Pharmacology
NCLEX® practice.

Free practice set · 9 questions

9 more free pharmacology NCLEX-RN® practice questions

Real questions from the same bank the app serves. Pick an answer in your head, then open the rationale to see why the correct option holds and why each other option falls short. No account needed for these.

1. Question 1 of 9 · Medication Administration & Safety

   A 9-year-old child weighing 30 kg is admitted with acute leukemia. The health care provider writes the following order: "Vincristine (Oncovin) 1.5 mg IV push stat for leukemia induction therapy." The child's allergy list documents a documented reaction to latex (anaphylaxis). The chart shows a 22-gauge peripheral IV catheter inserted in the left forearm 2 hours ago with no signs of infiltration. The nurse reviews the order and notes this is the first dose of the chemotherapy protocol. No independent double-check has yet been performed.

   1. AAdminister the vincristine through the peripheral catheter but monitor the site every 5 minutes for the first 30 minutes after administration.
   2. BDocument the allergy and infiltration assessment in the EHR, then proceed with administration once charting is complete.
   3. CAdminister the vincristine IV push immediately via the peripheral catheter since the catheter is patent and the order is valid.
   4. DRequest an independent double-check from a second RN of the drug, dose, concentration, and IV access before administering.
   Show the answer and rationale

   Correct answer: D. Request an independent double-check from a second RN of the drug, dose, concentration, and IV access before administering.

   Vincristine is a vesicant chemotherapy agent and an ISMP high-alert medication that requires two critical safety controls before administration. First, an independent double-check by a second RN must verify the drug name, dose (1.5 mg for this 30 kg child), concentration, and client identification from the original order, not from the administering nurse's statements, before any administration occurs. Second, vincristine must be administered through a central venous access device (CVAD), not a peripheral IV, because extravasation of vesicant chemotherapy causes severe tissue necrosis. This client has only a 22-gauge peripheral catheter, which is inappropriate for vesicant chemotherapy. The latex allergy (anaphylaxis) adds a third consideration: non-latex gloves and equipment must be used throughout preparation and administration. Requesting an independent double-check satisfies the ISMP requirement for high-alert medications and provides a safety moment to address the route concern: the second RN will identify that central access is required and escalate the order before any administration.

   A. Administer the vincristine through the peripheral catheter but monitor the site every 5 minutes for the first 30 minutes after administration.

   Violates the route requirement for vesicant chemotherapy and the high-alert medication rule. Vincristine must be administered via central venous access (PICC, tunneled catheter, or implanted port), not peripheral IV, because extravasation causes tissue necrosis. Frequent monitoring of a peripheral site does not mitigate the risk of a vesicant administered through an inappropriate route. An independent double-check and central access are required before administration.

   B. Document the allergy and infiltration assessment in the EHR, then proceed with administration once charting is complete.

   Violates 'Verify all six rights before administering.' Documentation (charting the allergy and assessing the catheter) is necessary but insufficient when a critical safety issue exists. The nurse must act, not just document, by requesting an independent double-check and escalating the route concern to the health care provider before proceeding. Documentation alone does not prevent a medication error.

   C. Administer the vincristine IV push immediately via the peripheral catheter since the catheter is patent and the order is valid.

   Violates 'Independent double-check before high-alert medication administration.' Vincristine is a high-alert chemotherapy requiring second-RN verification before administration; proceeding without this check omits a mandatory safety control. Additionally, this option violates the route requirement: vincristine is a vesicant and must not be given via peripheral IV. The peripheral catheter cannot safely deliver this drug.

   D. Request an independent double-check from a second RN of the drug, dose, concentration, and IV access before administering.

   Correct. Vincristine is a ISMP high-alert vesicant chemotherapy requiring an independent double-check before administration per the rule: 'Independent double-check before high-alert medication administration.' The second RN verifies drug, dose, concentration, and IV access (which will reveal the peripheral route is contraindicated for vesicant agents). This check is the critical safety control that prevents both wrong drug/dose errors and inappropriate route selection.

