, tachycardia and hypotension within the first 15 minutes suggest ABO or Rh incompatibility.
- At 90 minutes: itchy raised welts on the chest; vital signs and breathing unchanged from baseline Mild allergic: hives and itching with unchanged vital signs and breathing fit a mild allergic reaction to donor proteins.
- At 2 hours: temperature 100.9°F (38.3°C) from a baseline of 98.8°F (37.1°C), chills, headache; BP and breathing unchanged Febrile non-hemolytic: a temperature rise of more than 1°C from baseline with chills and headache, but stable blood pressure, fits this reaction.
Learn this topic: How nurses give blood safely and spot transfusion reactions 5-minute lesson
Source: Open RN Nursing Advanced Skills, 3.2 Basic Concepts (blood products) · MedlinePlus: Hemolytic transfusion reaction ·
Ten minutes after a unit of packed red blood cells is started, the client reports chills and low back pain. BP is 88/52 mm Hg, down from 128/76 mm Hg. Which actions should the nurse take? Select all that apply.
Select all that apply.
Correct answer: A, C, D
Chills, back pain and hypotension in the first 15 minutes suggest an acute hemolytic reaction. The nurse stops the transfusion, keeps the vein open with saline through new tubing attached at the hub, and notifies the provider and blood bank. The bag and tubing are saved and sent to the lab with blood and urine samples so the cause can be found.
- A Correct: stopping the transfusion immediately limits how much incompatible blood the client receives.
- B Incorrect: flushing the old tubing would push the blood left in the line into the client.
- C Correct: new primed tubing with 0.9% sodium chloride keeps IV access without giving any more of the blood product.
- D Correct: the provider and the blood bank are notified so treatment and the reaction work-up can begin.
- E Incorrect: the bag and tubing are kept and sent to the lab per policy, not thrown away.
- F Incorrect: slowing the rate still delivers incompatible blood; a suspected reaction calls for stopping, not slowing.
Learn this topic: How nurses give blood safely and spot transfusion reactions 5-minute lesson
Source: Open RN Nursing Advanced Skills, 3.2 Basic Concepts (blood products) · Open RN Nursing Advanced Skills, 3.3 Applying the Nursing Process · MedlinePlus: Hemolytic transfusion reaction ·
History
Rafael Ortega, 68 years old, was admitted on Day 1 at 1400 with a deep vein thrombosis (DVT) of the left lower leg. Weight 80 kg (176 lb). History of hypertension. No known allergies.
Orders
- Heparin 25,000 units in 250 mL D5W, continuous IV infusion by pump. Current dose per the facility heparin protocol: 18 units/kg/hour (rate last changed per protocol at 0100 on Day 2).
- aPTT every 6 hours; adjust heparin per the facility protocol (protocol aPTT target 46–70 seconds).
- CBC daily.
Nurses' Notes
Day 2, 0730: Received report. Client states, "I feel lightheaded when I sit up." Passed one large black, tarry stool at 0640. Small amount of blood oozing from gums after brushing teeth. Urine in urinal is pink-tinged. Left calf swollen and tender; circumference unchanged from admission. Alert and oriented x4. Heparin pump display reads 144 mL/hr. Per night-shift report, the heparin bag was replaced three times after 0100.
Vital Signs
Day 1, 1400 Day 2, 0730 Temperature 98.6°F (37.0°C) 98.4°F (36.9°C) Heart rate 82/min 114/min Blood pressure 138/84 mm Hg 100/62 mm Hg Respiratory rate 16/min 22/min SpO2 97% on room air 96% on room air Laboratory Results
Test Day 1, 1300 Day 2, 0600 (resulted 0720) Normal range aPTT 30 seconds 142 seconds 25–35 seconds Hemoglobin 14.6 g/dL 10.9 g/dL 13.8–17.2 g/dL (male) Platelets 248,000/mm³ 236,000/mm³ 150,000–400,000/mm³ The nurse reviews the 0730 assessment. Click to highlight the findings that require immediate follow-up.
Client states feeling . Passed at 0640. Left calf swollen and tender, . Urine is . Client is . Temperature . Heparin pump display reads .
Click each part of the text to highlight it. Click again to remove the highlight.
