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NHA Medical Assistant (CCMA) Exam Cram Sheet (2026)

A free, printable NHA Medical Assistant (CCMA) exam cram sheet: the 150 highest-yield points to know, grouped into 5 sections that follow the exam's content areas, each section with its published weight.

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  • 300 free NHA Medical Assistant (CCMA) practice questions on the same material, every one explained.
  • Last updated: August 2026.
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Patient Care: Vital Signs, Intake, and Direct Assistance

28% of the exam
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Adult oral temperature
Average 98.6 degrees F (37 degrees C), with a normal range of roughly 97.0 to 99.0 degrees F. Rectal readings run about 1 degree higher and axillary readings about 1 degree lower than oral.
Adult resting pulse
60 to 100 beats per minute. Below 60 is bradycardia and above 100 is tachycardia. Count a regular pulse for 30 seconds and double it, but count an irregular pulse for a full 60 seconds.· American Heart Association
Adult respirations
12 to 20 breaths per minute. Count them without telling the patient, because awareness changes the breathing rate, and remember that one respiration equals one full inhalation plus exhalation.
Blood pressure categories
Normal is less than 120/80 mmHg, elevated is 120 to 129 systolic with diastolic under 80, stage 1 hypertension is 130 to 139 or 80 to 89, and stage 2 is 140/90 or higher.· ACC/AHA Hypertension Guideline
Cuff size changes the reading
The inflatable bladder should cover about 80 percent of the arm circumference, with a width near 40 percent. A cuff that is too small falsely raises the reading and one that is too large falsely lowers it.· American Heart Association
Pulse oximetry
Normal oxygen saturation on room air is 95 to 100 percent. Nail polish, artificial nails, cold fingers, and poor perfusion all produce falsely low or unreadable results.
Two patient identifiers
Verify identity with two identifiers such as full name and date of birth before any specimen collection, medication, or procedure. A room number or bed location is never an acceptable identifier.· The Joint Commission National Patient Safety Goals
Chief complaint in the patient's own words
Record the chief complaint briefly and in quotation marks using the patient's own language, such as burning when I urinate for three days, rather than substituting a diagnosis like dysuria or urinary tract infection.
Subjective versus objective data
Subjective data is what the patient reports and cannot be measured, such as nausea, dizziness, or pain. Objective data is what you can measure or observe, such as a temperature of 101.4 degrees F or visible swelling.
Medication reconciliation
List every medication with name, dose, route, and frequency, including over-the-counter products, vitamins, and herbal supplements, because these interact with prescription drugs.
Allergies must include the reaction
Document what the substance is and what it did, for example penicillin causing hives and throat swelling. Flag allergies prominently in the chart so the provider sees them before prescribing.
Ask open-ended questions
Use open-ended prompts such as tell me about the pain during history taking, and avoid leading questions that suggest an answer. Reserve closed yes or no questions for confirming specific details.
Supine and dorsal recumbent
Supine is flat on the back and is used for general, chest, and abdominal exams. Dorsal recumbent is supine with knees flexed and feet flat, used for abdominal or genital exams when the patient cannot tolerate lithotomy.
Lithotomy
The patient lies supine with feet in stirrups and buttocks at the table edge, which is the standard position for pelvic exams and Pap collection. Drape in a diamond shape and never leave the patient alone in this position.
Sims position
Left lateral with the left leg slightly flexed and the right knee drawn up toward the chest, used for rectal exams, enemas, and rectal temperature.
Fowler's variations
High Fowler's is roughly 90 degrees, standard Fowler's is 45 to 60 degrees, and semi-Fowler's is 30 to 45 degrees. Any Fowler's position eases breathing and is preferred for patients in respiratory distress.
Prone and Trendelenburg
Prone is face down and is used for exams of the back and posterior legs. Trendelenburg tilts the head lower than the feet and is used in some shock states and abdominal procedures.
Draping and privacy
Expose only the area under examination, keep the drape in place while the patient moves, and knock before entering. Patients should be given time and privacy to change into a gown.
