Introduction
Medication administration and pharmacological safety constitute one of the most heavily weighted and critical content areas on the NCLEX-PN examination, accounting for 10-17% of all test questions and representing a fundamental competency that every Licensed Practical Nurse must master to ensure patient safety. The complexity of modern pharmacotherapy requires practical nurses to possess comprehensive knowledge spanning multiple domains: accurate dosage calculations, proper administration techniques across various routes, recognition of therapeutic effects and adverse reactions, understanding of drug interactions, and the ability to provide appropriate patient education. Unlike many other nursing skills that can be supervised or double-checked, medication administration often occurs independently, making it essential that LPN/LVN candidates demonstrate mastery of the “five rights” (right patient, right medication, right dose, right route, right time) along with the additional considerations of right documentation, right reason, right to refuse, and right assessment. The NCLEX-PN tests not only factual knowledge about specific medications but also the clinical judgment required to recognize when to hold medications, identify contraindications, monitor for complications, and respond appropriately to adverse events. High-alert medications such as insulin, anticoagulants (heparin and warfarin), opioids, and cardiac medications like digoxin receive particular emphasis on the examination due to their potential for causing significant patient harm if administered incorrectly. Understanding the pharmacokinetics and pharmacodynamics of different drug classes enables practical nurses to anticipate patient responses, time medications appropriately, and recognize when therapeutic levels have been achieved or when toxicity may be developing. The practical nurse’s role in medication management extends beyond the mechanical act of administration to include critical assessment skills such as checking apical pulse before cardiac medications, monitoring laboratory values like aPTT for heparin or INR for warfarin, and evaluating pain levels before and after analgesic administration. Patient education represents another crucial dimension of pharmacological safety, as practical nurses must be able to teach clients about medication purposes, proper self-administration techniques, potential side effects to report, dietary considerations, and the importance of adherence to prescribed regimens. Special considerations for medication administration—such as the proper technique for mixing insulins, the correct sequence for administering multiple inhalers, the importance of flushing IV lines when medications are incompatible, and the selection of appropriate injection sites—demonstrate the depth of procedural knowledge expected of entry-level practical nurses. These practice questions are designed to challenge your ability to integrate pharmacological knowledge with clinical judgment, preparing you to make safe medication decisions in diverse patient care scenarios and to excel on the NCLEX-PN examination.
Practice Questions
Question 1: A practical nurse is preparing to administer digoxin 0.25 mg PO to a client. Before administering the medication, the nurse notes the client’s apical pulse is 58 beats per minute. What is the nurse’s PRIORITY action?
A) Administer the medication as ordered
B) Withhold the medication and notify the healthcare provider
C) Recheck the pulse in 30 minutes and then administer
D) Administer half the dose and document the pulse rate
Correct Answer: B
Explanation: Digoxin should be withheld if the apical pulse is below 60 beats per minute in adults (or below 90-110 in infants and young children) due to the risk of bradycardia and heart block. The nurse must notify the healthcare provider before administering the medication. Administering the medication (A) could cause dangerous bradycardia. Rechecking and then administering (C) ignores the contraindication. Altering the prescribed dose (D) is outside the LPN/LVN scope of practice and could still cause harm.
Question 2: A client is receiving heparin 5,000 units subcutaneously every 12 hours. Which laboratory value should the practical nurse monitor MOST closely?
A) Prothrombin time (PT)
B) International normalized ratio (INR)
C) Activated partial thromboplastin time (aPTT)
D) Platelet count
Correct Answer: C
Explanation: The activated partial thromboplastin time (aPTT) is the laboratory test used to monitor heparin therapy. The therapeutic range is typically 1.5 to 2.5 times the control value. PT (A) and INR (B) are used to monitor warfarin (Coumadin) therapy, not heparin. While platelet count (D) should be monitored for heparin-induced thrombocytopenia (HIT), aPTT is the primary test for monitoring therapeutic effectiveness.
Question 3: A practical nurse is preparing to administer insulin lispro (Humalog) to a client with diabetes. When should the nurse plan to administer this medication?
A) 30 minutes before meals
B) Immediately before or with meals
C) 1 hour after meals
D) At bedtime only
Correct Answer: B
Explanation: Insulin lispro is a rapid-acting insulin with an onset of 10-15 minutes, peak at 30-90 minutes, and duration of 3-5 hours. It should be administered immediately before meals (within 15 minutes) or with meals to match the rapid rise in blood glucose from food intake. Administering 30 minutes before meals (A) is appropriate for regular insulin, not rapid-acting insulin. Administering after meals (C) would not adequately control postprandial glucose. Bedtime administration (D) is typically for long-acting insulin like glargine.
Question 4: A client is prescribed morphine sulfate 4 mg IV push for severe pain. The medication is available as 10 mg/mL. How many mL should the practical nurse administer?