Correct answer: lightheaded when sitting up; one large black, tarry stool; pink-tinged; 144 mL/hr
Tarry stool and pink urine are signs of bleeding, and lightheadedness with a falling blood pressure and rising heart rate suggests the bleeding is affecting circulation. The ordered dose is 18 units/kg/hr x 80 kg = 1,440 units/hr; the bag holds 25,000 units/250 mL = 100 units/mL, so the correct rate is 14.4 mL/hr. A pump running at 144 mL/hr is delivering 10 times the prescribed dose of a high-alert drug.
- lightheaded when sitting up Requires follow-up: new lightheadedness with tachycardia and a lower blood pressure can signal blood loss.
- one large black, tarry stool Requires follow-up: black, tarry stool is a sign of gastrointestinal bleeding, the chief adverse effect of heparin.
- circumference unchanged from admission Expected: an unchanged calf circumference fits the known DVT and shows no new change.
- pink-tinged Requires follow-up: blood in the urine is a listed sign of heparin overdose.
- alert and oriented x4 Expected: the client is oriented, so there is no new neurological change.
- 98.4°F (36.9°C) Expected: the temperature is normal and similar to admission.
- 144 mL/hr Requires follow-up: the correct rate is 14.4 mL/hr, so 144 mL/hr is a tenfold overdose of heparin.
Learn this topic: How to give insulin, heparin and warfarin safely 5-minute lesson
Source: DailyMed: Heparin Sodium in Dextrose Injection label · MedlinePlus: Heparin injection · Open RN Nursing Pharmacology, 6.12 Blood Coagulation Modifiers · Open RN Nursing Skills 2e, 5.15 IV Infusion by Pump ·
History
Rafael Ortega, 68 years old, was admitted on Day 1 at 1400 with a deep vein thrombosis (DVT) of the left lower leg. Weight 80 kg (176 lb). History of hypertension. No known allergies.
Orders
- Heparin 25,000 units in 250 mL D5W, continuous IV infusion by pump. Current dose per the facility heparin protocol: 18 units/kg/hour (rate last changed per protocol at 0100 on Day 2).
- aPTT every 6 hours; adjust heparin per the facility protocol (protocol aPTT target 46–70 seconds).
- CBC daily.
Nurses' Notes
Day 2, 0730: Received report. Client states, "I feel lightheaded when I sit up." Passed one large black, tarry stool at 0640. Small amount of blood oozing from gums after brushing teeth. Urine in urinal is pink-tinged. Left calf swollen and tender; circumference unchanged from admission. Alert and oriented x4. Heparin pump display reads 144 mL/hr. Per night-shift report, the heparin bag was replaced three times after 0100.
Vital Signs
Day 1, 1400 Day 2, 0730 Temperature 98.6°F (37.0°C) 98.4°F (36.9°C) Heart rate 82/min 114/min Blood pressure 138/84 mm Hg 100/62 mm Hg Respiratory rate 16/min 22/min SpO2 97% on room air 96% on room air Laboratory Results
Test Day 1, 1300 Day 2, 0600 (resulted 0720) Normal range aPTT 30 seconds 142 seconds 25–35 seconds Hemoglobin 14.6 g/dL 10.9 g/dL 13.8–17.2 g/dL (male) Platelets 248,000/mm³ 236,000/mm³ 150,000–400,000/mm³ For each finding, indicate whether it supports or does not support that the client is bleeding because of excess heparin effect.
Supports Does not support aPTT 142 seconds Platelets 236,000/mm³ (admission 248,000/mm³) Hemoglobin 10.9 g/dL, down from 14.6 g/dL Temperature 98.4°F (36.9°C) Heart rate 114/min with blood pressure 100/62 mm Hg Left calf circumference unchanged from admission Select one option in each row.
Correct answer: aPTT 142 seconds: Supports; Platelets 236,000/mm³ (admission 248,000/mm³): Does not support; Hemoglobin 10.9 g/dL, down from 14.6 g/dL: Supports; Temperature 98.4°F (36.9°C): Does not support; Heart rate 114/min with blood pressure 100/62 mm Hg: Supports; Left calf circumference unchanged from admission: Does not support
An aPTT of 142 seconds is about four times the upper normal limit and far above the protocol target, showing excess heparin effect. A falling hemoglobin and a rising heart rate with a falling blood pressure show that blood is being lost. The platelet count is normal and has dropped only about 5%, which argues against heparin-induced thrombocytopenia, and the temperature and calf findings are unchanged.
