NCLEX-RNSafety and Infection Prevention and ControlHard
A nurse is reviewing the medication administration record (MAR) for a client and notes a new order for a medication that the client's electronic health record (EHR) lists as an allergy. The client is currently asymptomatic. Which action should the nurse take first?
- ADocument the allergy in the MAR and administer an antihistamine proactively.
- BWithhold the medication and contact the prescribing healthcare provider.
- CAdminister a different medication from the same class that the client is not allergic to.
- DAdminister the medication and observe for an allergic reaction.
Show answer & explanationAnswer & explanation
Correct answer: B. Withhold the medication and contact the prescribing healthcare provider.
If a medication order conflicts with a known client allergy, the nurse must immediately withhold the medication and contact the prescribing healthcare provider for clarification. Administering a medication to which a client has a documented allergy is a serious medication error that could lead to a severe, life-threatening allergic reaction.
Why the other options are wrong
- A. Documenting the allergy is important but does not address the immediate conflict. Administering an antihistamine proactively does not negate the risk of a severe allergic reaction and is not a substitute for clarifying the order.
- C. The nurse cannot unilaterally change a medication order or substitute one medication for another, even if they are in the same class.
- D. Administering a medication to which a client is allergic is a direct violation of medication safety principles and could cause severe harm.
Medication Allergy Discrepancy
A situation where a prescribed medication is listed as an allergy in the client's record, necessitating immediate intervention to prevent harm.
- Always verify client allergies before administering any medication.
- If an allergy is identified after an order is placed, withhold the medication immediately.
- Contact the prescribing provider for clarification and a new, safe order.
- This is a critical step in preventing medication errors and ensuring client safety.
Memory trick: ALLERGY is a RED FLAG, STOP and CALL the DOC!