Parenteral Dosages of Drugs

Question 1

Used to designate routes of administration such as the injection routes of intramuscular (IM), subcutaneous (subcut), intradermal (ID), and intravenous (IV).

Answer 1

Parenteral

Question 2

Refers to an injection given into a muscle, for example, dimenhydrinate given IM for nausea.

Answer 2

Intramuscular

Question 3

Refers to an injection given into the subcutaneous tissue, such as an insulin injection for the management of diabetes.

Answer 3

Subcutaneous

Question 4

Refers to an injection given directly into a vein, either by direct injection (IV push) or an injection diluted in a larger volume of IV fluid and administered as part of an IV infusion.

Answer 4

Intravenous

Question 5

Refers to an injection given under the skin, such as an allergy test or tuberculin skin test.

Answer 5

Intradermal

Question 6

Injectable drugs are measured in ___.

Answer 6

syringes

Question 7

Most parenteral medications are supplied in ___ or ___ form, and packaged in dosage vials, ampules, or prefilled syringes.

Answer 7

liquid / solution

Question 8

An IM injection is the choice when two things are required:

Answer 8

1) A reasonably rapid systemic uptake of the drug (usually within 15 to 20 minutes)
2) A relatively prolonged action

Question 9

There are various recommendations in the literature regarding the maximum volume that can be administered in one injection site. However, in general, the amount of solution that can be given depends on the amount of the ___ (i.e., the ventrogluteal site is free of nerves and major blood vessels and can usually accommodate a larger volume) and ___ mass, and ranges from 1 mL to 3 mL for adults.

Answer 9

muscle / subcutaneous

Question 10

The maximum dose volumes to be administered in an IM injection site are as follows:

1. An average adult weighing __ kg receives a maximum dose volume of ___ mL (with lower maximums proposed for adult patients with less-developed or small muscle mass). The maximum volume for the ___ is 1 mL.
2. Children ages ___ through __ years receive a maximum dose volume of ___ mL.
3. Children between ___ and ___ years receive a maximum dose volume of ___ mL.

Note: These are recommended ages and doses. Always check the institution’s policy prior to administering any injection.

Answer 10

75 / 3 / deltoid

6 / 12 / 2

birth / 6 / 0.5 - 1

Question 11

Drugs administered intravenously may be injected ___ into the infusion port located on the side of the IV tubing. For safety, some drugs may need to be ___ further prior to infusion.

Answer 11

directly / diluted

Question 12

When calculating parenteral dosages,

1. For an amount greater than 1 mL, round the amount to be administered to the tenths. Measure in a ___ mL syringe.
2. For an amount less than 0.5 mL, round the amount to be administered to the hundredths. Measure in a ___ mL syringe.
3. An amount of 0.5 to 1 mL, calculated in tenths, can be accurately measured in either a ___ mL or ___ mL syringe.

Answer 12

3

1

1 / 3

Question 13

Dosages measured in hundredths (e.g., 0.25 mL) and all amounts less than 0.5 mL should be prepared in a ___ mL syringe, which is calibrated in hundredths. However, if the route is IM, you may need to change needles to a more appropriate length and gauge. Often a blunt needle is used for drawing up the medication and then the needle is changed to the appropriate length and gauge.

Answer 13

1

Question 14

The Institute for Safe Medication Practices Canada (ISMP, 2018) defines ___ as “drugs that bear a heightened risk of causing significant patient harm when they are used in error”.

Answer 14

high-alert medications

Question 15

___ and ___ have been identified as two such medications with the greatest safety risk.

Answer 15

Heparin sodium / insulin

Question 16

When double-checking, the nurses should check the medication ___, the ___ selected, the calculated ___, and the dose ___.

Answer 16

order / product / dose / drawn up

Question 17

A hormone produced by the pancreas, is necessary for the metabolism of glucose, proteins, and fats.

Answer 17

Insulin

Question 18

Patients who are deficient in insulin are required to take insulin daily by ___, as it cannot be taken orally.

Answer 18

injection

Question 19

Insulin is a ready-to-use solution that is measured in ___. The most common supply dosage is ___ per mL.

Answer 19

units / 100 units

Question 20

Insulin should always be administered in an insulin syringe measured in ___.

Answer 20

units

Question 21

Drug classified by the action times and species, which are critical identifiers.

