Level: Clinical
Difficulty: Medium
Subtopic: Congenital disorders
NCLEX: A 2-year-old toddler in the emergency department is being evaluated for newly diagnosed congenital heart disease….
Pediatric nursing Health Promotion and Maintenance Physiological Adaptation
Case Study
A 2-year-old toddler in the emergency department is being evaluated for newly diagnosed congenital heart disease. Assessment data include temperature 103.1°F (39.5°C) with a new petechial rash. 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.