Gait belt technique
Apply the belt snugly around the waist over clothing with two fingers of space, and grasp it underhand from below. Never pull a patient up by the arms or under the axillae.
Body mechanics
Stand with feet shoulder-width apart, bend at the knees and hips rather than the waist, keep the load close to your body, and pivot with your feet instead of twisting your spine.
Transfer toward the strong side
Position the wheelchair on the patient's stronger side, lock both brakes, and raise or remove the footrests before any transfer.
Cane and walker rules
A cane is held on the strong side and advanced together with the weak leg. With a walker the patient moves the walker first, then the weak leg, then the strong leg.
Crutch fitting
The axillary pad should sit two to three finger widths below the armpit, with the elbows flexed about 20 to 30 degrees. Weight rests on the hands, not the armpits, to avoid nerve damage.
If a patient starts to fall
Do not try to hold the patient upright. Widen your stance, pull the patient toward your body, and ease them slowly to the floor while protecting the head, then call for help and do not move them until they are assessed.
Phases of wound healing
Healing proceeds through the inflammatory phase with redness and swelling, the proliferative phase where granulation tissue forms, and the maturation or remodeling phase where scar tissue strengthens over months.
Clean from clean to dirty
Wipe from the center of the wound outward, or from the least contaminated area to the most contaminated, and use a new sterile gauze for each stroke. Never return a used swab to the wound.
Signs of wound infection
Report increasing redness, warmth, swelling, worsening pain, purulent drainage, foul odor, red streaking, or fever, because these indicate infection rather than normal healing.
Drainage terminology
Serous drainage is clear and watery, sanguineous is bright red blood, serosanguineous is thin and pink, and purulent is thick and opaque, often yellow or green, indicating infection.
Sterile field integrity
The outer one inch of a sterile field is considered contaminated, anything below waist level or out of your line of sight is contaminated, and moisture soaking through a sterile drape contaminates the field.
Pressure injury staging
Stage 1 is intact skin with nonblanchable redness, stage 2 is partial-thickness loss with a shallow open ulcer, stage 3 extends into subcutaneous fat, and stage 4 exposes muscle, tendon, or bone.· National Pressure Injury Advisory Panel

Clinical Procedures: Injections, EKG, Phlebotomy, and Instrument Processing

24% of the exam
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Intradermal injection
Insert at a 10 to 15 degree angle with the bevel up, using a 25 to 27 gauge needle three-eighths to five-eighths inch long and a volume of about 0.1 mL into the inner forearm. A raised wheal confirms correct placement; a tuberculin skin test is read at 48 to 72 hours.· CDC
Subcutaneous injection
Insert at a 45 degree angle, or 90 degrees with a short needle in a pinched skin fold, using a 25 to 27 gauge needle three-eighths to five-eighths inch long and no more than about 1 mL. Common sites are the abdomen, the upper outer arm, and the anterior thigh.· CDC
Intramuscular injection
Insert at a 90 degree angle with a 22 to 25 gauge needle one to one and a half inches long. Adult deltoid volume is usually limited to 1 mL, while larger muscles such as the ventrogluteal and vastus lateralis tolerate up to 3 mL.· CDC
Site selection by patient
The vastus lateralis is the site of choice for infants, the deltoid is used for most adult vaccines, and the ventrogluteal is preferred for large or irritating volumes in adults. The dorsogluteal site is avoided because of sciatic nerve risk.
Z-track technique
Pull the skin laterally before inserting the needle, inject, wait about ten seconds, withdraw, then release the skin so the tissue layers seal the tract. This prevents irritating medication such as iron dextran from leaking into subcutaneous tissue and staining the skin.
Sharps safety at the point of care
Do not recap, bend, shear, or break used needles. Activate the engineered sharps injury protection device and dispose of the whole unit in a closable, puncture-resistant, labeled sharps container immediately.· OSHA 29 CFR 1910.1030
The core six rights
Right patient, right drug, right dose, right route, right time, and right documentation. Documentation is a right because an unrecorded dose can lead to a duplicate dose.
