Level: Foundational
Difficulty: Easy
Subtopic: Acids, bases, and pH
NCLEX: A 73-year-old client on a telemetry unit is being evaluated for nursing care related to acids, bases, and ph. Ass…
Chemistry or biochemistry basics Physiological Adaptation
Case Study
A 73-year-old client on a telemetry unit is being evaluated for nursing care related to acids, bases, and ph. Assessment data include vital signs change from earlier: blood pressure 94/60 mm Hg and heart rate 112/min. 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.