- aPTT 142 seconds Supports: the aPTT is far above both the normal range (25–35 seconds) and the protocol target (46–70 seconds).
- Platelets 236,000/mm³ (admission 248,000/mm³) Does not support: the count is normal and fell less than 30%, so it is not evidence of bleeding or of heparin-induced thrombocytopenia.
- Hemoglobin 10.9 g/dL, down from 14.6 g/dL Supports: a drop of 3.7 g/dL in less than a day, below the normal range, points to active blood loss.
- Temperature 98.4°F (36.9°C) Does not support: a normal, unchanged temperature does not point to bleeding.
- Heart rate 114/min with blood pressure 100/62 mm Hg Supports: a rising heart rate with a falling blood pressure is a sign of internal bleeding.
- Left calf circumference unchanged from admission Does not support: the unchanged calf reflects the known DVT, not bleeding.
Learn this topic: How to give insulin, heparin and warfarin safely 5-minute lesson
Source: Open RN Nursing Pharmacology, 6.12 Blood Coagulation Modifiers · DailyMed: Heparin Sodium in Dextrose Injection label · MedlinePlus: Partial thromboplastin time (PTT) · MedlinePlus: Hemoglobin · MedlinePlus: Platelet count ·
History
Rafael Ortega, 68 years old, was admitted on Day 1 at 1400 with a deep vein thrombosis (DVT) of the left lower leg. Weight 80 kg (176 lb). History of hypertension. No known allergies.
Orders
- Heparin 25,000 units in 250 mL D5W, continuous IV infusion by pump. Current dose per the facility heparin protocol: 18 units/kg/hour (rate last changed per protocol at 0100 on Day 2).
- aPTT every 6 hours; adjust heparin per the facility protocol (protocol aPTT target 46–70 seconds).
- CBC daily.
Nurses' Notes
Day 2, 0730: Received report. Client states, "I feel lightheaded when I sit up." Passed one large black, tarry stool at 0640. Small amount of blood oozing from gums after brushing teeth. Urine in urinal is pink-tinged. Left calf swollen and tender; circumference unchanged from admission. Alert and oriented x4. Heparin pump display reads 144 mL/hr. Per night-shift report, the heparin bag was replaced three times after 0100.
Vital Signs
Day 1, 1400 Day 2, 0730 Temperature 98.6°F (37.0°C) 98.4°F (36.9°C) Heart rate 82/min 114/min Blood pressure 138/84 mm Hg 100/62 mm Hg Respiratory rate 16/min 22/min SpO2 97% on room air 96% on room air Laboratory Results
Test Day 1, 1300 Day 2, 0600 (resulted 0720) Normal range aPTT 30 seconds 142 seconds 25–35 seconds Hemoglobin 14.6 g/dL 10.9 g/dL 13.8–17.2 g/dL (male) Platelets 248,000/mm³ 236,000/mm³ 150,000–400,000/mm³ Complete the statement. The client is most likely experiencing caused by . The nurse's priority is to prevent .
Choose the best option from each list to complete the sentence.
Correct answer: bleeding from excess anticoagulation; a tenfold infusion rate error; shock from blood loss
The findings fit bleeding from too much heparin: the pump is delivering 144 mL/hr (14,400 units/hr) instead of 14.4 mL/hr (1,440 units/hr), and the aPTT is 142 seconds. The client already has tachycardia, a lower blood pressure and lightheadedness, so circulation is the priority (airway, breathing, circulation). A new clot is a real risk but is less immediate than ongoing blood loss.
- Bleeding from excess anticoagulation fits the tarry stool, pink urine, falling hemoglobin and very high aPTT; platelets are normal, which argues against HIT, and nothing suggests infection or clot extension.
- The pump is running at 144 mL/hr, 10 times the calculated 14.4 mL/hr; the platelet drop is only about 5%, and the very high aPTT shows too much heparin, not too little.
- Tachycardia, lower blood pressure and lightheadedness show blood loss is affecting circulation, which takes priority over clot or skin concerns.