The added rights
Modern practice adds the right reason or indication, the right patient education, the right assessment before administration, the right to refuse, and the right response or evaluation afterward.
Three checks of the label
Read the medication label when you remove it from storage, when you draw up or pour the dose, and again before you administer it or return the container to the shelf.
Never give what you did not prepare
Do not administer a medication drawn up by someone else, and never give a dose from an unlabeled, illegible, expired, discolored, or cloudy container. When in doubt, discard it and start over.
Verify allergies before every dose
Ask the patient about allergies and check the chart even when the record already lists them, because new allergies develop and patients often remember reactions at the last moment.
Document immediately after, never before
Chart the drug, dose, route, site, time, lot number and expiration for vaccines, and the patient's response right after administration. Charting in advance is falsification of the record.
Chest lead positions V1 through V3
V1 sits in the fourth intercostal space at the right sternal border, V2 in the fourth intercostal space at the left sternal border, and V3 midway between V2 and V4.· American Heart Association
Chest lead positions V4 through V6
V4 sits in the fifth intercostal space at the midclavicular line, V5 at the anterior axillary line level with V4, and V6 at the midaxillary line level with V4 and V5.· American Heart Association
Limb lead placement and color code
Place limb electrodes on fleshy areas of all four limbs, avoiding bone. The common memory aid is white on the right arm, black on the left arm, red on the left leg, and green on the right leg, or white on right and smoke over fire.
Standard calibration
Standard paper speed is 25 millimeters per second and standard sensitivity is 10 millimeters per millivolt. One small box equals 0.04 second and one large box equals 0.20 second.
Recognizing artifact
Somatic tremor produces jagged irregular spikes from muscle movement or shivering, wandering baseline comes from loose electrodes, lotion, or respiration, and alternating current interference shows uniform small spikes from nearby electrical equipment.
Skin preparation
Clean the site with alcohol and let it dry, gently abrade dry or oily skin, and clip rather than shave excess hair. Poor skin contact is the most common cause of a poor-quality tracing.
Order of draw
Draw blood culture bottles or yellow SPS tubes first, then light blue sodium citrate, then red or gold serum tubes, then green heparin, then lavender EDTA, and finally gray sodium fluoride and potassium oxalate.· CLSI GP41
Tourniquet time
Leave the tourniquet on for no more than one minute. Prolonged application causes hemoconcentration, which falsely elevates results such as potassium, protein, and packed cell volume.
Vein selection
The median cubital vein is the first choice, followed by the cephalic and then the basilic vein, which sits near the brachial artery and median nerve. Avoid the arm on the side of a mastectomy, an arm with an active IV above the site, and areas with hematoma, scarring, or edema.
Mix, do not shake
Invert additive tubes gently three to eight times per manufacturer instructions immediately after collection. Vigorous shaking causes hemolysis, and no mixing causes clotting in anticoagulant tubes.
Hemolysis changes results
Hemolyzed specimens falsely elevate potassium, magnesium, phosphorus, and certain enzymes because these leak out of ruptured red cells. Common causes are a needle that is too small, vigorous shaking, and forcing blood through a needle into a tube.
Coagulation tube fill requirement
A light blue citrate tube must be filled completely to maintain the nine parts blood to one part anticoagulant ratio. A short-draw blue tube is rejected because it falsely prolongs clotting times.
Common CLIA-waived tests
Waived tests include blood glucose meters, urine dipsticks, urine pregnancy tests, rapid strep, rapid influenza, hemoglobin, and fecal occult blood. A facility must hold at least a Certificate of Waiver to perform them.· CLIA 42 CFR Part 493
Quality control is mandatory
Run and log controls at the frequency the manufacturer specifies, and do not report patient results if a control falls outside its acceptable range. Correct the problem, repeat the control, and document what you did.