Answer 21

insulin

Question 22

Insulins vary in onset, peak, and duration of action. A sampling of insulin labels arranged by the four action times—___-acting, ___-acting, ___-acting, and ___-acting

Answer 22

rapid / short / intermediate / long

Question 23

Upper case, bold letter R for ___ insulin, and the upper case bold letter N on the Humulin label for ___ insulin.

Answer 23

regular / NPH (intermediate acting)

Question 24

A short-acting insulin (Humulin R and Toronto insulin) or a rapid-acting insulin for example analog lispro (Humalog), aspart (NovoRapid), and glulisine (Apidra) is usually administered at each ___ and for continuous subcutaneous insulin infusions.

Answer 24

meal

Question 25

An intermediate-acting insulin or a long-acting insulin analog is administered once or twice daily to manage ___ daily blood glucose fluctuations. Intermediate insulins (e.g., Humulin N and Novolin® ge NPH) are crystalline zinc suspensions of human ___ insulin combined with the polypeptide protamine, which ___ the onset of action. NPH insulin has a ___ white or cloudy appearance.

Answer 25

normal / regular / delays / milky

Question 26

Insulin glargine (Lantus) and detemir (Levemir and Toujeo; 100 unit and 300 unit insulins) are long-acting insulin analogs that are released steadily and continuously over ___ hours, with no ___ of action, after once-daily subcutaneous administration. They should be administered at the ___ time each day. The long-acting insulins are ___ and colourless and should not be confused with rapid- or short-acting insulins, which are also clear.

Answer 26

24 / peak / same / clear

Question 27

Combination insulins are premixed ___-acting and ___-acting insulins that are combined in a fixed proportion in a vial and commercially manufactured by pharmaceutical companies (e.g., Novolin).

Answer 27

short / intermediate

Question 28

___-acting types of insulin should not be combined or diluted with any other insulin preparations. Combining long-acting insulin with other insulin solutions may interfere with blood glucose control, which can be life-threatening.

Answer 28

Long

Question 29

Do not confuse ___ names for aspart (NovoRapid) and lispro (Humalog) with the ___ names for regular insulins (Humulin R and Novolin® ge).

Answer 29

trade x2

Question 30

Human ___ insulin is the most commonly used insulin. Pork regular insulin (Hypurin Regular Insulin Pork) and pork isophane insulin (Hypurin NPH Insulin Isophane) are available but are rarely used any more.

Answer 30

biosynthetic

Question 31

Commercially available premixed insulin combinations contain a combination of a short-acting insulin and an intermediate-acting insulin in fixed proportions in an insulin vial or pen. These product combinations are convenient for patients who are in a treatment plan that uses a standard ratio of these insulins because the number of injections required is ___ . However, premixed insulin preparations are not suitable for patients with type ___ diabetes who require intensive therapy and frequent adjustments of insulin.

Answer 31

reduced / 1

Question 32

It is important to carefully read the labels to understand which types of insulin are included in each combination. For example, the 30/70 insulin concentration contains ___-acting insulin and ___ intermediate-acting insulin in each unit. Therefore, if the order is 10 units of 30/70 insulin, the patient would receive 10 units (composed of ___ units of short-acting insulin (___%) and ___ units of ___-acting insulin (___). If the order is 20 units of 30/70 insulin, the patient would receive 20 units (composed of ___ units of short-acting insulin (30%) and ___ units (70%) of intermediate-acting insulin).

Answer 32

30% short / 70% / 3 / 30% / 7 / intermediate / 70% / 20 / 6 / 14

Question 33

The 50/50 insulin concentration contains 50% NPH insulin and 50% regular insulin in each unit. Therefore, if the prescriber orders 12 units of 50/50 insulin, the patient would receive ___ units (composed of ___ units of NPH insulin (50%) and ___ units of regular insulin (50%)).

Answer 33

12 / 6 x2

Question 34

An insulin order should contain the following:

1. The ___ and ___ names, and the ___ time. Patients are instructed to stay with the same manufacturer’s trade-name insulin. Slight variations between trade names can affect an individual’s response. Before administration, verify with the patient both the usual trade name used and the actual insulin supplied. Look for one of the four action times: rapid-acting (e.g., lispro, aspart, and glulisine), short-acting (e.g., Novolin® ge Toronto and Humulin R), intermediate-acting (e.g., Humulin N and Novolin® ge NPH), or long-acting (e.g., insulin glargine and insulin detemir).
2. The ___ (concentration) and the number of ___ to be given, for example, 40 units of regular 100 unit insulin.
3. The ___ of administration and ___ or ___. All insulin may be administered by the ___ route, and regular 100 unit insulin may additionally be administered intravenously (IV)

