NCLEX-PN Medication Safety — High-Alert Drugs and Administration Checks

ASPIRATION PRECAUTIONS: POSITIONING: 90° upright (not just slightly elevated) during and 30-45 min after meals — gravity assists swallowing and reduces reflux/aspiration risk; THICKENED LIQUIDS: Thin liquids are the most dangerous for dysphagia — thickening agents (nectar, honey, pudding consistency) as ordered by speech therapy; PACE: Small bites, allow full swallow before next bite, no rushing; SUCTION: Available at bedside in case of aspiration; MONITORING: Watch for coughing, choking, wet/gurgly voice quality after swallowing (sign of aspiration); SPEECH THERAPY: Dysphagia evaluation and specific dietary texture orders should be coordinated with SLP; PN SCOPE: Implement and monitor aspiration precautions; report changes to RN; do not independently modify diet consistency orders.

OLIGURIA (<30 mL/hr or <0.5 mL/kg/hr): This is a critical assessment finding. CAUSES: Hypovolaemia (most common post-surgical — inadequate fluid replacement, haemorrhage); cardiac output reduction (heart failure, MI); renal causes (ATN, contrast nephropathy); obstruction (kinked catheter — check first); PRE-RENAL vs RENAL: Pre-renal oliguria responds to fluids; renal oliguria does not — distinguishing them guides treatment; IMMEDIATE NURSING ACTIONS: Check catheter for kinks, clots, or position issues (simple fix first); assess vital signs (hypotension + oliguria = volume depletion until proven otherwise); notify RN urgently — this requires medical assessment; ANTICIPATED ORDERS: IV fluid bolus if pre-renal; renal panel, BMP; strict intake/output; PN SCOPE: Assess, check equipment, NOTIFY RN IMMEDIATELY — do not wait; time-sensitive finding.

SUPRATHERAPEUTIC INR (4.8 vs target 2-3): This represents excessive anticoagulation — significantly increased bleeding risk. ASSESSMENT PRIORITIES: Urine colour (haematuria); stool colour/occult blood (GI bleed); skin for excessive bruising or haematomas; neurological status (headache, confusion, focal deficits = possible intracranial haemorrhage); injection/IV sites for prolonged bleeding; CRITICAL: Any neurological change + supratherapeutic INR = possible intracranial bleed = IMMEDIATE emergency response; NURSING ACTIONS: Do not administer the next warfarin dose; notify RN/provider with INR value; anticipate: hold warfarin; possibly vitamin K administration; possible fresh frozen plasma if active major bleeding; FOLLOW-UP: Repeat INR; dietary review (increased vitamin K intake?); medication interactions (new antibiotics, NSAIDs); PN SCOPE: Assess for bleeding, hold warfarin, notify — do not independently administer vitamin K without order.

POST-LUMBAR PUNCTURE CARE: POSITIONING: Flat (supine or prone) 4-8 hours per order — the evidence for preventing post-LP headache with positioning has evolved (some studies suggest not clearly beneficial) but most institutions still recommend flat positioning; the rationale: CSF leaks through the dural puncture site when upright; lying flat reduces pressure differential; POST-LP HEADACHE: Most common complication; worst when upright, relieved when flat; typically occurs 24-48 hrs post-procedure; TREATMENT: Fluids (increases CSF production); caffeine (vasoconstrictive, reduces headache); blood patch (definitive treatment if severe — autologous blood injected at puncture site to seal the leak); MONITORING: Vital signs; neurological status; headache assessment; check puncture site for CSF leak or haematoma; ADDITIONAL POST-LP CARE: Encourage PO fluids if not restricted; monitor sensation/movement in lower extremities; report any numbness, weakness, or bowel/bladder changes immediately.

PRESSURE INJURY STAGING AND DRESSING SELECTION: STAGE 2: Partial thickness skin loss — epidermis and part of dermis; wound appears as shallow open ulcer with red-pink wound bed; MOIST WOUND HEALING: Evidence consistently shows moist wound healing accelerates epithelialisation compared to dry; DRY GAUZE: Creates a dry environment, adheres to wound bed, traumatises healing tissue on removal — NOT appropriate for stage 2; WET-TO-DRY: Appropriate for debridement of necrotic tissue (stage 3-4) — mechanically removes tissue including viable; contraindicated for clean, healing wounds; HYDROCOLLOID: Contains moisture, promotes healing, self-adhesive — appropriate for stage 2 without infection; HYDROFIBER/ALGINATE: For highly exudative wounds; SILVER-CONTAINING: For infected wounds; PN SCOPE: Perform wound assessment, apply ordered dressings, report changes in wound status to RN; do not independently change wound care orders.

