A 79-year-old client is admitted to the medical unit with new-onset severe confusion and a temperature of (). The client's medication orders include a stat intravenous (IV) push antibiotic and a routine intramuscular influenza vaccine. The registered nurse delegates the administration of both medications to the practical nurse. Which action is most appropriate for the practical nurse to take?
- Refuse the delegation for the IV push antibiotic due to scope limitations, and withhold the influenza vaccine because of the acute febrile illness, reporting to the registered nurse.Answer
- BAdminister the routine intramuscular influenza vaccine as ordered for respiratory protection, but request that the registered nurse administer the IV push antibiotic.
- CAttribute the severe confusion to expected age-related cognitive changes, and proceed to administer the IV push antibiotic slowly to minimize potential adverse effects.
- DAccept the complete medication delegation to ensure timely treatment of the infection, making certain to inject the IV push antibiotic over the recommended duration.
Answer
The practical nurse should decline the IV push medication because it is outside their scope of practice, and withhold the influenza vaccine because the client is currently experiencing a severe acute febrile illness.
The correct action requires the practical nurse to recognize two distinct safety issues. First, the administration of IV push medications generally falls outside the scope of practice for a practical nurse, as it requires advanced assessment and clinical judgment during rapid drug delivery. Second, the client's high fever and sudden confusion indicate an acute, moderate-to-severe illness, which is a recognized clinical precaution for withholding the influenza vaccine until the acute phase resolves.
Step-by-Step Solution
Key Concept
Scope of Practice and Immunization Contraindications