Level: Clinical
Difficulty: Medium
Subtopic: Take action
NCLEX: A client in an unfolding case study is being evaluated for nursing care related to take action. Assessment data i…
Clinical judgment / Next Gen NCLEX case studies Clinical Judgment
Case Study
A client in an unfolding case study is being evaluated for nursing care related to take action. Assessment data include new vital signs show blood pressure 88/50 mm Hg, heart rate 124/min, and increasing confusion. 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.