2. Question 2 of 9 · Adverse Effects, Contraindications & Interactions

   A 68-year-old woman with rheumatoid arthritis is in an emergency-department observation area on postoperative day 3. The order reads: “Infliximab (Remicade) 5 mg/kg IV infusion once today for rheumatoid arthritis; prescriber: Elena Morris, MD; ordered 06/18/2026 at 1400.” She has penicillin anaphylaxis and latex rash, but no biologic reaction. Temperature is 100.6°F (38.1°C), with a new productive cough; WBC is 3,800/mm³, ANC 1,200/mm³, K+ 4.1 mEq/L, INR 1.1, and creatinine 0.8 mg/dL. Medications include methotrexate, prednisone, acetaminophen, and an herbal multivitamin; a chest radiograph 2 months ago was clear after treated latent tuberculosis. Which action should the nurse take first?

   1. AAdminister the infusion, then notify the health care provider about the fever and leukopenia.
   2. BAsk assistive personnel to complete medication reconciliation while the nurse starts the infusion for another client.
   3. CDocument the cough, temperature, and WBC count, then continue the infusion because tuberculosis was treated.
   4. DHold the infliximab, assess the respiratory findings, notify the health care provider, and document the held dose.
   Show the answer and rationale

   Correct answer: D. Hold the infliximab, assess the respiratory findings, notify the health care provider, and document the held dose.

   Hold the infliximab before administration, assess the new respiratory illness, notify the health care provider, and document the decision. The six rights of medication administration include the right assessment and right response, not merely matching the drug, dose, route, and client. This client has fever, productive cough, leukopenia, and an ANC of 1,200/mm³, findings that require evaluation before immunosuppressive therapy. Her treated latent tuberculosis and clear recent radiograph do not erase the current infection concern. Penicillin anaphylaxis is not cross-reactivity with infliximab, and the listed medications and laboratory values do not establish a separate interaction or renal contraindication. The dose should resume only after a new order.

   A. Administer the infusion, then notify the health care provider about the fever and leukopenia.

   Administering first violates the hold-parameter safety rule and reverses the required sequence: hold, assess, notify, then resume only with a new order. The 100.6°F fever, new productive cough, and ANC 1,200/mm³ must be evaluated before infliximab is given.

   B. Ask assistive personnel to complete medication reconciliation while the nurse starts the infusion for another client.

   Medication reconciliation and medication-administration decisions require the registered nurse’s assessment and clinical judgment; they cannot be shifted to assistive personnel while the nurse proceeds. Delegating this work would also fail to address the client’s immediate infection and leukopenia concerns.

   C. Document the cough, temperature, and WBC count, then continue the infusion because tuberculosis was treated.

   Documentation is required but cannot replace clinical intervention when a potentially active infection and leukopenia are present. Treated latent tuberculosis and a clear radiograph from 2 months ago are not reasons to ignore today’s fever and productive cough.

   D. Hold the infliximab, assess the respiratory findings, notify the health care provider, and document the held dose.

   This action applies the six rights of medication administration by completing the right assessment and right response before giving an immunosuppressant. Fever, productive cough, WBC 3,800/mm³, and ANC 1,200/mm³ make holding and prompt provider notification safer than infusion.

3. Question 3 of 9 · Medication Administration & Safety

   A 68-year-old client with history of penicillin anaphylaxis (angioedema) is admitted to the surgical unit post-op day 1 following hip replacement. The client weighs 72 kg. Current medications include metoprolol 25 mg PO BID for hypertension. Recent labs: K+ 4.2 mEq/L, apical pulse 62 bpm, SBP 118 mmHg. The health care provider has written the following order: "Cephalexin 500 mg PO QID for surgical site prophylaxis. Date/time: today 0800. Prescriber: Dr. Chen." The charge nurse asks you to administer the first dose at 0900. Before proceeding, you review the order against the client's allergies and active medication list.

   1. AContact the clinical pharmacist and request a pharmacy-to-prescriber consultation before any administration decision is made.
   2. BAdminister cephalexin but monitor closely for any signs of allergy; the apical pulse of 62 indicates the client can tolerate the medication.
   3. CProceed with administration; cephalosporins have a different chemical structure and do not cross-react with penicillin allergy.
   4. DHold the dose and contact the prescriber to discuss the penicillin cross-reactivity risk and request an alternative antibiotic.
   Show the answer and rationale

   Correct answer: D. Hold the dose and contact the prescriber to discuss the penicillin cross-reactivity risk and request an alternative antibiotic.

