Level: Clinical
Difficulty: Medium
Subtopic: Hypoxia and impaired gas exchange
NCLEX: A 73-year-old client on a telemetry unit is being evaluated for nursing care related to hypoxia and impaired gas…
Pathophysiology Physiological Adaptation
Case Study
A 73-year-old client on a telemetry unit is being evaluated for nursing care related to hypoxia and impaired gas exchange. 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. Administer on schedule even when the client is unarousable.
B. Right client, medication, dose, route, time, allergies, indication, and relevant monitoring per protocol.
C. Skip allergy checks if the drug was given previously without reaction.
D. Delegate medication judgment to UAP to save time.
B. Right client, medication, dose, route, time, allergies, indication, and relevant monitoring per protocol.
C. Skip allergy checks if the drug was given previously without reaction.
D. Delegate medication judgment to UAP to save time.
Rationale
Correct answer: B. 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.