Level: Foundational
Difficulty: Easy
Subtopic: Cardiac disorders
NCLEX: A 73-year-old client on a telemetry unit is being evaluated for heart failure exacerbation. Assessment data inclu…
Adult health / medical-surgical nursing Physiological Adaptation
Case Study
A 73-year-old client on a telemetry unit is being evaluated for heart failure exacerbation. Assessment data include the client has crackles bilaterally, SpO2 88% on room air, and reports increased shortness of breath. Before a medication-related action, what must the nurse verify?
Question
A. Administer on schedule even when the client is unarousable.
B. Skip allergy checks if the drug was given previously without reaction.
C. Delegate medication judgment to UAP to save time.
D. Right client, medication, dose, route, time, allergies, indication, and relevant monitoring per protocol.
B. Skip allergy checks if the drug was given previously without reaction.
C. Delegate medication judgment to UAP to save time.
D. Right client, medication, dose, route, time, allergies, indication, and relevant monitoring per protocol.
Rationale
Correct answer: D. Right client, medication, dose, route, time, allergies, indication, and relevant monitoring per protocol.
Rationale: Medication safety requires full rights verification and monitoring; shortcuts increase error risk on the NCLEX and at the bedside.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Medication safety requires full rights verification and monitoring; shortcuts increase error risk on the NCLEX and at the bedside.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.