Medication Routes and the Errors the NCLEX Tests

Giving the right drug the wrong way is still a medication error. Here is what gets tested.

The rights of medication administration

Traditionally five, now often taught as more:

• Right client — two identifiers, never the room number
• Right drug
• Right dose
• Right route
• Right time
• Right documentation — after giving, never before
• Right reason
• Right response — did it work?

Documenting before giving is always wrong. It appears as a distractor.

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By mouth (PO)

Do not crush:

• Enteric-coated tablets — the coating protects the stomach or protects the drug from stomach acid
• Extended-release / sustained-release — crushing releases the whole dose at once, which can be dangerous
• Sublingual tablets — they are meant to dissolve under the tongue

If a client cannot swallow a pill that must not be crushed, do not crush it. Contact the prescriber for a different form.

Check for a liquid form rather than crushing.

Sublingual: under the tongue, let it dissolve, do not swallow, no food or drink until dissolved.

Buccal: between the cheek and gum.

Injections

Subcutaneous

• Small volumes, usually up to about 1 mL
• Angle: 45 to 90 degrees depending on the amount of tissue
• Sites: abdomen, upper outer arm, thigh, upper back
• Insulin: rotate sites within one area
• Heparin: abdomen, 2 inches from the belly button, do not aspirate, do not massage

Intramuscular

• Larger volumes
• Angle: 90 degrees

Sites:

• Ventrogluteal — the preferred site for adults. Away from major nerves and blood vessels.
• Vastus lateralis — the thigh. Preferred for infants.
• Deltoid — small volumes only, usually up to about 1 mL. Common for vaccines.
• Dorsogluteal — no longer recommended. Risk of sciatic nerve injury.

Z-track technique: pull the skin to one side, inject, wait, withdraw, release the skin. This traps the drug in the muscle and prevents it leaking into tissue.

Used for drugs that stain or irritate tissue, such as iron dextran. Many facilities now use Z-track for all IM injections.

Intradermal

• Very small amounts, just under the skin surface
• Angle: 5 to 15 degrees, bevel up
• Used for TB skin tests and allergy testing
• A small bleb or wheal should form. If it does not, the injection went too deep and must be repeated at another site.
• Do not massage.

Eye drops

• Wash hands, put on gloves
• Have the client look up
• Pull the lower lid down to make a pocket
• Drop into the pocket, not directly onto the eyeball
• Do not touch the dropper to the eye or lashes
• Have the client close the eye gently — do not squeeze shut
• Press on the inner corner for 30 to 60 seconds to stop the drug draining into the throat and being absorbed
• Wait about 5 minutes between different drops
• Drops before ointment if both are ordered

Ear drops

Position depends on age:

• Adults and children over 3: pull the ear up and back
• Children under 3: pull the ear down and back

Other points:

• Warm the drops to room temperature — cold drops cause dizziness
• Have the client lie with the affected ear up for a few minutes after
• Never insert the dropper into the canal

Inhalers

Metered dose inhaler:

• Shake it
• Breathe out fully
• Use a spacer if available — it improves delivery
• Press and breathe in slowly and deeply
• Hold breath about 10 seconds
• Wait about a minute between puffs

If both a bronchodilator and a steroid are ordered: bronchodilator first. It opens the airways so the steroid gets deeper.

After an inhaled steroid: rinse the mouth. This prevents oral yeast infection (thrush). Heavily tested.

Transdermal patches

• Remove the old patch before applying a new one. Leaving old patches on causes overdose. Commonly tested.
• Rotate sites
• Apply to clean, dry, hairless skin
• Do not cut a patch unless the manufacturer says it is allowed
• Wear gloves — you can absorb the drug through your own skin
• Write the date and time on the patch
• Do not apply heat over a patch — it speeds absorption

Rectal

• Position on the left side
• Insert past the internal sphincter
• Have the client stay lying down for a few minutes
• Useful when a client is vomiting or cannot swallow

IV

• Check the site before every dose
• Check compatibility before mixing anything
• Flush per policy
• Know which drugs can be given IV push and which cannot
• Potassium is never IV push

The errors that appear most

Crushing something that should not be crushed.

Not removing the old patch.

Not rinsing after an inhaled steroid.

Massaging a heparin site.

Using the dorsogluteal site.

Documenting before giving.

Using the room number to identify a client.

Steroid before bronchodilator (wrong order).

Aspirating for heparin or insulin (do not).

The short version

• Do not crush enteric-coated, extended-release, or sublingual
• Ventrogluteal for adult IM, vastus lateralis for infants, never dorsogluteal
• Heparin: abdomen, no aspirate, no massage
• Eye drops: into the pocket, press the inner corner
• Ear drops: up and back for adults, down and back for under 3
• Inhalers: bronchodilator first, rinse after steroids
• Patches: remove the old one first
• Document after giving, never before

Sources

• NCSBN. 2026 NCLEX-RN Test Plan. https://www.nclex.com/files/2026_RN_Test%20Plan_English-F.pdf
• NCSBN. Clinical Judgment Measurement Model. https://www.nclex.com/clinical-judgment-measurement-model.page

Injection site and administration technique recommendations change. Check current guidance and your facility’s policy.