Midwife Licensure Exam Fundamentals of Care & the Health-Care Process — Medication Administration & Dosage CalculationRevision Notes

Exam Tips

• NLE often asks: 'Which organ is primarily responsible for drug metabolism?' → Answer: LIVER.
• NLE often asks: 'Which organ is primarily responsible for drug excretion?' → Answer: KIDNEYS.
• If a patient has elevated creatinine or BUN, think RENAL impairment → drug accumulation risk.
• Anaphylaxis priority intervention = EPINEPHRINE (not Benadryl, not corticosteroids — those are secondary).
• Know the difference: therapeutic effect vs. side effect vs. adverse effect vs. toxic effect — NLE distinguishes them.

Key Points

• Pharmacokinetics = what the BODY does to the DRUG: Absorption → Distribution → Metabolism → Excretion (ADME).
• Pharmacodynamics = what the DRUG does to the BODY: mechanism of action, therapeutic effect, adverse effects.
• Absorption is affected by route, drug formulation, and GI motility; oral drugs pass through the first-pass effect in the liver.
• Distribution is affected by protein binding, lipid solubility, and blood-brain barrier permeability.
• Metabolism (biotransformation) occurs mainly in the LIVER — impaired in liver disease; drugs accumulate.
• Excretion occurs mainly via the KIDNEYS — impaired in renal disease; doses must be adjusted to prevent toxicity.
• Half-life (t½): time for the plasma drug concentration to fall by 50%; determines dosing interval.
• Onset = time for the drug to start working; Peak = time of maximum drug effect; Duration = length of drug action.
• Therapeutic effect = intended, desired effect of the drug.
• Side effect = predictable, usually mild, unwanted effect (e.g., dry mouth with antihistamines).
• Adverse/toxic effect = harmful, potentially dangerous effect requiring intervention.
• Allergic reaction = immune-mediated response; anaphylaxis is the most severe form — a medical emergency requiring epinephrine.

Definitions

Section Title

Basic Pharmacology Concepts

Common Mistakes

• Confusing pharmacokinetics (body's effect on drug) with pharmacodynamics (drug's effect on body) — remember: kinetics = movement of drug THROUGH the body.
• Forgetting that reduced renal or hepatic function in elderly patients requires dose adjustments — drug accumulation leads to toxicity.
• Assuming all side effects require stopping the drug — many are predictable and manageable; adverse/toxic effects require intervention.
• Confusing onset, peak, and duration — NLE questions often ask when to assess for peak effects or adverse reactions.

Exam Tips

• Memorize injection angles: ID = 10–15°; SC = 45–90°; IM = 90°.
• Safest IM site for adults = VENTROGLUTEAL; for infants = VASTUS LATERALIS.
• Z-track = for IRRITATING drugs (iron dextran, hydroxyzine); pull skin sideways, inject, wait 10 seconds, release.
• Mantoux test: read at 48–72 hours; induration ≥10 mm = positive for most Filipinos (high-TB-burden country context).
• For eye drops: instill into the LOWER conjunctival sac; press on the nasolacrimal duct (inner canthus) for 1–2 minutes to reduce systemic absorption.

Key Points

• ORAL (PO): safest, most convenient, slowest onset; includes sublingual (SL) and buccal routes.
• Sublingual (SL): under the tongue (e.g., nitroglycerin) — bypasses first-pass effect; fast onset.
• Buccal: between cheek and gum — also bypasses first-pass; do not swallow or drink until absorbed.
• Do NOT crush enteric-coated (EC) or sustained-release (SR/XL/XR/ER/SA) tablets — alters absorption and may cause toxicity.
• TOPICAL/TRANSDERMAL: applied to skin; rotate patch sites; always remove the OLD patch before applying a new one.
• INHALATION: rapid absorption via lungs; used for bronchodilators (MDI, nebulizer).
• INSTILLATION: eye drops, ear drops, nasal drops — position-dependent technique.
• RECTAL/VAGINAL: suppositories; useful when oral route unavailable.
• PARENTERAL injections: ID, SC, IM, IV — each has specific angle, volume, and site requirements.
• IV route has IMMEDIATE onset and 100% bioavailability — highest risk; greatest precision required.

