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 client has new facial swelling and difficulty swallowing after the first dose. Before teaching, what should the nurse assess first?
Question
A. Begin a long lecture while the client is in acute distress.
B. Assume understanding without checking literacy or readiness.
C. Immediate safety, readiness to learn, literacy, cultural needs, barriers, and baseline understanding.
D. Delegate all teaching without RN evaluation of learning needs.
B. Assume understanding without checking literacy or readiness.
C. Immediate safety, readiness to learn, literacy, cultural needs, barriers, and baseline understanding.
D. Delegate all teaching without RN evaluation of learning needs.
Rationale
Correct answer: C. Immediate safety, readiness to learn, literacy, cultural needs, barriers, and baseline understanding.
Rationale: Teaching is effective only after safety and learning readiness are confirmed; the RN cannot delegate assessment of learning needs on unstable clients.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Teaching is effective only after safety and learning readiness are confirmed; the RN cannot delegate assessment of learning needs on unstable clients.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.