Learn this topic: How to give insulin, heparin and warfarin safely 5-minute lesson
Source: Open RN Nursing Pharmacology, 6.12 Blood Coagulation Modifiers · DailyMed: Heparin Sodium in Dextrose Injection label · Open RN Nursing Skills 2e, 5.15 IV Infusion by Pump ·
History
Rafael Ortega, 68 years old, was admitted on Day 1 at 1400 with a deep vein thrombosis (DVT) of the left lower leg. Weight 80 kg (176 lb). History of hypertension. No known allergies.
Orders
- Heparin 25,000 units in 250 mL D5W, continuous IV infusion by pump. Current dose per the facility heparin protocol: 18 units/kg/hour (rate last changed per protocol at 0100 on Day 2).
- aPTT every 6 hours; adjust heparin per the facility protocol (protocol aPTT target 46–70 seconds).
- CBC daily.
Nurses' Notes
Day 2, 0730: Received report. Client states, "I feel lightheaded when I sit up." Passed one large black, tarry stool at 0640. Small amount of blood oozing from gums after brushing teeth. Urine in urinal is pink-tinged. Left calf swollen and tender; circumference unchanged from admission. Alert and oriented x4. Heparin pump display reads 144 mL/hr. Per night-shift report, the heparin bag was replaced three times after 0100.
Vital Signs
Day 1, 1400 Day 2, 0730 Temperature 98.6°F (37.0°C) 98.4°F (36.9°C) Heart rate 82/min 114/min Blood pressure 138/84 mm Hg 100/62 mm Hg Respiratory rate 16/min 22/min SpO2 97% on room air 96% on room air Laboratory Results
Test Day 1, 1300 Day 2, 0600 (resulted 0720) Normal range aPTT 30 seconds 142 seconds 25–35 seconds Hemoglobin 14.6 g/dL 10.9 g/dL 13.8–17.2 g/dL (male) Platelets 248,000/mm³ 236,000/mm³ 150,000–400,000/mm³ The nurse plans care for the client. Which actions should the nurse include? Select all that apply.
Select all that apply.
Correct answer: A, C, E
New bleeding on heparin is reported to the provider immediately. Protamine sulfate, given by slow IV infusion, is the reversal agent for heparin, and frequent vital signs and bleeding checks show whether the client is stabilizing. Vitamin K reverses warfarin, aspirin adds to bleeding risk, and heparin is avoided in major bleeding unless the provider decides the benefit outweighs the risk.
- A Correct: new signs of bleeding and vital sign changes on heparin are reported to the provider immediately.
- B Incorrect: vitamin K reverses warfarin, not heparin.
- C Correct: protamine sulfate by slow infusion neutralizes heparin when bleeding requires reversal.
- D Incorrect: heparin is avoided during major bleeding unless the provider judges the benefit greater than the risk; restarting is not the nurse's decision.
- E Correct: frequent vital signs and bleeding assessment track whether the hemorrhage is slowing.
- F Incorrect: aspirin is avoided with heparin because it increases bleeding risk.
Learn this topic: How to give insulin, heparin and warfarin safely 5-minute lesson
Source: Open RN Nursing Pharmacology, 6.12 Blood Coagulation Modifiers · DailyMed: Heparin Sodium in Dextrose Injection label ·
History
Rafael Ortega, 68 years old, was admitted on Day 1 at 1400 with a deep vein thrombosis (DVT) of the left lower leg. Weight 80 kg (176 lb). History of hypertension. No known allergies.
Orders
- Heparin 25,000 units in 250 mL D5W, continuous IV infusion by pump. Current dose per the facility heparin protocol: 18 units/kg/hour (rate last changed per protocol at 0100 on Day 2).
- aPTT every 6 hours; adjust heparin per the facility protocol (protocol aPTT target 46–70 seconds).
- CBC daily.
Nurses' Notes
Day 2, 0730: Received report. Client states, "I feel lightheaded when I sit up." Passed one large black, tarry stool at 0640. Small amount of blood oozing from gums after brushing teeth. Urine in urinal is pink-tinged. Left calf swollen and tender; circumference unchanged from admission. Alert and oriented x4. Heparin pump display reads 144 mL/hr. Per night-shift report, the heparin bag was replaced three times after 0100.