Sanitization, disinfection, sterilization
Sanitization removes visible soil, disinfection destroys most microorganisms on surfaces, and sterilization destroys all microorganisms including bacterial spores. Instruments entering sterile tissue or the vascular system must be sterilized.· CDC
Autoclave parameters
A standard gravity-displacement cycle runs at 250 degrees F (121 degrees C) at 15 pounds per square inch for roughly 20 to 30 minutes, with longer times for wrapped packs. It is the steam under pressure, not the heat alone, that sterilizes.· CDC
Loading the autoclave
Load packs on edge with space between them so steam circulates, do not overcrowd the chamber, place containers on their side, and open hinged instruments before wrapping. Trapped air and crowding are the main causes of sterilization failure.
Monitoring and pack labeling
Use a chemical indicator on or in every pack and run a biological spore test with Geobacillus stearothermophilus at least weekly. Label each pack with contents, sterilization date, and your initials, and treat any wet, torn, or dropped pack as contaminated.· CDC

Administrative and Legal Practice: HIPAA, Scope, Documentation, and Billing

18% of the exam
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Protected health information
PHI is any health information that can identify a patient, including name, address, dates, phone number, email, medical record number, insurance number, and photographs. Removing identifiers is what makes data de-identified.· HIPAA Privacy Rule
Minimum necessary standard
Access, use, and disclose only the smallest amount of PHI needed to accomplish the purpose. This standard does not apply to disclosures to the patient or to the treating provider for treatment purposes.· HIPAA Privacy Rule
Treatment, payment, and operations
Disclosures for treatment, payment, and health care operations generally do not require the patient's written authorization. Marketing, sale of PHI, and most psychotherapy notes do require specific written authorization.· HIPAA Privacy Rule
Notice of Privacy Practices
The practice must give each patient a Notice of Privacy Practices describing how PHI is used and disclosed, and must make a good-faith effort to obtain written acknowledgment of receipt.· HIPAA Privacy Rule
Security Rule safeguards for electronic PHI
Electronic PHI requires administrative safeguards such as workforce training, physical safeguards such as locked workstations, and technical safeguards such as unique user IDs, automatic logoff, and encryption.· HIPAA Security Rule
Breach notification
Following a breach of unsecured PHI, affected individuals must be notified without unreasonable delay and no later than 60 days from discovery, with additional notice to the Secretary of HHS and, for large breaches, the media.· HIPAA Breach Notification Rule
Delegated authority, not independent authority
Medical assistants act on the specific delegation of a supervising physician or provider. Scope varies by state, so verify your state's rules rather than assuming a task allowed in one state is allowed in another.
Tasks generally outside the MA scope
Medical assistants generally do not diagnose, do not independently triage or assess, do not give medical advice by telephone beyond provider-approved protocols, and in most states do not administer intravenous medications or perform independent nursing assessments.
Elements of informed consent
Valid informed consent requires the nature of the procedure, the risks and benefits, reasonable alternatives, the risks of refusing, and the patient's voluntary agreement. The provider must obtain and explain consent; the medical assistant may witness the signature.
Implied versus expressed consent
Implied consent is inferred from the patient's actions, such as rolling up a sleeve for an injection, or from an emergency in which the patient cannot respond. Expressed consent is stated in words and is documented in writing for invasive procedures.
Consent for minors
A parent or legal guardian consents for a minor, except where state law allows a mature or emancipated minor, or a minor seeking care for specific conditions, to consent independently.
Liability terms you must know
Negligence is failing to act as a reasonable person would, malpractice is professional negligence, standard of care is what a similarly trained person would do, and respondeat superior makes the employer responsible for employees acting within their duties.
The SOAP format
S is subjective information the patient reports, O is objective data such as vital signs and exam and laboratory findings, A is the provider's assessment or impression, and P is the plan including treatment, medications, testing, and follow-up.
Correcting a paper record
Draw a single line through the error so the original remains readable, write the word error or the correction above or beside it, then add your initials and the date. Never erase, black out, or use correction fluid.
Late entries and addenda
Label a delayed entry as a late entry, state the date and time of the event and the date and time of the entry, then sign it. In an electronic record the system creates an audit trail automatically.
Objective, factual charting
Record what you can see, hear, measure, or quote, such as patient states she vomited twice, rather than subjective labels such as patient seems drunk or patient is uncooperative.
