Name: ________________________________________
Date: _________________________________________
POINT VALUE
✦ = 3–6 points
✶ = 7–9 points
GRADED
TRIAL
# 1
GRADED
TRIAL
# 2
NOTES
1. ✦ Gather supplies, perform hand
hygiene, and apply gloves.
2. ✶ Select the correct medication
and diluent. As instructed in the
“three befores,” verify the dosage
against the physician’s order, and
calculate dosage if necessary.
3. ✦ Remove the top from the powder
medication and the top from the
diluent, then wipe the tops of both
vials with separate alcohol swabs.
4. ✶ Insert a sterile needle through
the rubber stopper on the vial of
diluent.
5. ✶ Withdraw the appropriate amount
of diluent and add to the powder
medication.
6. ✦ Remove the needle and syringe
unit from the medication vial and
discard the needle and syringe in
the sharps container.
7. ✶ To ensure that the medication is
mixed well, roll the vial between
the palms of your hands.
8. ✶ Label the mixed vial with
the strength of the prepared
medication, time and date, your
initials, and the expiration date.
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