IV SITE COMPLICATIONS: PHLEBITIS: Inflammation of the vein wall — redness, warmth, pain, and a palpable cord along the vein; can be caused by mechanical trauma, chemical irritation from medications, or infection; INFILTRATION: IV catheter has displaced from the vein — fluid infusing into surrounding tissue; swelling, pallor, cool skin, pain; EXTRAVASATION: Infiltration of vesicant (tissue-damaging) medication — more serious; requires specific antidote in some cases; IMMEDIATE ACTION: Stop the infusion; remove the IV catheter; do NOT continue infusing through a compromised site; TREATMENT: Elevate the extremity; warm compress for phlebitis; cold or warm compress per policy for infiltration (depends on infiltrated substance); document the complication; notify RN for assessment and orders; VESICANT EXTRAVASATION: Some chemotherapy agents and vasopressors require specific antidotes (hyaluronidase for some agents, phentolamine for norepinephrine extravasation) — report immediately.

CHEST TUBE MANAGEMENT DURING TRANSPORT: DRAINAGE SYSTEM POSITIONING: Must remain upright to maintain the water seal; the water seal prevents air from entering the pleural space; SYSTEM TIPPED: Priority is to return to upright position quickly; if water seal is disrupted (water spilled), notify RN immediately — the seal must be maintained; CLAMPING CONTROVERSY: Chest tubes should NOT be routinely clamped during transport (risk: tension pneumothorax if air is entering and tube is clamped); EXCEPTIONS: Clamp briefly only if the system must be changed, or per specific physician order; DURING TRANSPORT: Keep system below chest level; prevent pulling on the tubing; have clamps available (not applied) in case system disconnects; if tube disconnects, submerge the end in sterile water to restore water seal until replacement system can be set up; PN SCOPE: Monitor the drainage system; report changes; do not independently clamp without RN/provider direction.

ORAL IRON SUPPLEMENTATION TEACHING: MOST COMMON ADVERSE EFFECT: GI distress — nausea, constipation, stomach cramps; dark/black stools (expected, not a sign of GI bleeding unless bright red); MANAGING GI EFFECTS: Take with small amount of food to reduce nausea (reduces absorption slightly but improves adherence); increase fluid and fibre intake; stool softener may be ordered; start at lower dose and increase gradually; MAXIMISING ABSORPTION: Vitamin C (ascorbic acid) significantly increases iron absorption — orange juice, tomato juice, or vitamin C supplement with the dose; avoid coffee, tea, milk, calcium supplements, antacids within 2 hours (inhibit absorption); DIFFERENT FORMULATIONS: Ferrous sulphate (most common); ferrous gluconate (more expensive, gentler on GI); LIQUID FORM: Use a straw to prevent tooth staining; PATIENT EDUCATION: Expected black stools; expected mild GI upset initially; do not stop without notifying provider; takes 4-8 weeks to see improvement in fatigue/haemoglobin.

HYPONATRAEMIA (Na <135 mEq/L): SEVERE (<125 mEq/L): Neurological symptoms — confusion, nausea, headache, seizures, and if untreated, cerebral oedema, herniation, and death; 128 mEq/L with symptoms = URGENT; CAUSES: SIADH (syndrome of inappropriate ADH secretion); heart failure; cirrhosis; excessive hypotonic IV fluids; psychogenic polydipsia; CRITICAL NURSING ACTION: Do NOT give free water or hypotonic fluids (water moves into cells and worsens cerebral oedema); Notify RN immediately; seizure precautions; TREATMENT (physician-ordered): Fluid restriction (most common); hypertonic saline (3% NaCl) for severe symptomatic cases — given only in ICU with strict monitoring; rate of correction must be controlled (correcting too fast causes osmotic demyelination syndrome); MONITORING: Neurological status (confusion, seizure activity); vital signs; serum sodium levels; strict I&O; safety measures (fall precautions for confusion).

TRACHEOSTOMY TUBE SAFETY DURING COUGHING: TUBE DISPLACEMENT RISK: Coughing generates significant intrathoracic pressure — a tracheostomy tube, especially one within the first 7-10 days of placement (before the stoma tract is established), can be expelled from the stoma; if this happens, the airway may close rapidly; NURSING ACTION: Pause the procedure; SECURE the tube — place a hand on the tube or hold the flanges to prevent accidental decannulation; allow the cough to complete naturally; suction if secretions are in the airway after coughing; DECANNULATION EMERGENCY SUPPLIES: An extra tracheostomy tube of the same size and one size smaller should be at the bedside at all times; tracheal dilators should be available; AFTER COUGHING: Assess breath sounds; assess tube placement (air movement through the tube); assess skin colour and SpO2; resume procedure only when stable; PN SCOPE: Perform routine tracheostomy care per protocol; report any concerns about tube placement or client distress to RN immediately.