Level: Foundational
Difficulty: Easy
Subtopic: Respiratory gas exchange
NCLEX: A 73-year-old client on a telemetry unit is being evaluated for nursing care related to respiratory gas exchange….
Anatomy & Physiology I/II Physiological Adaptation
Case Study
A 73-year-old client on a telemetry unit is being evaluated for nursing care related to respiratory gas exchange. Assessment data include a family member reports the client seems confused since this morning. 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. Delegate medication judgment to UAP to save time.
D. Right client, medication, dose, route, time, allergies, indication, and relevant monitoring per protocol.
B. Skip allergy checks if the drug was given previously without reaction.
C. Delegate medication judgment to UAP to save time.
D. Right client, medication, dose, route, time, allergies, indication, and relevant monitoring per protocol.
Rationale
Correct answer: D. 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.