   Before administering any medication, the nurse must independently verify the absence of documented allergies and prior severe reactions, including class cross-reactivity. This client has documented anaphylaxis (angioedema) to penicillin. First-generation cephalosporins like cephalexin share a beta-lactam ring structure with penicillins and carry a clinically significant cross-reactivity risk of 1–3% for anaphylaxis in penicillin-allergic clients. The six rights verification (right drug, right dose, right route, right time, right client) cannot proceed until this contraindication is clarified. Holding the dose and contacting the prescriber to request an alternative antibiotic (e.g., clindamycin or fluoroquinolone) is the standard-of-care action. The prescriber may choose to proceed with caution or substitute a different class entirely. The nurse cannot override the allergy documentation or assume tolerance without explicit prescriber review.

   A. Contact the clinical pharmacist and request a pharmacy-to-prescriber consultation before any administration decision is made.

   Escalates to the wrong role and violates the scope rule. While pharmacists are valuable consultants, the RN already has sufficient information to act: a documented penicillin anaphylaxis and a known cross-reactivity risk with the ordered drug. The RN's independent duty is to screen for contraindications and notify the prescriber directly, not to delegate the decision to pharmacy.

   B. Administer cephalexin but monitor closely for any signs of allergy; the apical pulse of 62 indicates the client can tolerate the medication.

   Administering a contraindicated drug overlooks the contraindication. The apical pulse of 62 is normal (metoprolol-induced bradycardia is expected and not a contraindication to cephalexin); this vital sign does not govern the allergy decision. The appropriate action is to hold, not monitor after administration.

   C. Proceed with administration; cephalosporins have a different chemical structure and do not cross-react with penicillin allergy.

   Missing documented cross-reactivity overlooks the contraindication. First-generation cephalosporins have a beta-lactam nucleus similar to penicillins; cross-reactivity rates are well-documented and clinically significant for anaphylaxis-level allergies.

   D. Hold the dose and contact the prescriber to discuss the penicillin cross-reactivity risk and request an alternative antibiotic.

   Correct. This action satisfies the contraindication screen rule: the nurse recognizes the documented penicillin anaphylaxis and identifies first-generation cephalosporin cross-reactivity as a clinically significant risk. Holding and notifying the prescriber ensures the prescriber is aware of the allergy and can choose an appropriate alternative.

4. Question 4 of 9 · Medication Administration & Safety

   A nurse receives the following medication order for a 14-year-old client: "Morphine 2 mg IV push every 4 hours as needed for pain." The client's weight is 45 kg. The allergy history documents a previous episode of nausea and vomiting after morphine administration, but no anaphylaxis or respiratory depression documented. The order was written by the prescriber at 0800 on the current date. After verifying the client's identity using two identifiers and reviewing the original medication order in the EHR, the nurse prepares the prescribed dose and concentration. Before administering this IV medication, which action is most appropriate?

   1. AAdminister the morphine IV push now and document that a second RN co-signed the MAR immediately after administration.
   2. BDocument the prior history of nausea and vomiting in the EHR but proceed with administration since anaphylaxis was not reported.
   3. CRequest a second RN to independently verify the drug, dose, concentration, and client identification before administering the morphine.
   4. DAdminister the morphine now and evaluate the client's pain relief in 2 minutes to confirm the medication's effectiveness.
   Show the answer and rationale

   Correct answer: C. Request a second RN to independently verify the drug, dose, concentration, and client identification before administering the morphine.

   Morphine is an ISMP-designated high-alert medication requiring an independent double-check before administration. The rule (the "independent double-check before high-alert medication administration" rule) mandates that a second RN independently verify the drug (morphine), dose (2 mg), concentration (preparation strength), pump settings (for IV delivery), and client identification BEFORE the first nurse administers it. The second RN must verify directly from the original order in the EHR, not by accepting the first nurse's statement. Although the client has a documented history of nausea and vomiting after morphine, this reaction is not a contraindication to administration (no anaphylaxis, no respiratory depression); premedication with an antiemetic or heightened postadministration monitoring may be appropriate, but the dose itself is not unsafe. The independent double-check is the critical safety control that must occur before the nurse pushes any amount of this high-alert opioid.

   A. Administer the morphine IV push now and document that a second RN co-signed the MAR immediately after administration.

   This violates the "independent double-check before high-alert medication administration" rule. Co-signing the MAR after administration is documentation, not an independent double-check. The independent verification must occur BEFORE administration so that a second set of eyes confirms the drug, dose, concentration, and client match before the medication enters the client's body. 'After the fact' co-signing does not prevent administration errors.