Definitions

Section Title

Routes of Administration

Common Mistakes

• Giving SC heparin/enoxaparin in the wrong area — must be in the ABDOMEN, at least 5 cm from the umbilicus; NEVER aspirate or massage after injection.
• Using the dorsogluteal site for IM injections — this is UNSAFE in modern practice due to sciatic nerve risk; use ventrogluteal instead.
• Forgetting to remove the old transdermal patch before applying a new one — causes drug toxicity (e.g., fentanyl patch overdose).
• Crushing enteric-coated or sustained-release medications — destroys the coating and causes rapid drug dump, increasing toxicity risk.
• Using deltoid site for volumes >1 mL — the deltoid muscle is small and cannot accommodate large volumes.
• Pulling pinna in the wrong direction for ear drops: adults and children ≥3 years = pull UP and BACK; children <3 years = pull DOWN and BACK.

Exam Tips

• NLE scenario: A patient says 'that pill looks different today' — correct response = STOP, verify the order, do not administer until confirmed.
• Apical pulse <60 bpm → HOLD DIGOXIN; BP too low → HOLD antihypertensive; RR <12 → HOLD OPIOID.
• The Right to Refuse is a patient right rooted in the principle of autonomy and RA 9173's mandate to respect patient dignity.
• Remember: 'Right Assessment' means checking BEFORE giving; 'Right Response' means monitoring AFTER giving.
• NLE tip: If asked the priority RIGHT when preparing an unfamiliar medication, the answer is often Right Drug — checking the drug label carefully.

Key Points

• Originally 5 Rights; expanded to 10 Rights in current nursing practice and NLE scope.
• RIGHT PATIENT: Verify using TWO identifiers — name + birthdate OR name + hospital/patient ID number. NEVER use room number alone.
• RIGHT DRUG: Check label 3 times; watch for look-alike/sound-alike (LASA) drug names.
• RIGHT DOSE: Calculate accurately; double-check high-alert medications with another nurse.
• RIGHT ROUTE: Confirm the prescribed and appropriate route for the drug and the patient's condition.
• RIGHT TIME: Give at the scheduled time; know which drugs require specific timing (e.g., insulin before meals, antibiotics at equal intervals).
• RIGHT DOCUMENTATION: Chart AFTER giving, NEVER before; include drug name, dose, route, time, and your signature.
• RIGHT REASON/INDICATION: Understand why the patient is receiving the drug; question orders that seem inconsistent with the diagnosis.
• RIGHT ASSESSMENT: Check relevant parameters BEFORE giving (e.g., apical pulse before digoxin, BP before antihypertensives, RR before opioids).
• RIGHT RESPONSE/EVALUATION: Monitor the patient AFTER administration for therapeutic effect and adverse reactions.
• RIGHT TO REFUSE: Patients have the legal right to refuse medication; document refusal and notify the physician.
• THREE CHECKS of the label: (1) When removing from storage, (2) when preparing/drawing up, (3) at the bedside before administering.
• If a patient questions a medication: STOP and RE-VERIFY the order before proceeding — never dismiss the concern.

Definitions

Section Title

The Rights of Medication Administration

Common Mistakes

• Documenting BEFORE giving the medication — this is a serious error; always chart AFTER administration.
• Using the patient's room number as the only identifier — NOT acceptable; always use TWO patient-specific identifiers.
• Giving the medication when the patient questions it without re-verifying — patients are the last line of defense; always recheck.
• Skipping the pre-administration assessment (e.g., giving digoxin without checking the apical pulse first — hold if <60 bpm in adults).
• Forgetting that documentation is a RIGHT, not just a duty — omitting it creates legal and patient safety problems.

Formulas

Exam Tips

• Memorize: 1 tsp = 5 mL; 1 tbsp = 15 mL; 1 oz ≈ 30 mL — these appear in community health and oral medication questions.
• Microdrip shortcut: gtt/min = mL/hr when using 60 gtt/mL set.
• NLE calculation tip: write out your units and cancel them — if the answer unit comes out as mL or tablets, you've set it up correctly.
• For any high-alert drug calculation (insulin, heparin, KCl), always state: 'I will have another nurse independently verify this dose.'
• Know leading zero rule: write 0.5 mg (YES) — never write .5 mg (NO). Know trailing zero rule: write 5 mg (YES) — never write 5.0 mg (NO).

