Level: Foundational
Difficulty: Easy
Subtopic: Autonomy and informed consent
NCLEX: A 58-year-old client on a telemetry unit is being evaluated for nursing care related to autonomy and informed con…
Ethics, legal nursing, delegation, prioritization Management of Care
Case Study
A 58-year-old client on a telemetry unit is being evaluated for nursing care related to autonomy and informed consent. Assessment data include family requests lab results by phone without verified authorization. Before a medication-related action, what must the nurse verify?
Question
A. Administer on schedule even when the client is unarousable.
B. Right client, medication, dose, route, time, allergies, indication, and relevant monitoring per protocol.
C. Skip allergy checks if the drug was given previously without reaction.
D. Delegate medication judgment to UAP to save time.
B. Right client, medication, dose, route, time, allergies, indication, and relevant monitoring per protocol.
C. Skip allergy checks if the drug was given previously without reaction.
D. Delegate medication judgment to UAP to save time.
Rationale
Correct answer: B. 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.