Vital Signs
Day 1, 1400 Day 2, 0730 Temperature 98.6°F (37.0°C) 98.4°F (36.9°C) Heart rate 82/min 114/min Blood pressure 138/84 mm Hg 100/62 mm Hg Respiratory rate 16/min 22/min SpO2 97% on room air 96% on room air Laboratory Results
Test Day 1, 1300 Day 2, 0600 (resulted 0720) Normal range aPTT 30 seconds 142 seconds 25–35 seconds Hemoglobin 14.6 g/dL 10.9 g/dL 13.8–17.2 g/dL (male) Platelets 248,000/mm³ 236,000/mm³ 150,000–400,000/mm³ The nurse confirms that the pump is infusing heparin at 144 mL/hr. Which action should the nurse take first?
Correct answer: C
Safety principle: when an infusion is actively harming the client, remove the source of harm first. The pump is delivering 10 times the prescribed dose of a high-alert anticoagulant to a client who is already bleeding, and the heparin label says heparin should be discontinued promptly when the clotting test is unduly prolonged or hemorrhage occurs. Stopping the pump is within the nurse's scope, while reversal with protamine sulfate needs a provider's order, so the provider is notified immediately after; the error report comes once the client is safe.
- A The provider must be called right away, but every minute the pump runs delivers about 240 units of heparin instead of the prescribed 24, so stopping it comes first.
- B A repeat aPTT delays action; the current aPTT and the bleeding already confirm excess heparin effect.
- C Correct: stopping the infusion ends the overdose immediately, which is the safety priority.
- D The error must be reported, but paperwork never comes before protecting the client.
Learn this topic: How to give insulin, heparin and warfarin safely 5-minute lesson
Source: DailyMed: Heparin Sodium in Dextrose Injection label · Open RN Nursing Pharmacology, 6.12 Blood Coagulation Modifiers · ISMP List of High-Alert Medications in Acute Care Settings (2024) ·
History
Rafael Ortega, 68 years old, was admitted on Day 1 at 1400 with a deep vein thrombosis (DVT) of the left lower leg. Weight 80 kg (176 lb). History of hypertension. No known allergies.
Orders
- Heparin 25,000 units in 250 mL D5W, continuous IV infusion by pump. Current dose per the facility heparin protocol: 18 units/kg/hour (rate last changed per protocol at 0100 on Day 2).
- aPTT every 6 hours; adjust heparin per the facility protocol (protocol aPTT target 46–70 seconds).
- CBC daily.
Nurses' Notes
Day 2, 0730: Received report. Client states, "I feel lightheaded when I sit up." Passed one large black, tarry stool at 0640. Small amount of blood oozing from gums after brushing teeth. Urine in urinal is pink-tinged. Left calf swollen and tender; circumference unchanged from admission. Alert and oriented x4. Heparin pump display reads 144 mL/hr. Per night-shift report, the heparin bag was replaced three times after 0100.
Vital Signs
Day 1, 1400 Day 2, 0730 Temperature 98.6°F (37.0°C) 98.4°F (36.9°C) Heart rate 82/min 114/min Blood pressure 138/84 mm Hg 100/62 mm Hg Respiratory rate 16/min 22/min SpO2 97% on room air 96% on room air Laboratory Results
Test Day 1, 1300 Day 2, 0600 (resulted 0720) Normal range aPTT 30 seconds 142 seconds 25–35 seconds Hemoglobin 14.6 g/dL 10.9 g/dL 13.8–17.2 g/dL (male) Platelets 248,000/mm³ 236,000/mm³ 150,000–400,000/mm³ The heparin infusion was stopped at 0735, and protamine sulfate was given by slow IV infusion as prescribed at 0800. At 1200, the nurse reassesses the client. For each finding, indicate whether it shows improvement or needs further follow-up.
Improved Needs further follow-up aPTT 38 seconds (25–35 seconds) Urine in urinal still pink-tinged Heart rate 90/min, blood pressure 124/78 mm Hg Hemoglobin 10.7 g/dL (13.8–17.2 g/dL) Client says the lightheadedness is gone New 4-cm bruise on the left upper arm under the blood pressure cuff Select one option in each row.
