Level: Advanced
Difficulty: Hard
Subtopic: Musculoskeletal structure and mobility
NCLEX: A 73-year-old client on a telemetry unit is being evaluated for nursing care related to musculoskeletal structure…
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 musculoskeletal structure and mobility. 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. 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.
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.
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.