Key Points

• Core formula: Dose to give = Desired (D) ÷ Have (H) × Quantity (Q) — abbreviated D/H × Q.
• Always convert to the SAME UNIT before calculating (e.g., mg to mg, not mg to g).
• Weight-based dose: Ordered mg/kg × patient weight in kg.
• Convert pounds to kg: divide by 2.2 (or 1 kg = 2.2 lb).
• Key unit conversions must be memorized: 1 g = 1,000 mg; 1 mg = 1,000 mcg; 1 L = 1,000 mL; 1 tsp = 5 mL; 1 tbsp = 15 mL; 1 oz ≈ 30 mL.
• IV rate in mL/hr = Total Volume (mL) ÷ Total Time (hours).
• IV drip rate in gtt/min = [Total Volume (mL) × Drop Factor (gtt/mL)] ÷ Total Time (minutes).
• Macrodrip sets: 10, 15, or 20 gtt/mL; MICRODRIP = 60 gtt/mL (used for pediatrics or precise rates).
• Always ROUND drops to the nearest whole number — you cannot administer a fraction of a drop.
• For high-alert drugs or unusual calculations, always have a second nurse independently verify.
• Pediatric dosing is ALWAYS weight-based; verify against safe dose range before giving.
• Safe dose range: if calculated dose is BELOW minimum or ABOVE maximum safe dose → DO NOT GIVE; verify with physician.

Definitions

Section Title

Dosage Calculation

Common Mistakes

• Forgetting to convert units before calculating — e.g., mixing mg and mcg or g and mg leads to 1,000-fold errors.
• Using hours instead of minutes in the gtt/min formula — always convert hours to minutes (multiply by 60).
• Rounding IV drip rates to decimals — drops must be WHOLE numbers; 31.25 gtt/min is rounded to 31 gtt/min.
• Forgetting to convert pounds to kilograms for weight-based dosing — dividing by 2.2 is required.
• Assuming microdrip drop factor — if a question does not specify the tubing, and uses microdrip context, the drop factor is ALWAYS 60.
• Not verifying the safe dose range in pediatric calculations before giving — this is a patient safety and NLE priority.

Exam Tips

• NLE scenario: patient with crackles, JVD, dyspnea during IV infusion → FLUID OVERLOAD: slow to KVO rate, sit upright, notify physician, give O2.
• Tonicity memory aid: Iso = stays; Hypo = goes IN to cells; Hyper = pulls OUT from cells.
• For head injury patients: AVOID hypotonic fluids; USE isotonic (NSS, LR) or hypertonic (3% NaCl) to reduce cerebral edema.
• Vesicant drugs (chemo, some antibiotics) → extravasation = EMERGENCY; stop infusion, do NOT flush, follow extravasation protocol, antidote may be needed.
• Air embolism: clamp tubing, position patient in LEFT lateral Trendelenburg, call physician — air trapped in right side of heart.

Key Points

• ISOTONIC solutions (same osmolality as plasma ~275–295 mOsm/L): expand extracellular volume WITHOUT shifting fluid into or out of cells.
• Examples of isotonic: 0.9% NaCl (normal saline/NSS), Lactated Ringer's (LR), D5W (isotonic in the bag but acts as hypotonic once dextrose is metabolized).
• HYPOTONIC solutions (lower osmolality than plasma): fluid shifts INTO cells — can cause cellular swelling; used for cellular dehydration.
• Example of hypotonic: 0.45% NaCl (half-normal saline); DO NOT use in patients with increased intracranial pressure (ICP) — can worsen cerebral edema.
• HYPERTONIC solutions (higher osmolality than plasma): pull fluid OUT of cells into the vascular space — used for severe hyponatremia.
• Examples of hypertonic: 3% NaCl, D10W, D5NSS, D5LR; give SLOWLY via pump; monitor for circulatory overload and vein irritation.
• IV complications to recognize and act on: infiltration, phlebitis, extravasation, fluid overload/circulatory overload, air embolism, speed shock.
• INFILTRATION: IV solution leaks into surrounding tissue; signs = swelling, coolness, pallor, pain, no blood return, slow/stopped flow.
• PHLEBITIS: inflammation of the vein; signs = redness, warmth, pain along the vein, palpable cord.
• EXTRAVASATION: vesicant drug leaks into tissue = medical emergency; causes tissue necrosis.
• FLUID OVERLOAD: too much IV fluid; signs = dyspnea, crackles, JVD (jugular vein distension), hypertension, bounding pulse, edema.
• Assess the IV site every 1–2 hours; maintain strict aseptic technique during IV insertion and maintenance.
• Verify drug COMPATIBILITY before mixing or co-infusing — incompatible drugs can precipitate or inactivate each other.

