NCLEX: The home health nurse during an initial home visit is being evaluated for risk related to tertiary prevention. As…

Community / public health nursing Health Promotion and Maintenance

Case Study

The home health nurse during an initial home visit is being evaluated for risk related to tertiary prevention. Assessment data include a home visit reveals no working smoke detectors and medications stored on the floor. 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.

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.

Level: Foundational

Difficulty: Easy

Subtopic: Tertiary prevention