Level: Foundational
Difficulty: Easy
Subtopic: Medication administration rights
NCLEX: A 34-year-old client on a telemetry unit is being evaluated for scheduled medications. Assessment data include th…
Pharmacology Pharmacological and Parenteral Therapies
Case Study
A 34-year-old client on a telemetry unit is being evaluated for scheduled medications. Assessment data include the barcode scanner shows a medication-client mismatch at the bedside. Which nursing action should the nurse take first?
Question
A. Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.
B. Implement the final step of the care plan before assessing the client.
C. Document the client as stable without reassessment.
D. Administer the next scheduled intervention before reassessing the client.
B. Implement the final step of the care plan before assessing the client.
C. Document the client as stable without reassessment.
D. Administer the next scheduled intervention before reassessing the client.
Rationale
Correct answer: A. Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.
Rationale: First-action questions on the NCLEX require assessment and safety before treatment, documentation alone, or delegation of nursing judgment.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: First-action questions on the NCLEX require assessment and safety before treatment, documentation alone, or delegation of nursing judgment.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.