Answer 34

trade / generic / action

supply dosage / units

route / time / frequency / subcutaneous

Question 35

Insulin is administered by syringe, pen, or pump (bolus, continuous subcutaneous insulin infusion (CSII)). Insulin regular can also be administered intravenously to manage hyperglycemic episodes. Insulin administration regimens (schedule and frequency) are individualized based on the needs of the patient. Insulin pen devices facilitate management requiring multiple injections of insulin. CSII is considered a safe and effective method to deliver flexible insulin therapy for patients with type 1 diabetes. CSII therapy may provide some advantages over other methods of flexible therapy such as NPH-based regimens. Insulin delivery systems deliver rapid- or short-acting insulins (e.g., insulin aspart or insulin lispro) over 24 hours through a catheter placed under the skin. The pump is usually worn on a belt and resembles a standard pager. Newer delivery systems can combine continuous blood sugar monitoring with insulin pump delivery. The newest device, called an OMNIPOD, delivers insulin through a tubeless insulin reservoir attached to the skin by a patch and is controlled wirelessly through a Personal Diabetes Manager. Pumps can be programmed to deliver a basal rate and/or bolus doses. Basal insulin is delivered continuously over 24 hours to keep blood glucose levels within a target range between meals and overnight. The basal rate can be programmed to deliver different rates at different times of the day or night. Bolus doses can be delivered at mealtimes to provide control for additional food intake.

Answer 35

syringe / pump / regular / intravenously / hyperglycemic

Question 36

Measure insulin in an insulin ___ only. Do not use a 3 mL or 1 mL or TB syringe to measure insulin.

Do not measure other drugs supplied in ___ in an ___ syringe.

Answer 36

syringe

units / insulin

Question 37

The standard insulin syringe in is a dual-scale syringe with ___ unit capacity. It is calibrated on one side in even-numbered, 2 unit increments (2, 4, 6,…) with every 10 units labelled (10, 20, 30,…). It is calibrated on the reverse side in odd-numbered, 2 unit increments (1, 3, 5,…) with every 10 units labelled (5, 15, 25,…). It is not necessary to use the ___ to measure the volume to prepare insulin. The insulin syringe is specially ___ to measure a dose of insulin in ___. The important skill is to correctly read the syringe calibrations.

Answer 37

100 / dosage calculations formula / designed / units

Question 38

Look carefully at the increments on the dual scale. The volume from one mark to the next (on either side) is ___ units. You are probably comfortable counting by ___s for even numbers. Pay close attention when counting by ___s with odd numbers

Answer 38

2 x3

Question 39

The ___ insulin syringe in is a single-scale syringe with 50 unit capacity. It is calibrated in ___ unit increments with every 5 units (5, 10, 15,…) labelled, up to 50 units. The enlarged 50 unit calibration of this syringe makes it easy to read and measure low dosages of insulin.

Answer 39

lo-dose (50 unit capcity) / 1

Question 40

The ___ insulin syringe is a single-scale syringe with 30 unit/0.3 mL capacity. It is calibrated in ___ unit increments with every 5 units (5, 10, 15,…) labelled, up to 30 units. The enlarged 30 unit calibration accurately measures very small amounts of insulin, such as for ___.

Answer 40

lo-dose (30 unit capcity) / 1 / children

Question 41

Always choose the ___-capacity insulin syringe available for accurate insulin measurement. Use standard and lo-dose syringes to measure insulin. Although the lo-dose insulin syringes measure a maximum of only 30 or 50 units, they may be used for the measurement of 100 unit insulin.

Answer 41

smallest

Question 42

The patient may have 2 types of insulin prescribed to be administered at the same time: a ___-or ___-acting insulin can be combined with an ___-acting insulin. To avoid injecting the patient twice, it is common practice to draw up both short and intermediate insulins in the ___ syringe. Remember that ___-acting insulin must not be administered with other insulins.

Answer 42

rapid / short / intermediate / same / long

Question 43

1. Draw up ___- or ___-acting insulin first, then draw up ___-acting insulin.
2. Rapid- and short-acting (regular, lispro, and aspart) insulins are ___. Intermediate-acting (NPH) insulin is ___.
3. Think: First ___- or ___-acting insulin, then ___-acting insulin.

