Level: Foundational
Difficulty: Easy
Subtopic: Hydration and fluid balance
NCLEX: A 58-year-old client after a stroke is being evaluated for nursing care related to hydration and fluid balance. A…
Nutrition Basic Care and Comfort
Case Study
A 58-year-old client after a stroke is being evaluated for nursing care related to hydration and fluid balance. Assessment data include the client coughs when drinking thin liquids and has wet vocal quality after swallowing. 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.