Definitions

Section Title

IV Therapy Fundamentals

Common Mistakes

• Using hypotonic fluids in patients with head injury or increased ICP — this worsens cerebral edema; use isotonic or hypertonic solutions.
• Thinking D5W is always isotonic — it is isotonic in the bag, but once dextrose is metabolized in the body, it acts as FREE WATER (hypotonic).
• Confusing infiltration with phlebitis — phlebitis has redness/warmth/cord (vein inflammation); infiltration has swelling/coolness/pallor (fluid in tissue).
• Continuing the infusion when infiltration is suspected — always STOP first, then assess.
• Giving hypertonic solutions too rapidly — causes circulatory overload; must be given slowly on a pump with close monitoring.
• Not checking IV site regularly in busy wards — routine assessment every 1–2 hours is standard of care.

Exam Tips

• Antidote quick guide: Heparin → Protamine sulfate; Warfarin → Vitamin K; Opioids → Naloxone; Paracetamol → N-Acetylcysteine; Benzodiazepines → Flumazenil.
• NLE tip: 'What is the priority nursing action after a medication error?' = ASSESS THE PATIENT first, then notify the physician, then document/file incident report.
• aPTT monitors HEPARIN; PT/INR monitors WARFARIN — do not mix these up on the NLE.
• Insulin syringe: ONLY insulin syringes should be used for insulin to ensure accuracy in unit measurement.
• When in doubt about any order: VERIFY before administering — this is both safe practice and a mandate under RA 9173.

Key Points

• High-alert medications: INSULIN, HEPARIN and other anticoagulants, OPIOIDS, CONCENTRATED ELECTROLYTES (KCl), CHEMOTHERAPY, NEUROMUSCULAR BLOCKERS.
• NEVER give IV push undiluted KCl — causes fatal cardiac arrest; always dilute and infuse via pump slowly.
• INSULIN: use ONLY insulin syringes (calibrated in units); when mixing NPH and Regular insulin, draw CLEAR (Regular) before CLOUDY (NPH) — 'clear before cloudy.'
• Insulin sites: rotate within the abdomen (fastest absorption), thigh, upper arm, buttocks; document injection sites.
• HEPARIN: monitor aPTT (activated partial thromboplastin time); therapeutic range = 60–100 seconds (1.5–2.5× control); antidote = PROTAMINE SULFATE.
• WARFARIN (Coumadin): monitor PT (prothrombin time) and INR; therapeutic INR for most indications = 2.0–3.0; antidote = VITAMIN K (phytonadione).
• ENOXAPARIN (Clexane): low molecular weight heparin (LMWH); given SC; monitor anti-Xa levels; NO routine aPTT monitoring needed.
• OPIOIDS (morphine, codeine, tramadol, fentanyl): assess RESPIRATORY RATE before giving; hold if RR <12/min; antidote = NALOXONE (Narcan).
• ACETAMINOPHEN (paracetamol) overdose: antidote = N-ACETYLCYSTEINE (Mucomyst).
• SAFE ABBREVIATION PRACTICES: Write 'units' in full (never 'U' — can be misread as a zero); use LEADING ZERO (write 0.5 mg, not .5 mg); NEVER use trailing zeros (write 5 mg, not 5.0 mg).
• Report medication errors honestly per the hospital's incident reporting policy; PRIORITY after an error = PATIENT ASSESSMENT AND SAFETY first, then notify physician, then document.
• Independent double-checks are REQUIRED for high-alert medications before administration.

Definitions

Section Title

High-Alert Medications and Safe Practice

Common Mistakes

• Giving IV KCl undiluted — NEVER acceptable; always dilute; maximum infusion rate is 10–20 mEq/hour via pump.
• Drawing NPH before Regular when mixing insulin — this contaminates the Regular vial and alters insulin action; always CLEAR before CLOUDY.
• Writing 'U' for units — can be misread as '0', turning 5U into 50 — always write 'units' in full.
• Skipping respiratory assessment before opioids — RR <12/min = HOLD, reassess, notify physician.
• Not reporting medication errors — ethically and legally required; the nurse's duty under RA 9173 includes honest, accurate reporting.
• Confusing aPTT (for heparin) with PT/INR (for warfarin) — each anticoagulant has its own monitoring parameter.