Ownership versus access
The physical record or its electronic file belongs to the practice, but the information in it belongs to the patient. Patients have a right to inspect and obtain a copy of their record, generally within 30 days of a request.· HIPAA Right of Access
Retention
Retention periods are set by state law and payer rules, commonly several years for adults, while records for minors are typically kept until the patient reaches the age of majority plus an additional period.
Matrix the schedule first
Block hospital rounds, meetings, lunch, vacations, and any other unavailable time before booking a single patient, so appointments are never made when the provider cannot be there.
Common scheduling systems
Stream scheduling gives each patient a specific time slot, wave scheduling books several patients at the top of the hour, modified wave staggers arrivals within the hour, double booking places two patients in the same slot, and open hours lets patients come without appointments.
Clustering and grouping
Clustering books similar visit types together, such as all physicals in one morning, which streamlines room setup and equipment use and reduces turnover time.
Triage urgent symptoms immediately
Chest pain, difficulty breathing, uncontrolled bleeding, signs of stroke, severe allergic reaction, and suicidal statements are escalated to the provider or to emergency services at once rather than given the next available appointment.
Document no-shows and cancellations
Record every no-show, cancellation, and reschedule in both the appointment system and the patient's chart, because repeated no-shows are clinically and legally significant.
Referrals and prior authorization
Many plans require prior authorization or a referral before a specialty visit, imaging, or surgery. Obtaining it before the service protects the patient from a denied claim.
ICD versus CPT versus HCPCS
ICD-10-CM codes report the diagnosis or reason for the visit, CPT codes report the procedures and services performed, and HCPCS Level II codes report supplies, durable medical equipment, and certain drugs and services.
ICD-10-CM code structure
Codes are three to seven characters, always begin with a letter, and must be reported to the highest level of specificity available. Never code a suspected diagnosis in the outpatient setting; code the signs and symptoms instead.
Evaluation and management codes
Office visits are reported with evaluation and management CPT codes, and modifiers are two-character additions that explain a special circumstance without changing the definition of the code.
Core insurance vocabulary
The premium is the recurring cost of coverage, the deductible is what the patient pays before benefits begin, the copay is a fixed per-visit amount, coinsurance is a percentage split, and the out-of-pocket maximum caps annual patient cost.
Major payer types
Medicare Part A covers hospital care, Part B covers outpatient and provider services, Part C is Medicare Advantage, and Part D covers prescription drugs, while Medicaid is jointly funded with each state, TRICARE covers military families, and workers' compensation covers job-related injury.· CMS
Communicating so the patient can act
Use plain language, avoid jargon, and confirm understanding with the teach-back method by asking the patient to explain the plan in their own words. Use a qualified interpreter for patients with limited English proficiency rather than family members or minors.· HHS National CLAS Standards

Infection Control and Workplace Safety

16% of the exam
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The six links
The chain runs from the infectious agent to the reservoir, the portal of exit, the mode of transmission, the portal of entry, and finally the susceptible host. Breaking any single link stops the infection.· CDC
Standard precautions apply to everyone
Treat blood, all body fluids, secretions, excretions except sweat, non-intact skin, and mucous membranes as potentially infectious for every patient, in every setting, every time.· CDC
What standard precautions include
Hand hygiene, personal protective equipment based on anticipated exposure, respiratory hygiene and cough etiquette, safe injection practices, safe handling of contaminated equipment and surfaces, and sharps safety.· CDC
Respiratory hygiene and cough etiquette
Offer a mask to coughing patients, provide tissues and no-touch waste containers, encourage hand hygiene after contact with secretions, and seat symptomatic patients at least three to six feet from others when possible.· CDC
Safe injection practices
Use one needle, one syringe, one time, for one patient. Never reuse a syringe to re-enter a vial, and treat single-dose vials as single-patient use even if medication remains.· CDC
Environmental cleaning
Clean and disinfect frequently touched surfaces and shared equipment between patients with an EPA-registered hospital disinfectant, observing the wet contact time printed on the product label.
