Level: Clinical
Difficulty: Medium
Subtopic: Postpartum assessment
NCLEX: A postpartum client on the mother-baby unit is being evaluated for immediate postpartum recovery. Assessment data…
Maternal-newborn nursing Health Promotion and Maintenance Reduction of Risk Potential
Case Study
A postpartum client on the mother-baby unit is being evaluated for immediate postpartum recovery. Assessment data include the client reports calf pain with unilateral warmth and swelling. 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. Right client, medication, dose, route, time, allergies, indication, and relevant monitoring per protocol.
D. Delegate medication judgment to UAP to save time.
B. Skip allergy checks if the drug was given previously without reaction.
C. Right client, medication, dose, route, time, allergies, indication, and relevant monitoring per protocol.
D. Delegate medication judgment to UAP to save time.
Rationale
Correct answer: C. 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.