Level: Clinical
Difficulty: Medium
Subtopic: Scope of practice
NCLEX: A 58-year-old client on a telemetry unit is being evaluated for nursing care related to scope of practice. Assess…
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 scope of practice. Assessment data include new chest pain rated 8/10 with diaphoresis. 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.