Contact precautions
Wear a gown and gloves for all interactions involving the patient or their environment. Typical indications include MRSA, VRE, Clostridioides difficile, scabies, lice, and respiratory syncytial virus.· CDC
Droplet precautions
Wear a surgical mask when within about six feet of the patient, because large respiratory droplets do not travel far. Typical indications include influenza, pertussis, mumps, rubella, and Neisseria meningitidis.· CDC
Airborne precautions
Wear a fit-tested N95 respirator or higher and place the patient in an airborne infection isolation room with negative pressure. Typical indications include tuberculosis, measles, varicella, and disseminated herpes zoster.· CDC
Spores need soap and water
Alcohol-based hand rub does not kill Clostridioides difficile spores or norovirus. After caring for these patients, wash with soap and running water and disinfect surfaces with a bleach-based or other sporicidal product.· CDC
Precautions are layered, not substituted
A patient on contact precautions still requires hand hygiene, eye protection when splashing is likely, and every other element of standard precautions.
Patient transport
Limit transport of patients on transmission-based precautions, and when transport is necessary, have the patient wear a mask for droplet or airborne organisms and cover infected skin lesions for contact organisms.· CDC
Donning order
Put on the gown first, then the mask or respirator, then goggles or a face shield, and finally gloves, pulling the glove cuffs over the gown sleeves.· CDC
Doffing order
Remove gloves first, then goggles or face shield, then the gown, and remove the mask or respirator last after leaving the patient room. Perform hand hygiene immediately afterward.· CDC
Alcohol-based hand rub
Use a product containing 60 to 95 percent alcohol, apply enough to cover all surfaces, and rub hands together until completely dry, which takes about 20 seconds.· CDC
When soap and water is required
Wash with soap and running water for at least 20 seconds when hands are visibly soiled, after using the restroom, before eating, and after caring for patients with C. difficile or norovirus.· CDC
Gloves do not replace hand hygiene
Perform hand hygiene before putting gloves on and after taking them off, change gloves between patients and between dirty and clean tasks on the same patient, and never wash and reuse disposable gloves.· CDC
Respirator fit testing
Employees required to wear a tight-fitting respirator must be medically evaluated, fit tested before first use and at least annually, and must perform a user seal check each time they put it on.· OSHA 29 CFR 1910.134
The governing standard
Occupational exposure to blood and other potentially infectious materials is regulated by the Bloodborne Pathogens Standard, which applies to any employee who can reasonably anticipate contact with blood as part of their duties.· OSHA 29 CFR 1910.1030
Written Exposure Control Plan
The employer must maintain a written Exposure Control Plan, review and update it at least annually and whenever new tasks or devices change exposure risk, and make it accessible to employees.· OSHA 29 CFR 1910.1030
Hepatitis B vaccination
The employer must offer the hepatitis B vaccine series at no cost within 10 working days of initial assignment to a job with occupational exposure. An employee who declines must sign a declination form and may request the vaccine later at any time.· OSHA 29 CFR 1910.1030
Engineering and work practice controls
Employers must provide sharps with engineered injury protection and puncture-resistant containers, and must prohibit eating, drinking, smoking, applying cosmetics, and handling contact lenses in areas of occupational exposure.· OSHA 29 CFR 1910.1030
Post-exposure evaluation
After a needlestick or other exposure, wash the area with soap and water or flush mucous membranes with water, report the incident immediately, and receive a confidential medical evaluation, source testing where permitted, and follow-up at no cost to you.· OSHA 29 CFR 1910.1030
Hazard communication
Employees must have access to safety data sheets for hazardous chemicals used in the workplace, containers must carry standardized GHS labels with pictograms, and training must be provided before first use.· OSHA 29 CFR 1910.1200
Medical asepsis, or clean technique
Medical asepsis reduces the number and spread of microorganisms through hand hygiene, gloves, disinfection of surfaces, and proper waste handling. It is used for injections of routine vaccines, vital signs, and most exam room tasks.
