Level: Clinical
Difficulty: Medium
Subtopic: Clotting and bleeding disorders
NCLEX: A 73-year-old client on a telemetry unit is being evaluated for clotting and bleeding disorder. Assessment data i…
Pathophysiology Physiological Adaptation
Case Study
A 73-year-old client on a telemetry unit is being evaluated for clotting and bleeding disorder. Assessment data include hemoglobin 6.8 g/dL with pallor and hypotension 90/55 mm Hg. 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. Right client, medication, dose, route, time, allergies, indication, and relevant monitoring per protocol.
D. Delegate medication judgment to UAP to save time.
B. Skip allergy checks if the drug was given previously without reaction.
C. Right client, medication, dose, route, time, allergies, indication, and relevant monitoring per protocol.
D. Delegate medication judgment to UAP to save time.
Rationale
Correct answer: C. 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.