Correct answer: aPTT 38 seconds (25–35 seconds): Improved; Urine in urinal still pink-tinged: Needs further follow-up; Heart rate 90/min, blood pressure 124/78 mm Hg: Improved; Hemoglobin 10.7 g/dL (13.8–17.2 g/dL): Needs further follow-up; Client says the lightheadedness is gone: Improved; New 4-cm bruise on the left upper arm under the blood pressure cuff: Needs further follow-up
The aPTT has fallen from 142 to 38 seconds and the heart rate, blood pressure and lightheadedness have returned toward baseline, so the overdose has been reversed. Ongoing blood in the urine, a hemoglobin that is still low and a new bruise show that bleeding has not fully resolved and still need monitoring and reporting.
- aPTT 38 seconds (25–35 seconds) Improved: the aPTT dropped from 142 to 38 seconds, close to normal, showing the heparin effect has been reversed.
- Urine in urinal still pink-tinged Needs follow-up: pink urine means some bleeding continues.
- Heart rate 90/min, blood pressure 124/78 mm Hg Improved: heart rate and blood pressure are back near the admission values, showing better circulation.
- Hemoglobin 10.7 g/dL (13.8–17.2 g/dL) Needs follow-up: hemoglobin is still well below normal and has not recovered, so the provider needs this trend.
- Client says the lightheadedness is gone Improved: the lightheadedness has resolved along with the blood pressure, suggesting circulation has improved.
- New 4-cm bruise on the left upper arm under the blood pressure cuff Needs follow-up: a new bruise is a sign of ongoing bleeding tendency and must be monitored.
Learn this topic: How to give insulin, heparin and warfarin safely 5-minute lesson
Source: Open RN Nursing Pharmacology, 6.12 Blood Coagulation Modifiers · DailyMed: Heparin Sodium in Dextrose Injection label · MedlinePlus: Partial thromboplastin time (PTT) · MedlinePlus: Hemoglobin ·
A client returns from abdominal surgery with patient-controlled analgesia (PCA) delivering IV morphine. Which actions by the nurse are appropriate? Select all that apply.
Select all that apply.
Correct answer: B, C, D
A PCA is safe because a client who is too sedated cannot press the button, so no one else, not even the nurse, presses it. A second RN verifies the programming when the PCA starts, and the nurse monitors respiratory rate, SpO2, sedation level and mental status, because sedation usually comes before respiratory depression. Uncontrolled pain is reported to the provider rather than handled by changing the pump limits.
- A "PCA by proxy" defeats the safety design and can cause oversedation and respiratory depression.
- B Correct: the client must be alert enough to press the button, which is the built-in safeguard against overdose.
- C Correct: agency policy has another RN verify the order and pump programming when a PCA is started.
- D Correct: clients on PCA opioids are watched closely for oversedation and respiratory depression.
- E A bowel program is started with the first opioid dose and continued, because opioids slow peristalsis.
- F The lockout and hourly limits are prescribed safety settings; ongoing pain is reported to the provider, not fixed by changing the limits.
Source: Open RN Nursing Advanced Skills, 1.7 Specialized Infusions · Open RN Nursing Fundamentals 2e, 11.4 Pain Management ·
A client's central venous catheter was placed 9 days ago for IV antibiotics. The last dose was given yesterday, and no further IV therapy is planned. Which action by the nurse best reduces the client's risk of a central line-associated bloodstream infection (CLABSI)?
Correct answer: C
Every day a central line stays in is another day of CLABSI risk, so the line's necessity is reviewed daily and a catheter that is no longer essential is removed promptly. Extra flushing, daily dressing changes and scheduled catheter replacement add handling without lowering risk. The nurse advocates for removal by raising it with the provider.
- A Flushing keeps an unneeded line in place and adds handling; it does not reduce infection risk.
- B Transparent dressings are changed at least every 7 days and when damp, loose or soiled, not every day.
- C Correct: CDC recommends promptly removing any intravascular catheter that is no longer essential.
- D CDC advises against routinely replacing central lines to prevent infection.