Answer 43

rapid / short / intermediate

clear / cloudy

rapid / short / intermediate

Question 44

When withdrawing two insulins into the same syringe,

1. Take care to accurately withdraw both amounts, especially with the second draw; and
2. Inject ___ into both insulin ___ ___ to the amount of insulin required to increase pressure in the vials to make it easier to withdraw accurate doses.

Answer 44

air / vial / equal

Question 45

The prescriber orders Novolin® ge Toronto insulin 10 units with Novolin® ge NPH insulin 30 units subcutaneously 30 min before dinner.

Notice that to withdraw ___ insulin first and then ___ insulin, you must inject the ___ amount of ___ into the ___ insulin before you inject the dose amount of air into the ___ insulin and then withdraw.

1. ___ vial of ___ insulin to mix do not shake. Draw back and inject ___ units of ___ into the ___ insulin ___. ___ the needle.
2. Draw back and inject ___ units of ___ into the ___ insulin ___ and ___ the needle in the ___.
3. Turn the ___ of ___ insulin ___, and draw out the insulin to the ___ unit mark on the syringe. Make sure all air bubbles are removed.
4. ___ the needle into the ___ insulin vial, turn the ___ ___, and slowly draw back to the ___ unit mark, being careful not to ___ the ___ unit calibration. If more ___ insulin is withdrawn, ___ and begin again with a new syringe. The cloudy solution contaminates the regular insulin and an accurate amount cannot be determined.

Answer 45

Novolin® ge Toronto / Novolin® ge NPH / dose / air / Novolin® ge NPH / regular

1. Roll / NPH / 30 / air / Novolin® ge NPH / vial / Remove
2. 10 / air / Novolin® ge Toronto / vial / leave / vial
3. vial / Novolin® ge Toronto / upside down / 10
4. Insert / Novolin® ge NPH / vial x2 / upside down / 40 / exceed / 40 / NPH / discard

Question 46

With a combined insulin medication, another ___ must be present to view steps 1 to 4 of the procedure.

Answer 46

nurse

Question 47

NovoRapid

Answer 47

Rapid-acting insulin trade name

Question 48

Novolin ge Toronto

Answer 48

Short-acting insulin trade name

Question 49

Novolin ge NPH

Answer 49

Intermediate-acting insulin trade name

Question 50

Humulin R

Answer 50

Regular-acting insulin trade name

Question 51

Humulin N

Answer 51

N for NHP (intermediate-acting insulin trade name)

Question 52

Humalog

Answer 52

Rapid-acting insulin trade name

Question 53

Lantus

Answer 53

Long-acting insulin trade name

Question 54

A reactive approach to rising blood glucose levels rather than a proactive approach and allows for hyperglycemia to occur before responding.

Answer 54

Sliding scale

Question 55

Consists of the administration of a predetermined amount of short-acting insulin in response to hyperglycemia in the hospital setting.

Answer 55

Sliding scale

Question 56

Capillary blood glucose is checked ___ times a day for patients on sliding scale insulin, ___ minutes prior to meals and at ___ (around ___). For patients who are on nothing by mouth (NPO), blood glucose is checked every ___ hours (___, ___, ___, ___, ___, ___). Only ___ insulin is used because of its ___ action. The prescriber will specify the amount of insulin in units, which “slide” up or down based on the specific blood glucose level range. Sliding scales are individualized for each patient. The goal is to use as ___ sliding-scale insulin as possible. A sliding scale is not used during ketoacidosis or if a patient is on IV insulin.

Answer 56

4 / 30 / bedtime (2200) / 4 (0400, 0800, 1200, 1600, 2000, 2400) / regular / fast / little

Question 57

___ is a trade name for regular insulin, a short-acting agent with an onset within 30 minutes.

Answer 57

Humulin R

Question 58

For this example, the patient had major abdominal surgery and is slowly returning to a regular diet. Yesterday, pharmacy delivered a multidose 10 mL vial of Humulin R. Until the patient fully recovers, the blood glucose levels will be monitored before each meal (ac) and at bedtime. The dose of insulin the nurse will administer will be based on a sliding scale. The glucose measurement before the evening meal was 15 mmol/L.

Answer 58

Order: Humulin R insulin subcutaneously ac and at bedtime per sliding scale. Apply the Three-Step Approach.

Step 1: Convert

No conversion needed. Order and supply for insulin will always be in units.