   B. Document the prior history of nausea and vomiting in the EHR but proceed with administration since anaphylaxis was not reported.

   This violates the "verify all six rights before administering any medication" rule in its full scope. While documenting the allergy history is necessary, documentation alone is insufficient. The nurse must evaluate whether the prior nausea and vomiting warrant premedication (e.g., an antiemetic), a delay pending prescriber discussion, or heightened monitoring. Documentation without clinical action does not address the client's known risk. Moreover, skipping the independent double-check for this high-alert medication remains required.

   C. Request a second RN to independently verify the drug, dose, concentration, and client identification before administering the morphine.

   This is correct. Morphine is a high-alert medication per ISMP standards. The rule the "independent double-check before high-alert medication administration" rule requires an independent double-check of the drug, dose, concentration, and client ID before administration. The second RN verifies independently from the original order, not from what the first nurse reports. This control is mandatory before any high-alert opioid is given.

   D. Administer the morphine now and evaluate the client's pain relief in 2 minutes to confirm the medication's effectiveness.

   This violates the "time the administration or evaluation outside the drug's peak/onset" error pattern. Morphine's onset via IV push is 1–5 minutes, with peak analgesia at 15–30 minutes. Evaluating pain relief at 2 minutes does not capture the drug's pharmacokinetic peak and will incorrectly suggest the dose is ineffective when in fact absorption and distribution are still occurring. Additionally, this option omits the mandatory independent double-check before administration.

5. Question 5 of 9 · Medication Administration & Safety

   A 68-year-old client with a new diagnosis of atrial fibrillation is admitted to the telemetry unit. Current medications include metoprolol 25 mg PO daily and digoxin 0.25 mg PO daily (initiated 3 days ago). The health care provider writes the following order: "Cephalexin 500 mg PO QID × 10 days for presumed UTI." Chart review reveals: • Documented allergy: Penicillin G (anaphylaxis) • Recent lab values: Apical pulse 62 bpm, K+ 4.2 mEq/L, digoxin trough 1.8 ng/mL • Weight: 72 kg • Current urinalysis shows bacteria and WBCs; no sepsis signs. The nurse receives the medication order and begins the verification process before administration. Which prescription should the nurse question?

   1. AAdminister cephalexin as ordered because the client's apical pulse is normal and the digoxin level is therapeutic.
   2. BHold the cephalexin order and contact the health care provider to clarify the antibiotic choice due to documented anaphylaxis to penicillin.
   3. CAdminister cephalexin as ordered because it is a different class than penicillin and cross-reactivity is unlikely.
   4. DContact pharmacy instead of the health care provider to request a substitution for the cephalexin order.
   Show the answer and rationale

   Correct answer: B. Hold the cephalexin order and contact the health care provider to clarify the antibiotic choice due to documented anaphylaxis to penicillin.

   Before administering any medication, the nurse must screen for contraindications, allergies, and cross-reactivity per the contraindication screen rule. This client has a documented allergy to penicillin G with a severe reaction (anaphylaxis). First-generation cephalosporins, including cephalexin, share a beta-lactam ring structure with penicillins and carry a clinically significant cross-reactivity risk for anaphylaxis estimated at 1–3% in clients with prior penicillin anaphylaxis. Although cross-reactivity with later-generation cephalosporins (second, third) is lower, the standard of care is to avoid all cephalosporins in clients with documented penicillin anaphylaxis unless no suitable alternative exists and the benefit clearly outweighs the risk. In this case, the client has uncomplicated UTI with no sepsis, and alternative antibiotics (e.g., fluoroquinolone, nitrofurantoin) are safe and effective. The apical pulse (62 bpm), digoxin trough (1.8 ng/mL), and potassium (4.2 mEq/L) are all within therapeutic and safe ranges and do not contraindicate the UTI treatment decision. The nurse must hold the order and notify the prescriber to discuss the allergy and request an alternative antibiotic that does not carry cross-reactivity risk.

