Level: Clinical
Difficulty: Medium
Subtopic: Parenteral nutrition
NCLEX: A 58-year-old client after a stroke is being evaluated for nursing care related to parenteral nutrition. Assessme…
Nutrition Basic Care and Comfort
Case Study
A 58-year-old client after a stroke is being evaluated for nursing care related to parenteral nutrition. Assessment data include the client has heart failure, 2+ edema, and a 2 kg weight gain in 24 hours. 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.