Step 2: Think
There is a glucose range of 14.1 to 16 mmol/L; 15 is greater than 14.1 but less than 16, so the insulin coverage for this range should be used. The amount of coverage, 6 units, is a small amount. The most appropriate choice of syringe to use to draw up 6 units would be a lo-dose syringe. Choose the 30 unit lo-dose syringe if available; otherwise, a 50 unit lo-dose syringe can be used. The 6 unit increment should fall between 5 and 10 units. Note that the lo-dose syringe is calibrated in 1 unit increments; the standard U-100 syringe is calibrated in 2 unit increments on the even and odd scales.

Step 3: Calculate
No calculation is necessary, but the accurate measurement is necessary. It may appear obvious how to fill the syringe to the correct calibration. Remember, though, that this is a high-alert medication and simple insulin measurement errors with potentially fatal consequences are quite common. Avoid distractions, and take your time when measuring insulin and other high-alert medications. Once the insulin has been drawn up into the syringe, give the order, the glucose measurement, vial, and syringe to another nurse for independent validation and documentation.

Question 59

A variety of insulin pen devices are currently available for patient use. Insulin pen devices facilitate the use of multiple injections of insulin, without having to withdraw from a ___. An insulin pen combines an insulin container and a syringe in a single unit, which allows for the precise and ___ delivery of insulin. Although there are many brands and models, insulin pens come in two basic types: (a) ___ devices and (b) ___ devices that are loaded with new insulin ___ when the old ones are used up. Each ___ is filled with ___ mL of a single insulin (e.g., glulisine, Humulin N insulin isophane, or Humulin R insulin regular) or a premixed combination of insulin (e.g., Humalog Mix 25, Humalog Mix 50, Humulin 30/70, or NovoMix 30). Needles come in a variety of sizes and lengths. Newer pen devices have a memory function and other added features.

Pen devices are a safe, convenient, easy, and accurate method for self-administration of insulin. They also improve patient comfort and provide optimal glycemic control. Some newer pens allow for easy correction of doses without wasting insulin. Some also have larger, easy-to-read numbers, or click as the dose is dialed or the plunger is depressed. However, only premixed combinations of insulin or a single insulin can be used, as different insulins cannot be ___ in an insulin pen device.

All devices require patient involvement to attach a ___ needle, prime the pen, dial up the dose, and depress a plunger to deliver the dose. It is recommended to leave the needle in the skin for at least ___ seconds to ensure complete delivery of insulin into the ___ tissue.

The insulin pen cartridge is marked to estimate the amount used or ___ for additional doses, but is not intended to measure ___ doses. To administer the correct dose, after adding a new cartridge and before each additional dose, the pen must be primed by releasing ___ units of insulin.

Answer 59

vial / convenient / disposable prefilled / reusable / cartridges / cartridge / 3

mixed

disposable / 5 / subcutaneous

remaining / individual / 2

Question 60

Order: Humalog insulin 12 units subcutaneously ac breakfast

Humalog is the ___ name for the ___-acting insulin ___, with an onset of action within 15 minutes. The amount remaining in the cartridge is shown in the picture.

Apply the Three-Step Approach.

Step 1: Convert
No conversion needed. Order and supply for insulin will always be in units.

Step 2: Think
There are 180 units of insulin remaining in the cartridge. After administering the 12 units ordered dose, the remaining amount should be between the 180 unit and 140 unit marks.

Step 3: Calculate
180 units − 12 units = 168 units (estimated amount remaining)
Dial the ordered amount until the dosage window reaches the correct number of units. After dialing the insulin amount, give the order and insulin pen to another ___ for independent verification and documentation.

Answer 60

trade / rapid / lispro / nurse

The amount remaining in the cartridge after administration of the insulin dose is shown in the picture.

Question 61

Humulin 30/70 insulin is the ___ name for the premixed combination containing 30% ___-acting insulin and 70% ___-acting insulin isophane suspension.

Answer 61

trade / short / regular / intermediate

Question 62

1. Best practice recommendations are that ___ nurses check insulin dosages to prevent patient safety incidents.
2. When combination dosages are prepared, best practice is that ___ nurses verify each step of the process.
3. In the community setting, when a second nurse is not available, an alert patient or ___ member may do the second independent check.

Answer 62

2

2

family

Question 63

Is there enough for a dose of 36 units in the insulin pen in the picture?

Answer 63

There is an insufficient amount for another dose. Discard the cartridge and needle safely in a sharps container. Store the pen for later use.