NCLEX-RN cheat sheet · Pharmacology
Medication safety and high-alert drugs
Order types, the rights and three checks, A Pinch drugs, controlled substances, before and after the dose
AI-checkedChecked by AI against current guidelines, with spot-checks by a registered nurse.
The nurse is the last check before a drug reaches the client: assess before, check during, and evaluate after.
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At a glance
Order types
| Order | What it means |
|---|---|
| Routine | Continues until it's cancelled |
| PRN | As needed for a symptom. Check when the last dose was given, against the ordered frequency |
| Standing | An order set or protocol: followed in defined situations without calling first |
| One-time | Given once, like an antibiotic just before surgery |
| Stat | A one-time order given right away |
| Titration | Adjust the dose within set limits, based on the client's response |
The three checks
- Check the rights three times: as you take it from the cart or dispensing system (check the expiration date), before you prepare it, and at the bedside, right before you give it.
- Barcoding: scan the wristband and the medication. It catches many errors, but you still check the rights yourself.
- Don't simply override a barcode alert: stop, find out why, and follow policy. No workarounds, like borrowing another client's medicine.
- A pill fell on the floor? Discard it. Check whether an NPO order includes medications. Coughing or gurgly when swallowing: hold oral medications and report it.
The rights of administration
| Right | What to check |
|---|---|
| Patient | Two identifiers, like full name and date of birth; never the room number. Scanning adds safety; it doesn't replace them |
| Drug | Matches the order and the medication administration record; no allergy; not expired |
| Dose | Matches the order, and is in a safe range for this client's age and condition |
| Time | The right frequency. Many agencies allow 30 minutes before or after the scheduled time |
| Route | The ordered route, and one that suits the client. If it doesn't, contact the prescriber |
| Documentation | Chart right after you give it, to prevent a repeat dose by mistake |
| Four more | History and assessment; interactions; education; the right to refuse: teach first, respect the choice, document, notify the prescriber |
Listen to the client: If a client questions a medication, stop. Explore the concern, and verify the order before giving it.
High-alert drugs: A Pinch
| Drugs, and what to know | |
|---|---|
| A | Anti-infectives, like amphotericin and aminoglycosides |
| P | Potassium and other concentrated electrolytes. Always diluted, never pushed: a push can be instantly fatal. Serum potassium above 2.5 mEq/L: the label limits the rate to 10 mEq an hour; faster rates for severe deficits need continuous cardiac monitoring |
| I | Insulin: many agencies require a second nurse to independently double-check it. The wrong type or amount can be life-threatening |
| N | Narcotics and sedatives, like morphine, fentanyl and benzodiazepines |
| C | Chemotherapy |
| H | Heparin and other anticoagulants. Look-alike vials in many strengths, including 10,000 units in 1 mL: check the strength every time |
Why: An error with these drugs causes devastating harm. Safeguards: standard ways of ordering, storing and preparing, computer alerts, and independent double checks. The full list is longer.
Controlled substance schedules
| Schedule | Abuse risk and examples |
|---|---|
| I | No accepted medical use; high abuse potential: heroin |
| II | High abuse potential: opioids like oxycodone, fentanyl and hydromorphone; stimulants like Adderall. No refills; phoned in only in an emergency, for a limited amount, with a follow-up prescription within 7 days |
| III | Moderate to low: acetaminophen with codeine, ketamine, anabolic steroids. Up to five refills |
| IV | Lower: alprazolam, lorazepam, diazepam, zolpidem, tramadol. Up to five refills |
| V | Lowest: some codeine cough syrups, pregabalin |
Counts, waste and diversion
- Kept locked. Count at every shift change with an authorized, qualified witness, per facility and state rules; report any mismatch. Never sign for a count you didn't do.
- Part of a dose given? Waste the rest in front of an authorized, qualified witness, who documents it.
- Diversion signs: wrong counts, large wastes, many record corrections, clients who keep reporting poor pain relief. Report suspected use to a manager.
Disposal
- Facility: follow the facility's waste and diversion policy; don't carry household flush or trash steps over. Never give an expired drug.