A) 0.2 mL
B) 0.4 mL
C) 2.5 mL
D) 4 mL
Correct Answer: B
Explanation: Using the formula: Desired dose / Available dose × Volume = 4 mg / 10 mg × 1 mL = 0.4 mL. This calculation ensures accurate dosing of this high-alert medication. Option A (0.2 mL) would deliver only 2 mg, underdosing the patient. Options C and D would result in dangerous overdoses of this opioid medication.
Question 5: A practical nurse is administering medications through a nasogastric (NG) tube. Which action demonstrates correct technique?
A) Mix all medications together before administration
B) Flush the tube with 30 mL of water before and after each medication
C) Crush enteric-coated tablets for easier administration
D) Administer medications with the tube clamped
Correct Answer: B
Explanation: The NG tube should be flushed with 15-30 mL of water before and after each medication to prevent clogging and ensure complete medication delivery. Each medication should be administered separately with water flushes between them. Mixing medications together (A) can cause drug interactions and tube clogging. Enteric-coated tablets (C) should never be crushed as this destroys the protective coating designed for intestinal absorption and can cause gastric irritation. The tube must be unclamped (D) during medication administration to allow flow.
Question 6: A client receiving vancomycin IV reports itching and the practical nurse observes facial flushing and a rash on the client’s chest. What is the nurse’s IMMEDIATE action?
A) Continue the infusion and apply a cool compress
B) Slow the infusion rate and monitor the client
C) Stop the infusion and notify the healthcare provider
D) Document the findings and reassess in 15 minutes
Correct Answer: C
Explanation: These symptoms indicate “red man syndrome,” a histamine-mediated reaction to rapid vancomycin infusion, or potentially a more serious allergic reaction. The nurse must stop the infusion immediately and notify the healthcare provider. Continuing the infusion (A) could worsen the reaction. While slowing the rate (B) might help with red man syndrome, stopping is safer when the diagnosis is uncertain. Delaying intervention (D) could allow a serious allergic reaction to progress to anaphylaxis.
Question 7: A practical nurse is teaching a client about newly prescribed warfarin (Coumadin). Which statement by the client indicates understanding of the teaching?
A) “I should increase my intake of green leafy vegetables for better nutrition.”
B) “I can take aspirin for headaches while on this medication.”
C) “I will use a soft toothbrush and electric razor to prevent bleeding.”
D) “I should stop taking this medication if I notice any bruising.”
Correct Answer: C
Explanation: Clients taking warfarin should use a soft toothbrush and electric razor to minimize bleeding risk from minor trauma. Green leafy vegetables (A) are high in vitamin K, which antagonizes warfarin’s effects; intake should be consistent, not increased. Aspirin (B) increases bleeding risk and should be avoided unless specifically prescribed. Clients should not stop warfarin (D) without provider guidance; minor bruising is expected, but significant bleeding should be reported.
Question 8: A client with chronic obstructive pulmonary disease (COPD) is prescribed albuterol (Ventolin) and beclomethasone (QVAR) inhalers. In what order should the practical nurse instruct the client to use these medications?
A) Beclomethasone first, then albuterol
B) Albuterol first, then beclomethasone
C) Either medication can be used first
D) Use both medications simultaneously
Correct Answer: B
Explanation: The bronchodilator (albuterol) should be used first to open the airways, followed 5-10 minutes later by the corticosteroid (beclomethasone). This sequence allows better penetration and distribution of the corticosteroid. Using the corticosteroid first (A) would be less effective as the airways are not maximally dilated. The order matters (C) for optimal therapeutic effect. The medications cannot be used simultaneously (D) as they are separate inhalers requiring proper technique for each.
Question 9: A practical nurse is preparing to administer an intramuscular (IM) injection to an adult client. Which site is MOST appropriate for this injection?
A) Dorsogluteal muscle
B) Ventrogluteal muscle
C) Deltoid muscle for volumes up to 5 mL
D) Rectus femoris muscle as first choice
Correct Answer: B
Explanation: The ventrogluteal site is the preferred site for IM injections in adults because it has no major nerves or blood vessels, has a thick muscle mass, and has a lower risk of complications. The dorsogluteal site (A) is no longer recommended due to proximity to the sciatic nerve and superior gluteal artery. The deltoid muscle (C) should only be used for volumes up to 1 mL (not 5 mL). The rectus femoris (D) can be used but is not the first choice for adults; it’s more commonly used for infants.
Question 10: A client is prescribed phenytoin (Dilantin) 100 mg PO three times daily for seizure control. Which instruction should the practical nurse include in client teaching?
A) “Take this medication on an empty stomach for better absorption.”
B) “You can stop taking this medication once your seizures are controlled.”
C) “Practice good oral hygiene and see your dentist regularly.”
D) “This medication may turn your urine orange, which is normal.”
