Level: Clinical
Difficulty: Medium
Subtopic: Incident reporting
NCLEX: The RN on a telemetry unit is being evaluated for nursing care related to incident reporting. Assessment data inc…
Leadership and management Management of Care
Case Study
The RN on a telemetry unit is being evaluated for nursing care related to incident reporting. Assessment data include telephone order received for a high-risk IV medication. 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.