Level: Clinical
Difficulty: Medium
Subtopic: Skin and wound assessment
NCLEX: A 74-year-old client on a medical-surgical unit is being evaluated for skin and wound assessment during hospitali…
Health assessment Reduction of Risk Potential
Case Study
A 74-year-old client on a medical-surgical unit is being evaluated for skin and wound assessment during hospitalization. Assessment data include the client reports no sleep and increasing agitation overnight. 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.