   A. Administer cephalexin as ordered because the client's apical pulse is normal and the digoxin level is therapeutic.

   The apical pulse (62 bpm), digoxin level (1.8 ng/mL), and potassium (4.2 mEq/L) are all normal and therapeutic; they do not govern the antibiotic order decision. The documented penicillin anaphylaxis allergy is directly relevant and must be screened before administration. Citing irrelevant normal parameters does not override the contraindication screen rule.

   B. Hold the cephalexin order and contact the health care provider to clarify the antibiotic choice due to documented anaphylaxis to penicillin.

   Correct. The contraindication screen rule requires the nurse to identify documented allergies and clinically significant cross-reactivity before administration. Cephalexin (first-generation cephalosporin) carries a 1–3% cross-reactivity risk with penicillin anaphylaxis; this is a contraindication. The nurse holds the order and contacts the prescriber to discuss the allergy and select a safe alternative antibiotic.

   C. Administer cephalexin as ordered because it is a different class than penicillin and cross-reactivity is unlikely.

   Although cephalosporins are technically a different class, first-generation cephalosporins share a beta-lactam core with penicillins and pose clinically significant cross-reactivity risk in anaphylaxis-level allergies. Proceeding with administration violates the contraindication screen rule and places the client at risk for anaphylactic reaction.

   D. Contact pharmacy instead of the health care provider to request a substitution for the cephalexin order.

   Medication order clarification and allergy reconciliation are nursing responsibilities within the RN scope of practice. Although the nurse may collaborate with pharmacy on alternatives, the initial contact must be with the health care provider to notify of the contraindication and request a revised order. Delegating this decision to pharmacy alone under-utilizes the appropriate resource and delays patient safety action.

6. Question 6 of 9 · Medication Administration & Safety

   A 68-year-old client with heart failure is admitted to the telemetry unit. The health care provider orders: "Potassium chloride 20 mEq in 100 mL 0.9% sodium chloride IV infusion over 2 hours, on pump with cardiac monitoring." The client has a functioning peripheral IV catheter (20-gauge) in the left forearm. Upon assessment, the IV site appears normal with brisk blood return and free-flowing infusion. The nurse recognizes the order and prepares to initiate the infusion. What is the nurse's priority action?

   1. ADocument the IV site assessment findings in the electronic health record, then verify the IV patency with normal saline flush before starting the infusion, without holding the dose or notifying the health care provider.
   2. BPlace a warm compress on the IV site, then call the laboratory to verify the serum potassium level before administering the medication.
   3. CStop and contact the health care provider to request a central venous access device before administering this medication.
   4. DInitiate the infusion through the peripheral IV as ordered since the catheter is patent and the site assessment is normal.
   Show the answer and rationale

   Correct answer: C. Stop and contact the health care provider to request a central venous access device before administering this medication.

   Concentrated potassium chloride must NEVER be administered peripherally. KCl 20 mEq/100 mL is a concentrated solution that can only be safely infused through a central venous access device (CVAD). The ISMP High-Alert Medication safety rule for potassium mandates that concentrated KCl infusions must be delivered via a central line to prevent fatal hyperkalemic arrhythmias from extravasation. Although the peripheral IV is currently patent and the site appears normal, these findings do not override the absolute contraindication to peripheral administration of concentrated potassium. The nurse must stop, notify the prescriber, and request insertion of a CVAD before proceeding. This protects the client from catastrophic extravasation injury and life-threatening cardiac dysrhythmias.

   A. Document the IV site assessment findings in the electronic health record, then verify the IV patency with normal saline flush before starting the infusion, without holding the dose or notifying the health care provider.

   Incorrect. This option expands the "document the finding without intervening clinically" error pattern. Documenting the IV assessment is necessary but does not address the critical safety issue: the order violates the rule against peripheral administration of concentrated KCl. Documentation without stopping the unsafe infusion is insufficient.

   B. Place a warm compress on the IV site, then call the laboratory to verify the serum potassium level before administering the medication.

   Incorrect. This option expands the "delay or skip intervention because of a finding unrelated to the drug" error pattern. Serum potassium level verification is a reasonable pre-infusion check but is secondary to the urgent safety issue: the peripheral IV is an unsafe route for this medication. Delaying intervention to verify labs misses the priority action of stopping the order.

   C. Stop and contact the health care provider to request a central venous access device before administering this medication.

   Correct. This action applies the rule that concentrated potassium chloride (>10 mEq/100 mL) must NEVER be administered through a peripheral IV. KCl 20 mEq/100 mL is a central-line-only medication. Stopping and escalating to the prescriber before administration is the priority safety action mandated by ISMP and standard practice.

