Level: Advanced
Difficulty: Hard
Subtopic: Emergency deterioration
NCLEX: A 73-year-old client on a telemetry unit is being evaluated for rapidly worsening vital signs. Assessment data in…
Adult health / medical-surgical nursing Physiological Adaptation
Case Study
A 73-year-old client on a telemetry unit is being evaluated for rapidly worsening vital signs. Assessment data include blood glucose 420 mg/dL with acetone breath and Kussmaul respirations. Before a medication-related action, what must the nurse verify?
Question
A. Right client, medication, dose, route, time, allergies, indication, and relevant monitoring per protocol.
B. Administer on schedule even when the client is unarousable.
C. Skip allergy checks if the drug was given previously without reaction.
D. Delegate medication judgment to UAP to save time.
B. Administer on schedule even when the client is unarousable.
C. Skip allergy checks if the drug was given previously without reaction.
D. Delegate medication judgment to UAP to save time.
Rationale
Correct answer: A. 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.