Correct Answer: C
Explanation: Phenytoin commonly causes gingival hyperplasia (overgrowth of gum tissue), so good oral hygiene and regular dental care are essential. Phenytoin can be taken with food (A) to reduce GI upset; food does not significantly affect absorption. Abruptly stopping phenytoin (B) can cause status epilepticus; it must be tapered under medical supervision. Orange urine (D) is associated with rifampin or phenazopyridine, not phenytoin.
Question 11: A practical nurse is administering an IV medication that is incompatible with the primary IV solution of normal saline. What is the BEST action?
A) Stop the primary IV and administer the medication through the same line
B) Flush the IV line with 10 mL normal saline before and after the medication
C) Mix the medication with the primary IV solution
D) Administer the medication through a different IV access site
Correct Answer: B
Explanation: When administering an IV medication incompatible with the primary IV solution, the nurse should flush the line with 10 mL of normal saline (or sterile water, depending on facility policy) before and after administering the medication. This prevents mixing of incompatible solutions. Stopping the primary IV (A) is unnecessary if proper flushing is done. Mixing incompatible solutions (C) can cause precipitation or inactivation. Using a different site (D) is not necessary if flushing is performed correctly, though it may be needed if no compatible flush solution exists.
Question 12: A client with hypertension is prescribed furosemide (Lasix) 40 mg PO daily. Which assessment finding should the practical nurse report to the healthcare provider IMMEDIATELY?
A) Blood pressure of 128/82 mmHg
B) Urine output of 1,500 mL in 8 hours
C) Serum potassium level of 2.8 mEq/L
D) Weight loss of 2 pounds in 24 hours
Correct Answer: C
Explanation: A serum potassium level of 2.8 mEq/L indicates hypokalemia (normal range: 3.5-5.0 mEq/L), a serious complication of loop diuretics like furosemide. Hypokalemia can cause cardiac arrhythmias and must be reported immediately. The blood pressure (A) is slightly elevated but acceptable for a hypertensive patient on treatment. Increased urine output (B) is an expected therapeutic effect of the diuretic. Weight loss of 2 pounds (D) indicates fluid loss, which is the desired effect; rapid weight loss of more than 2-3 pounds per day would be concerning.
Question 13: A practical nurse is preparing to administer NPH insulin and regular insulin in the same syringe. Which action is CORRECT?
A) Draw up NPH insulin first, then regular insulin
B) Draw up regular insulin first, then NPH insulin
C) These insulins cannot be mixed in the same syringe
D) Mix the insulins in the syringe and let stand for 5 minutes before administering
Correct Answer: B
Explanation: When mixing insulins, the clear insulin (regular) should be drawn up first, followed by the cloudy insulin (NPH). The mnemonic “clear before cloudy” or “RN” (Regular before NPH) helps remember this sequence. This prevents contamination of the regular insulin vial with NPH. Drawing NPH first (A) could contaminate the regular insulin vial. These insulins can be mixed (C) in the same syringe. The mixture should be administered immediately (D), not allowed to stand, as this could affect insulin action.
Question 14: A client is receiving a continuous IV infusion of regular insulin at 10 units/hour. The nurse notes the client is diaphoretic, shaky, and reports feeling anxious. The blood glucose is 65 mg/dL. What is the nurse’s PRIORITY action?
A) Continue the insulin infusion and recheck glucose in 1 hour
B) Stop the insulin infusion and notify the healthcare provider
C) Decrease the insulin infusion rate to 5 units/hour
D) Administer the next scheduled dose of long-acting insulin
Correct Answer: B
Explanation: The client is experiencing hypoglycemia (blood glucose <70 mg/dL) with symptoms. The insulin infusion must be stopped immediately to prevent further glucose decrease, and the healthcare provider must be notified for orders (likely including IV dextrose or oral glucose if the client can swallow). Continuing the infusion (A) would worsen hypoglycemia. Decreasing the rate (C) is insufficient; the infusion must be stopped. Administering more insulin (D) would be dangerous and worsen the hypoglycemia.
Question 15: A practical nurse is teaching a client about sublingual nitroglycerin for angina. Which instruction is MOST important?
A) “Swallow the tablet with a full glass of water.”
B) “Take up to 3 tablets, 5 minutes apart; call 911 if pain persists after the first dose.”
C) “Store the medication in the bathroom medicine cabinet.”
D) “Take one tablet daily to prevent angina attacks.”
Correct Answer: B
Explanation: Current guidelines recommend calling 911 if chest pain is not relieved after the first nitroglycerin dose, as this may indicate myocardial infarction. The client can take up to 3 tablets, 5 minutes apart, while waiting for emergency services. The tablet should be placed under the tongue to dissolve (A), not swallowed. Nitroglycerin should be stored in a cool, dark, dry place (C), not in the bathroom where heat and moisture can degrade it. Sublingual nitroglycerin is for acute angina relief (D), not daily prevention; long-acting nitrates or other medications are used for prevention.