   D. Initiate the infusion through the peripheral IV as ordered since the catheter is patent and the site assessment is normal.

   Incorrect. This option expands the "administer central-only medication through a peripheral IV" error pattern. A normal site assessment and patent IV do not permit peripheral administration of concentrated potassium. This violates the absolute rule prohibiting concentrated KCl via peripheral lines and risks fatal extravasation and hyperkalemic arrhythmia.

7. Question 7 of 9 · Medication Administration & Safety

   A 62-year-old client is admitted with acute coronary syndrome. The health care provider's order reads: "Heparin 5000 units IV bolus, then 18 units/kg/hr continuous infusion. Indication: acute MI prophylaxis. Drug allergy: NKDA. Start: 0900 today." The client weighs 70 kg. The nurse prepares a 25,000-unit/250 mL heparin infusion in normal saline. The peripheral IV (20 G, inserted 6 hours ago, site clean and intact) is appropriate for infusion. The nurse has completed the six-rights verification against the original order. What should the nurse do before administering the heparin bolus?

   1. AVerify the order for the generic heparin sodium versus the brand name Liquaemin before administering.
   2. BDocument the six-rights verification in the EHR and proceed to administer the bolus to the peripheral IV immediately.
   3. CAdminister the heparin bolus via slow IV push, then escalate the infusion rate once the bolus is given.
   4. DRequest an independent double-check by a second RN of the drug, dose, concentration, pump settings, and client identification before administration.
   Show the answer and rationale

   Correct answer: D. Request an independent double-check by a second RN of the drug, dose, concentration, pump settings, and client identification before administration.

   Heparin is an ISMP high-alert medication that requires an independent double-check by a second RN before administration. The rule (the "independent double-check before high-alert medication administration" rule) mandates that the second nurse independently verify the drug, dose (5000 units bolus, then 18 units/kg/hr = 1260 units/hr for this 70 kg client), concentration (25,000 units/250 mL = 100 units/mL), pump settings for the continuous infusion, and the client's identity from the original order, not from the first nurse's summary. Although the initial nurse completed the six rights verification, an independent double-check is a separate control that addresses the high-alert status and reduces medication error rates. This control is particularly critical for anticoagulants because dosing errors can result in bleeding or thrombosis.

   A. Verify the order for the generic heparin sodium versus the brand name Liquaemin before administering.

   Violates the LASA principle (the "look-alike/sound-alike (LASA) drug name confusion" error pattern). Heparin sodium and the brand name Liquaemin are not a look-alike/sound-alike pair requiring clarification; 'heparin' is the generic drug name and the order is clear. This option creates a false problem that distracts from the actual critical control needed: the independent double-check required for this high-alert medication before any administration.

   B. Document the six-rights verification in the EHR and proceed to administer the bolus to the peripheral IV immediately.

   Violates the "independent double-check before high-alert medication administration" rule. Documentation of the six-rights verification is necessary but insufficient for high-alert medications. Proceeding directly to administration without an independent double-check by a second RN misses a critical ISMP control. Co-signing after administration does not substitute for a pre-administration independent check.

   C. Administer the heparin bolus via slow IV push, then escalate the infusion rate once the bolus is given.

   Violates the "verify all six rights before administering any medication" rule and best practice for heparin route. While the peripheral IV is intact, heparin boluses are typically administered via slow IV push in a designated port or central line with specific dilution protocols. The option's phrasing about 'slow IV push' and 'escalating' the infusion suggests improper technique, and it omits the required independent double-check before any administration.

   D. Request an independent double-check by a second RN of the drug, dose, concentration, pump settings, and client identification before administration.

   Correct. Heparin is designated by ISMP as a high-alert medication. The rule the "independent double-check before high-alert medication administration" rule requires an independent double-check by a second RN of the drug, dose, concentration, pump settings, and client ID before administration. For this client, the second RN must verify the 5000-unit bolus and the 1260 units/hr infusion rate (18 units/kg/hr × 70 kg) from the original order, independently.