- Home: a take-back site or prepaid mail-back envelope first.
- If neither is available: flush only drugs on the FDA flush list (check the exact list). Others: mix with dirt, cat litter or used coffee grounds, without crushing, seal in a bag, and trash it. Scratch out the label.
Before the dose: check first
| Drug | Check first |
|---|---|
| Blood pressure or heart drug | Blood pressure and heart rate against the ordered parameters. Below a hold parameter: hold it, and follow the order or policy. Suddenly dizzy? Postpone it until you've assessed |
| Inhaled breathing drug | Oxygen saturation, heart rate, respiratory rate and lung sounds; recheck them afterwards |
| Furosemide | Potassium. If low: assess how low and any symptoms, then follow the hold parameters or the prescriber's plan |
| Pain medicine | A full pain assessment, so you have something to compare with afterwards |
| Any drug | Allergies: what drug, what happened, how severe. A related drug can cross-react: tell the prescriber first |
Levels, age and the response
- Trough: just before the next dose, when the level is lowest. Peak: when the drug is highest.
- Narrow therapeutic window: small changes can cause failure or toxicity. Monitoring fits the drug: phenytoin levels, warfarin INR.
- After the dose, compare with the baseline. Anaphylaxis: hives, itching, a swollen tongue or throat, shortness of breath, dizziness, low blood pressure. Skin signs may be absent. Suspect it? Stop the drug, get emergency help, and expect epinephrine.
Medication reconciliation
- Admission, transfer and discharge are high-risk moments. Get the best possible history: the client plus at least one other source, like a pharmacy record, the bottles or family. Compare with the new orders, resolve differences, communicate the changes.
- Look-alike names, like Adderall and Inderal: use brand and generic names, and the purpose.
Priority and safety calls
- ★ Potassium chloride ordered by IV push: hold it and contact the prescriber. Potassium is diluted and given slowly; a push can stop the heart.
- ★ After a medication error: assess and monitor the client first; then notify the nurse manager and the prescriber, and report it per policy.
- The ordered route doesn't suit the client, like by mouth when he is NPO with a PEG tube: contact the prescriber to clarify the route. Don't change it yourself.
- Furosemide due, potassium below the ordered hold parameter: hold it and notify the prescriber.
How the NCLEX tests it
- Two identifiers. The room number is the trap.
- Check, then give, then chart. Charting before giving is the trap.
- Waste and count with an authorized witness. Wasting alone, or signing a count you didn't do, is the trap.
- At home: take-back first, flush only listed drugs. Flushing every medicine is the trap.
- Giving below a hold parameter, or skipping the potassium before a diuretic, are traps.
Practice it next
This sheet comes from Medication safety: rights, orders and reconciliation and High-alert and controlled medications and Before and after you give a medication in our NCLEX-RN course. Try free practice questions, or see the lessons it was written from.
Quick self-quiz
- Many agencies allow ___ minutes before or after the scheduled time.
Show answer
30 - Check the rights ___ times.
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three - With a serum potassium above 2.5 mEq/L, the label limits the rate to ___ mEq an hour.
Show answer
10 - A phoned emergency Schedule 2 order needs a follow-up prescription within ___ days.
Show answer
7
Sources
- Open RN, Nursing Skills 2e, 15.2 Basic Concepts of Administering Medications
- Open RN, Nursing Pharmacology 2e, 2.5 Preventing Medication Errors
- DailyMed, Potassium Chloride for Injection Concentrate label
- DEA, Practitioner's Manual
- FDA, Drug Disposal: FDA's Flush List for Certain Medicines
More pharmacology cheat sheets
- Anticoagulants and clotting NCLEX cheat sheet
- Dosage calculation NCLEX cheat sheet
- Drug-name stems NCLEX cheat sheet
- IV therapy and central lines NCLEX cheat sheet
Educational use only. This sheet is a study aid for the NCLEX-RN, not a substitute for clinical judgment, your facility’s policy or the provider’s orders. Where practice varies, follow facility policy and state law. NCLEX® and NCLEX-RN® are registered trademarks of NCSBN, which does not endorse these materials.