Level: Foundational
Difficulty: Easy
Subtopic: Medication administration rights
NCLEX: A 72-year-old client in a long-term care facility is being evaluated for scheduled medications. Assessment data i…
Pharmacology Pharmacological and Parenteral Therapies
Case Study
A 72-year-old client in a long-term care facility is being evaluated for scheduled medications. Assessment data include the client develops urticaria and wheezing 10 minutes after IV antibiotic administration. Which assessment approach should the nurse use first?
Question
A. Screen for instability, then perform a focused assessment related to the presenting concern.
B. Begin invasive procedures before any focused assessment.
C. Use only the chart from admission without current data.
D. Defer assessment until all medications are administered.
B. Begin invasive procedures before any focused assessment.
C. Use only the chart from admission without current data.
D. Defer assessment until all medications are administered.
Rationale
Correct answer: A. Screen for instability, then perform a focused assessment related to the presenting concern.
Rationale: Assessment begins with stability screening and focused data collection before invasive or delayed actions.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Assessment begins with stability screening and focused data collection before invasive or delayed actions.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.