Exam Tips

• NLE often presents a scenario with an elderly patient on multiple medications — recognize polypharmacy risk and the need for medication reconciliation.
• For pediatric IM: vastus lateralis is preferred; for pediatric ear drops (<3 years): pull pinna DOWN and BACK.
• Remember: reduced renal clearance in elderly = drugs that are renally excreted accumulate (e.g., digoxin, aminoglycosides, metformin).
• Pregnancy drug safety: Vitamin A excess is teratogenic; folic acid is protective against neural tube defects — common Philippine MCH (maternal-child health) nursing content.

Key Points

• PEDIATRICS: All doses are WEIGHT-BASED (mg/kg); always verify calculated dose against the safe dose range.
• Use oral syringes (not household spoons) for pediatric liquid medications — household teaspoons are inaccurate.
• Vastus lateralis muscle (anterolateral thigh) is the preferred IM injection site for INFANTS AND TODDLERS.
• Children are at HIGHER RISK for dosing errors due to small weight, narrow therapeutic windows, and inability to communicate symptoms clearly.
• OLDER ADULTS (Geriatric): 'START LOW, GO SLOW' — reduced hepatic metabolism and renal clearance cause drug accumulation.
• Polypharmacy (multiple medications) increases the risk of drug interactions, falls, and adverse effects in older adults.
• Assess renal function (creatinine, BUN, GFR) and hepatic function regularly in elderly patients on medications.
• Beers Criteria: a list of potentially inappropriate medications for older adults — commonly tested in geriatric nursing.
• PREGNANCY/LACTATION: Consider FDA pregnancy risk categories and drug transfer into breast milk; many drugs are contraindicated.
• In the Philippine context, medication management in elderly patients often intersects with comorbidities like hypertension, diabetes, and TB — all common in the Philippine population.

Definitions

Section Title

Special Populations

Common Mistakes

• Using household teaspoons to measure pediatric liquid medications — they are inaccurate; always use a calibrated oral syringe.
• Applying adult dosing principles to children — pediatric dosing is ALWAYS weight-based; never give an adult dose to a child.
• Overlooking renal/hepatic impairment in elderly patients when administering medications — leads to drug accumulation and toxicity.
• Forgetting to check the safe dose range in pediatric calculations before administering — a critical safety step.

Exam Tips

• NLE scenario on TB: remember DOTS, the importance of adherence, and the 6-month standard regimen (RIPE: Rifampicin, Isoniazid, Pyrazinamide, Ethambutol).
• Antibiotic teaching priority: 'Take ALL the medication even if you feel better' — incomplete courses lead to antibiotic resistance.
• Stay with the patient until oral medications are SWALLOWED — this is a key safety and supervision principle, especially in psychiatric and pediatric settings.

Key Points

• Teach: drug name (generic and brand), purpose, dose, timing, and route.
• Explain common side effects vs. serious adverse effects to report (e.g., chest pain, difficulty breathing, unusual bleeding, severe rash).
• Stress ADHERENCE: emphasize the importance of completing the full antibiotic course (prevents resistance), continuing antihypertensives/antidiabetics even when feeling well.
• Anticoagulant teaching: avoid OTC NSAIDs (aspirin, ibuprofen), use soft toothbrush, electric razor; report unusual bruising, bleeding gums, blood in urine/stool.
• TB medications (DOTS — Directly Observed Treatment, Short-course): under DOH Philippines, patients take medications under direct observation; emphasize adherence to prevent MDR-TB.
• Food/drug interactions: e.g., warfarin and vitamin K-rich foods (consistent intake, not avoidance); MAOIs and tyramine-rich foods (avoid); grapefruit juice and many drugs (avoid).
• Safe storage: away from heat, light, and moisture; child-proof containers; proper disposal of unused medications.
• Use the patient's PREFERRED LANGUAGE for teaching — in the Philippines, Tagalog or regional dialect may be more effective than English.
• Verify understanding using the TEACH-BACK method — ask the patient to explain the instructions back to you.

Definitions

Section Title

Patient and Family Teaching for Medications

Common Mistakes

• Leaving oral medications at the bedside for the patient to take later — nurse must stay until the patient swallows the medication.
• Providing patient teaching only in English when the patient is more comfortable in Filipino or a regional dialect — always use the patient's preferred language.
• Teaching only about side effects without emphasizing which symptoms require IMMEDIATE reporting.