Surgical asepsis, or sterile technique
Surgical asepsis destroys all microorganisms and their spores and is required for minor surgery, urinary catheterization, sterile dressing changes, and any procedure entering a normally sterile body area.
Rules of the sterile field
The outer one inch is contaminated, anything below waist level or out of your direct sight is contaminated, never reach across the field or turn your back on it, and any moisture that soaks through the drape contaminates it.
Sharps containers
Containers must be closable, puncture-resistant, leak-proof on sides and bottom, and labeled with the biohazard symbol or color-coded red. Replace them when they reach roughly two-thirds to three-quarters full and never force items in.· OSHA 29 CFR 1910.1030
Regulated waste versus ordinary trash
Regulated waste includes liquid or semi-liquid blood, items caked with dried blood that could release it if compressed, contaminated sharps, and pathological waste, and it goes in a labeled red biohazard bag. A gauze pad with a small dried spot of blood generally does not.· OSHA 29 CFR 1910.1030
Blood spill cleanup
Put on gloves and other appropriate PPE, absorb the spill with disposable material, clean the area, then disinfect with an EPA-registered disinfectant effective against bloodborne pathogens or a freshly prepared one-to-ten bleach solution.· CDC

Pharmacology: Drug Classes, Routes, Calculations, and Vaccines

14% of the exam
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Cardiovascular agents
Antihypertensives include ACE inhibitors ending in -pril, angiotensin receptor blockers ending in -sartan, beta blockers ending in -olol, and calcium channel blockers often ending in -dipine. Statins ending in -statin lower cholesterol and anticoagulants reduce clot formation.
Respiratory agents
Bronchodilators such as short-acting beta agonists relieve acute bronchospasm, inhaled corticosteroids prevent airway inflammation over time, and antihistamines, decongestants, antitussives, and expectorants treat allergy and cough symptoms.
Nervous system agents
Analgesics relieve pain, opioids act centrally and carry addiction risk, benzodiazepines ending in -pam or -lam reduce anxiety, SSRIs treat depression, anticonvulsants control seizures, and anesthetics produce local or general loss of sensation.
Endocrine agents
Insulin and oral agents such as metformin lower blood glucose, levothyroxine replaces thyroid hormone in hypothyroidism, and corticosteroids suppress inflammation and immune response.
Gastrointestinal agents
Antacids neutralize existing stomach acid, proton pump inhibitors ending in -prazole reduce acid production, antiemetics control nausea and vomiting, and laxatives and antidiarrheals regulate bowel movement.
Anti-infectives
Antibiotics such as penicillins ending in -cillin, macrolides ending in -mycin or -thromycin, and fluoroquinolones ending in -floxacin treat bacterial infection, while antivirals treat viral infection and antifungals often end in -azole. Antibiotics have no effect on viruses.
Enteral routes
Oral is the most common and convenient but the slowest, sublingual under the tongue and buccal against the cheek absorb rapidly through mucosa and bypass the liver, and rectal is useful when the patient is vomiting or unconscious.
Parenteral routes
Intradermal, subcutaneous, intramuscular, and intravenous all bypass the digestive tract. Intravenous produces the fastest onset because the drug enters circulation directly, and intradermal is the slowest to absorb.
Topical and mucosal routes
Transdermal patches deliver a steady dose through the skin, ophthalmic drops go into the lower conjunctival sac rather than directly on the cornea, and inhaled medication acts directly on the airways.
Otic administration by age
For an adult, pull the pinna up and back before instilling ear drops. For a child under about three years, pull the pinna down and back, because the ear canal is angled differently.
Frequency and timing abbreviations
BID is twice daily, TID is three times daily, QID is four times daily, q4h is every four hours, ac is before meals, pc is after meals, hs is at bedtime, PRN is as needed, and stat means immediately.
Dangerous abbreviations to avoid
Do not use U for units, IU for international units, QD or QOD for daily and every other day, or a trailing zero such as 1.0 mg. Always use a leading zero, writing 0.5 mg rather than .5 mg.· The Joint Commission Do Not Use List
Desired over have
Divide the desired dose by the dose on hand and multiply by the quantity that dose comes in. For 500 mg desired from a 250 mg per tablet supply, 500 divided by 250 times 1 tablet equals 2 tablets.