Learn this topic: How nurses care for central lines and keep TPN safe 5-minute lesson
Source: CDC: Summary of Recommendations, Guidelines for the Prevention of Intravascular Catheter-Related Infections · Open RN Nursing Advanced Skills, 4.2 Basic Concepts (central venous access devices) · Open RN Nursing Advanced Skills, 4.3 Applying the Nursing Process (central venous access devices) ·
A client has received total parenteral nutrition (TPN) through a peripherally inserted central catheter (PICC) for 4 days. For each finding, indicate whether it is expected (acceptable for safe TPN care) or requires follow-up.
Expected Requires follow-up Capillary blood glucose 118 mg/dL (random; usually 125 mg/dL or lower) Temperature 101.4°F (38.6°C) with chills Transparent dressing dated 2 days ago, clean, dry and intact Current TPN bag hung 30 hours ago and still infusing Capillary blood glucose 262 mg/dL Upper arm circumference unchanged from baseline Select one option in each row.
Correct answer: Capillary blood glucose 118 mg/dL (random; usually 125 mg/dL or lower): Expected; Temperature 101.4°F (38.6°C) with chills: Requires follow-up; Transparent dressing dated 2 days ago, clean, dry and intact: Expected; Current TPN bag hung 30 hours ago and still infusing: Requires follow-up; Capillary blood glucose 262 mg/dL: Requires follow-up; Upper arm circumference unchanged from baseline: Expected
TPN care centers on three risks: hyperglycemia from the dextrose, infection because the nutrients support microbial growth, and problems with the line itself. A normal glucose, a current intact dressing and an unchanged arm circumference are reassuring. Fever with chills, a glucose well above the usual range and a bag that has hung longer than 24 hours all need action.
- Capillary blood glucose 118 mg/dL (random; usually 125 mg/dL or lower) Expected: a random glucose of 125 mg/dL or lower is in the usual range.
- Temperature 101.4°F (38.6°C) with chills Requires follow-up: fever and chills can be early signs of infection in a client receiving TPN.
- Transparent dressing dated 2 days ago, clean, dry and intact Expected: transparent dressings are changed at least every 7 days and when damp, loose or soiled.
- Current TPN bag hung 30 hours ago and still infusing Requires follow-up: the label says to complete the infusion within 24 hours, so a bag still running after 30 hours is past that limit.
- Capillary blood glucose 262 mg/dL Requires follow-up: dextrose given faster than it can be used causes hyperglycemia, which is monitored and treated.
- Upper arm circumference unchanged from baseline Expected: an increase of 3 cm or more would suggest thrombosis; no change is reassuring.
Learn this topic: How nurses care for central lines and keep TPN safe 5-minute lesson
Source: DailyMed: Clinimix E (amino acids with electrolytes in dextrose with calcium) injection label · Open RN Nursing Advanced Skills, 4.3 Applying the Nursing Process (central venous access devices) · MedlinePlus: Blood sugar test ·
A subclavian central venous catheter is placed at the bedside without fluoroscopy. Before the catheter is used, the nurse makes sure that . Two hours later, the client reports sharp chest pain that worsens with each breath and shortness of breath; SpO2 is 88%. All lumens are capped and clamped, and no line has been opened. The nurse suspects and should .
Choose the best option from each list to complete the sentence.
Correct answer: a chest X-ray confirms the tip position; a pneumothorax; stay, call for help and give oxygen
When fluoroscopy is not used during insertion, a chest X-ray confirms the catheter tip position and also checks for a pneumothorax, which can happen if the needle punctures the lung. Sharp, stabbing chest pain that worsens on inspiration with dyspnea after a neck or chest insertion points to pneumothorax rather than air embolism, especially with a closed system. The nurse stays with the client, calls for help and the rapid response team, and gives high-flow oxygen.
- A post-procedure chest X-ray confirms tip placement when fluoroscopy was not used; a dated dressing and a normal glucose do not show where the tip is.
- Sharp chest pain that worsens with breathing after a subclavian insertion fits pneumothorax; air embolism needs air entry through an open line, and CLABSI causes fever, not sudden pleuritic pain.
- For pneumothorax, the nurse stays, calls for help and gives high-flow oxygen; the left-side, head-down position is for air embolism, and flushing does not treat a collapsed lung.