8. Question 8 of 9 · Medication Administration & Safety

   A 68-year-old client is admitted with acute coronary syndrome. The health care provider orders: "Potassium chloride 20 mEq in 100 mL 0.9% sodium chloride IV infusion over 2 hours; monitor ECG during infusion." The client has a functioning peripheral IV catheter (20-gauge) in the left forearm, inserted 18 hours ago. The site appears intact with no erythema, edema, or client-reported discomfort. The IV is infusing freely with good blood return. The client's current vital signs are: BP 118/76, HR 68, RR 16, SpO2 98%, temp 37.2°C. Which action should the nurse take first?

   1. ADocument the IV site assessment in the electronic health record and proceed with hanging the ordered potassium infusion.
   2. BProceed with the infusion through the peripheral IV since the concentration is appropriate for a 2-hour infusion time.
   3. CAdminister the potassium chloride IV push over 2 minutes to prevent fluid overload in the acute coronary syndrome client.
   4. DStop the infusion and request the health care provider place a central line before administering the potassium chloride.
   Show the answer and rationale

   Correct answer: D. Stop the infusion and request the health care provider place a central line before administering the potassium chloride.

   Concentrated potassium chloride must never be administered through a peripheral IV line and must never be given as an IV push. The order specifies 20 mEq in 100 mL, which equals 20 mEq/100 mL, this concentration exceeds the safe peripheral limit of 10 mEq/100 mL. Additionally, peripheral administration of concentrated potassium carries extreme risk of extravasation and fatal cardiac arrhythmia. Potassium chloride at concentrations >10 mEq/100 mL must be administered through a central venous access device (central line, PICC, or implanted port) with continuous cardiac monitoring and infusion-pump delivery. The nurse must immediately recognize this contraindication, discontinue the order as written, and escalate to the health care provider to either (1) reduce the concentration to ≤10 mEq/100 mL for peripheral delivery, or (2) obtain central vascular access to safely deliver the ordered concentration. This action takes precedence over documentation because patient safety is immediate and non-negotiable. The client's vital signs and site integrity are reassuring for current IV function but do not mitigate the fundamental contraindication of the medication-route pairing.

   A. Document the IV site assessment in the electronic health record and proceed with hanging the ordered potassium infusion.

   Documenting the assessment is necessary, but it does not substitute for the critical intervention: stopping an inappropriate medication order. Documentation without action violates patient safety when an active clinical decision, central-line requirement, must precede any administration.

   B. Proceed with the infusion through the peripheral IV since the concentration is appropriate for a 2-hour infusion time.

   Extending infusion time, 2 hours, does not make concentrated potassium safe peripherally. The rule is absolute: KCl concentrations >10 mEq/100 mL require a central line regardless of infusion duration. The 20-gauge peripheral catheter is inappropriate for this order.

   C. Administer the potassium chloride IV push over 2 minutes to prevent fluid overload in the acute coronary syndrome client.

   IV push of any potassium chloride, concentrated or dilute, is contraindicated and causes fatal arrhythmia. The order specifies infusion over 2 hours; an IV push would be both a route violation and a concentration error, creating compounded lethal risk.

   D. Stop the infusion and request the health care provider place a central line before administering the potassium chloride.

   Correct. This option recognizes that 20 mEq/100 mL potassium chloride (a 20% concentration) exceeds the safe peripheral limit of ≤10 mEq/100 mL and mandates central-line administration per the rule 'never give vesicants or concentrated KCl peripherally.' The nurse must escalate before any infusion begins to prevent fatal arrhythmia and extravasation tissue necrosis.

9. Question 9 of 9 · Medication Administration & Safety

   A 6-year-old child weighing 20 kg is hospitalized with acute lymphoblastic leukemia. The oncology health care provider has ordered methotrexate 500 mg/m² IV once weekly. The child's body surface area (BSA) is 0.8 m². The pharmacy has dispensed methotrexate 50 mg/mL in a 20 mL vial. Before the nurse prepares and administers this chemotherapy, what is the appropriate action?