Metric conversions
One gram equals 1000 milligrams, one milligram equals 1000 micrograms, one liter equals 1000 milliliters, and one kilogram equals 1000 grams. Moving from a larger to a smaller unit multiplies, and the reverse divides.
Household and weight conversions
One teaspoon is about 5 mL, one tablespoon is about 15 mL, one fluid ounce is about 30 mL, and one kilogram equals 2.2 pounds.
Weight-based pediatric dosing
Pediatric orders are commonly written as milligrams per kilogram per day. Convert the child's weight from pounds to kilograms first by dividing by 2.2, then multiply by the ordered milligrams per kilogram.
Body surface area dosing
Body surface area, expressed in square meters and derived from height and weight, is used for chemotherapy and some pediatric drugs because it estimates metabolic capacity more accurately than weight alone.
High-alert medications need a second check
Insulin, heparin, opioids, and concentrated electrolytes cause disproportionate harm when given in error, so independent double checks and standardized concentrations are standard safeguards.· ISMP List of High-Alert Medications
Side effect versus adverse reaction versus allergy
A side effect is a known, usually tolerable secondary effect, an adverse drug reaction is harmful and unintended, an allergic reaction is immune-mediated and can escalate, and an idiosyncratic reaction is an unexpected individual response.
Recognizing anaphylaxis
Look for hives, swelling of the lips, tongue, or throat, wheezing or stridor, difficulty breathing, hypotension, rapid weak pulse, and a sense of impending doom. Activate emergency services immediately and notify the provider.
Epinephrine is the first-line treatment
For anaphylaxis, epinephrine is given by intramuscular injection into the mid-outer thigh, the vastus lateralis, because that site provides the fastest absorption. Antihistamines are adjuncts and never a substitute.
Post-vaccination observation
Observe patients for 15 minutes after vaccination and keep them seated or lying down, because syncope and the rare immediate hypersensitivity reaction usually occur within that window.· CDC
Reporting adverse events
Serious adverse events involving drugs and devices are reported to the FDA through MedWatch, while adverse events following immunization are reported to the Vaccine Adverse Event Reporting System.· FDA MedWatch and VAERS
Common interactions to know
Grapefruit juice raises blood levels of certain statins and calcium channel blockers, warfarin interacts with vitamin K rich foods and with NSAIDs, and antibiotics can reduce the effectiveness of oral contraceptives.
The five schedules
Schedule I has no accepted medical use, Schedule II has high abuse potential with accepted use such as oxycodone and methylphenidate, Schedule III includes moderate potential such as buprenorphine and anabolic steroids, Schedule IV includes benzodiazepines and tramadol, and Schedule V includes low-dose codeine preparations.· Controlled Substances Act
Prescription limits
Schedule II prescriptions cannot be refilled and require a new prescription each time, while Schedule III and IV prescriptions may be refilled up to five times within six months of the date written.· DEA 21 CFR Part 1306
Storage and inventory
Controlled substances must be stored in a securely locked, substantially constructed cabinet, a biennial inventory must be taken, and required records must be kept for at least two years and available for inspection.· DEA 21 CFR Part 1304
Vaccine storage temperatures
Refrigerated vaccines are stored at 36 to 46 degrees F (2 to 8 degrees C) and frozen varicella-containing vaccines at the manufacturer's specified freezer range. Temperatures must be monitored and logged with a calibrated digital data logger.· CDC Vaccine Storage and Handling Toolkit
Vaccine Information Statements
The current Vaccine Information Statement must be given to the patient or parent before every dose of a covered vaccine, and the chart must record the VIS edition date and the date it was provided.· National Childhood Vaccine Injury Act
Documenting an immunization
Record the vaccine name, manufacturer, lot number, expiration date, dose, route, anatomic site, date given, and the name and title of the person administering it. The recommended schedules are published annually.· CDC ACIP Immunization Schedules

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