Learn this topic: How nurses care for central lines and keep TPN safe 5-minute lesson
Source: Open RN Nursing Advanced Skills, 4.2 Basic Concepts (central venous access devices) · Open RN Nursing Advanced Skills, 4.3 Applying the Nursing Process (central venous access devices) ·
For each anticoagulant, indicate the agent used to reverse it when serious bleeding or an overdose occurs.
Protamine sulfate Vitamin K (phytonadione) Idarucizumab Continuous IV heparin Warfarin Dabigatran Enoxaparin Select one option in each row.
Correct answer: Continuous IV heparin: Protamine sulfate; Warfarin: Vitamin K (phytonadione); Dabigatran: Idarucizumab; Enoxaparin: Protamine sulfate
Each anticoagulant has its own reversal plan. Protamine sulfate neutralizes heparin and partly neutralizes enoxaparin, vitamin K reverses warfarin, and idarucizumab reverses only dabigatran. Giving the wrong agent wastes time and adds its own risks.
- Continuous IV heparin Protamine sulfate: protamine by slow infusion neutralizes heparin.
- Warfarin Vitamin K (phytonadione): warfarin blocks vitamin K-dependent clotting factors, so vitamin K is its reversal agent.
- Dabigatran Idarucizumab: it is the specific reversal agent for dabigatran and has no effect on other anticoagulants.
- Enoxaparin Protamine sulfate: slow IV protamine largely neutralizes enoxaparin, although anti-factor Xa activity is never fully reversed.
Learn this topic: How nurses keep clients on anticoagulants from bleeding 5-minute lesson
Source: Open RN Nursing Pharmacology, 6.12 Blood Coagulation Modifiers · DailyMed: Enoxaparin Sodium Injection label · DailyMed: Idarucizumab injection label · DailyMed: Dabigatran etexilate capsules label ·
A client who had spinal anesthesia for knee surgery will give enoxaparin injections at home. Which statements by the client show correct understanding? Select all that apply.
Select all that apply.
Correct answer: B, D, E
Enoxaparin goes into a pinched fold of abdominal skin, using the whole needle and holding the fold during the injection, and sites alternate between the left and right sides. The air bubble in the prefilled syringe stays in to avoid losing drug, and the site is not rubbed, which limits bruising. After spinal anesthesia, numbness, tingling or leg weakness is reported immediately because it can signal a spinal hematoma, and NSAIDs are avoided because they add to bleeding risk.
- A The label says not to expel the air bubble from the prefilled syringe, to avoid losing drug.
- B Correct: the whole needle goes into a skin fold on the abdomen that is held throughout the injection.
- C Rubbing the site after the injection increases bruising and is avoided.
- D Correct: injections alternate between the left and right sides of the abdomen.
- E Correct: numbness, tingling or leg weakness after spinal anesthesia can signal a spinal or epidural hematoma and is reported at once.
- F NSAIDs such as ibuprofen increase bleeding risk with enoxaparin and are avoided unless the provider approves.
Learn this topic: How nurses keep clients on anticoagulants from bleeding 5-minute lesson
Source: DailyMed: Enoxaparin Sodium Injection label · MedlinePlus: Enoxaparin Injection · Open RN Nursing Pharmacology, 6.12 Blood Coagulation Modifiers ·
A client with atrial fibrillation starts apixaban 5 mg by mouth twice daily. Which statement by the client shows that the teaching was effective?
Correct answer: D
Stopping apixaban early raises the risk of stroke and other clots, so the client does not stop it without the prescriber's direction. A missed dose is taken the same day as soon as remembered, and the dose is never doubled. Routine PT/INR checks are not useful for monitoring apixaban, but bleeding signs such as black stools or pink urine are reported.
- A The label says a missed dose should not be doubled; it is taken the same day as soon as possible.
- B Minor bruising is expected with anticoagulants; stopping the drug on one's own raises the risk of stroke and clots.
- C Changes in PT, INR and aPTT with apixaban are small and variable, so they are not used to monitor or adjust the dose.
- D Correct: premature discontinuation increases the risk of thrombotic events, so the drug is stopped only on the prescriber's advice.
Learn this topic: How nurses keep clients on anticoagulants from bleeding 5-minute lesson
Source: DailyMed: Apixaban tablets label · MedlinePlus: Apixaban ·
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|---|---|
| Management of Care | 15–21% |
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