   1. ACalculate the dose using dimensional analysis (500 mg/m² × 0.8 m² = 400 mg ÷ 50 mg/mL = 8 mL), then request an independent double-check of the drug, dose, concentration, and syringe labeling by a second RN before administration.
   2. BCalculate the dose as 400 mcg (converting from mg), reconstitute with normal saline, and proceed to administration after checking the client's recent complete blood count.
   3. CCalculate the dose as 8 mL, draw it into a syringe, and administer it immediately after the primary RN signs off on the preparation.
   4. DCalculate the dose using the weight-based formula (20 kg × 25 mg/kg = 500 mg ÷ 50 mg/mL = 10 mL) and administer after verifying the client's platelet count is above 50,000.
   Show the answer and rationale

   Correct answer: A. Calculate the dose using dimensional analysis (500 mg/m² × 0.8 m² = 400 mg ÷ 50 mg/mL = 8 mL), then request an independent double-check of the drug, dose, concentration, and syringe labeling by a second RN before administration.

   Safe methotrexate administration requires mastery of two critical safety rules: (1) calculation safety using dimensional analysis with explicit unit cancellation, and (2) independent double-check for high-alert medications before administration. Methotrexate is an ISMP high-alert chemotherapy drug that requires both accurate dose calculation and a second RN's independent verification of the drug name, dose, concentration, and syringe label before any administration, not after-the-fact co-signing. The calculation: 500 mg/m² × 0.8 m² = 400 mg (dose ordered). Then convert to volume: 400 mg ÷ 50 mg/mL = 8 mL. The dose is in correct units (mL), the decimal placement is correct (8, not 8.0), and a leading zero is not needed here because the dose is a whole number. The dose is clinically plausible for a pediatric chemotherapy dose and matches the concentration on hand. Co-signing after preparation violates the independent double-check rule: the second RN must verify from the original order independently before administration. Converting the dose from mg to mcg is a unit-conversion error (changing mg to mcg is a 1000× error: 400 mg = 400,000 mcg, not 400 mcg) and incorrectly assumes CBC abnormalities alone should delay a correctly calculated chemotherapy dose without clinical contraindication. Using a weight-based formula is incorrect (weight-based dosing is not appropriate for methotrexate; BSA-based dosing is the standard) and delaying administration based on a platelet count check is also incorrect. Although the platelet count is important for monitoring chemotherapy toxicity, it does not contraindicate administration of an appropriately calculated dose when the count is being managed.

   A. Calculate the dose using dimensional analysis (500 mg/m² × 0.8 m² = 400 mg ÷ 50 mg/mL = 8 mL), then request an independent double-check of the drug, dose, concentration, and syringe labeling by a second RN before administration.

   Correct. This option applies the key rules: dimensional analysis (500 mg/m² × 0.8 m² = 400 mg; 400 mg ÷ 50 mg/mL = 8 mL) with explicit unit cancellation and a clinically plausible answer in mL. It mandates an independent double-check by a second RN before administration, as required by ISMP for high-alert chemotherapy. The check is independent, the second nurse verifies from the original order, not from the first nurse's statement.

   B. Calculate the dose as 400 mcg (converting from mg), reconstitute with normal saline, and proceed to administration after checking the client's recent complete blood count.

   Incorrect (the "unit-conversion / decimal-placement / unit-mismatch error" error pattern). This option contains a critical unit-conversion error: 400 mg does NOT equal 400 mcg. The conversion is 1 mg = 1000 mcg, so 400 mg = 400,000 mcg. This is a 1000× overdose error. Additionally, the option incorrectly assumes a CBC finding alone (without a specific contraindication such as sepsis or severe thrombocytopenia) warrants delaying an appropriately calculated dose.

   C. Calculate the dose as 8 mL, draw it into a syringe, and administer it immediately after the primary RN signs off on the preparation.

   Incorrect (the "skip the independent double-check for a high-alert medication" error pattern). This option violates the independent double-check rule. Methotrexate is an ISMP high-alert chemotherapy drug. Co-signing after preparation is NOT an independent double-check; the second RN must independently verify the drug name, dose, concentration, and labeling from the original order BEFORE administration, not after the first RN has already prepared it.

   D. Calculate the dose using the weight-based formula (20 kg × 25 mg/kg = 500 mg ÷ 50 mg/mL = 10 mL) and administer after verifying the client's platelet count is above 50,000.

   Incorrect (the "delay or skip intervention because of a finding unrelated to the drug" error pattern). This option uses an incorrect formula: methotrexate is dosed by BSA (body surface area), not by weight (kg). While platelet monitoring is clinically important for chemotherapy toxicity surveillance, a normal or recovering platelet count does not contraindicate administration of a correctly calculated dose. The parameter does not govern the decision to hold the dose in this context.