# Situation: A 36-bed orthopedic and ophthalmology ward of a public hospital is staffed by a charge nurse, staff nurses, and nursing attendants. Nursing students from an affiliated college have clinical duty on the ward three days a week. A staff nurse finds that an ordered dose of an anticoagulant appears higher than the hospital's weight-based dosing guide allows. The nurse tells the resident physician twice, showing the guide and the client's weight each time; both times the resident says to give it as ordered without rechecking. Using the two-challenge rule, what should the nurse do NEXT?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=630553  
> language: ko  
> subject: Nursing Practice IV — Care of Clients with Problems in Nutrition and Gastrointestinal, Metabolism and Endocrine, Perception and Coordination

## 문제

Situation: A 36-bed orthopedic and ophthalmology ward of a public hospital is staffed by a charge nurse, staff nurses, and nursing attendants. Nursing students from an affiliated college have clinical duty on the ward three days a week.

A staff nurse finds that an ordered dose of an anticoagulant appears higher than the hospital's weight-based dosing guide allows. The nurse tells the resident physician twice, showing the guide and the client's weight each time; both times the resident says to give it as ordered without rechecking. Using the two-challenge rule, what should the nurse do NEXT?

## 보기

1. Hold the dose and discuss it again at the resident's next ward round
2. Give the dose as ordered and write the resident's reply in the chart
3. Take the concern up the chain of command to the attending physician **✔ 정답**
4. Raise the concern a third time with the resident, adding new data

**정답: 3**

## 해설

Under the two-challenge rule, a team member voices a safety concern at least twice; if it is still ignored, the concern goes to the next level of authority through the chain of command. Following an order the nurse believes to be wrong does not protect the client or the nurse.

## 심화 해설

The two-challenge rule
The two-challenge rule is a patient safety tool used in team communication. A team member who believes something is unsafe voices the concern at least twice. If the concern is still ignored after two attempts, the team member takes it to the next level of authority through the chain of command. The rule exists because errors often continue when a junior member raises a concern, is brushed aside, and then goes along with the decision. It gives the nurse a clear, accepted next step and empowers anyone on the team to stop an unsafe action.

Applying it here
The nurse finds that an anticoagulant dose appears higher than the hospital's weight-based dosing guide allows. The nurse has already told the resident twice, each time showing the guide and the client's weight. Both times the resident says to give it as ordered without rechecking. Two challenges have been made. The next step is to take the concern up the chain of command to the attending physician, following hospital policy, which may also involve the charge nurse and the pharmacist. The dose is not given until the concern is resolved.

| Option | Follows the rule? | Reason |
| --- | --- | --- |
| Escalate to the attending physician | Yes | Required after two unanswered challenges |
| Give as ordered and chart the reply | No | Carrying out an order believed wrong is not a defense |
| Hold and discuss at the next ward round | No | Leaves the risk unresolved and delays care |
| Challenge a third time | No | Delays action; the rule calls for escalation |

Why the other actions are wrong
Giving the dose as ordered and documenting the reply does not protect the client or the nurse; the nurse is accountable for medications given, and following an order the nurse believes to be wrong is not a defense. Holding the dose until the next ward round without escalating leaves a time-sensitive anticoagulant problem unresolved for hours. Raising the concern a third time with the resident delays action; the rule exists precisely so that the nurse moves up after two attempts.

Safety culture
The two-challenge rule belongs to a just and safety-focused culture, together with tools such as SBAR communication and closed-loop communication. After the event, the nurse documents the facts objectively and may file an incident report according to policy. The goal is not blame but safe care.

Exam takeaway
Key point Two challenges ignored, then escalate through the chain of command. Never give a medication you believe is unsafe simply because it was ordered.

## 임상 시나리오

Two-Challenge Rule in PracticeEscalating an unsafe medication order
Under the two-challenge rule, a safety concern is voiced at least twice. If it is still ignored, it goes up the chain of command.

The nurse showed the dosing guide and weight to the resident twice. The next step is to escalate to the attending physician per policy.

The dose is not given until the concern is resolved, and the facts are documented objectively.

CautionFollowing an order the nurse believes is wrong is not a defense. Do not give the dose just because the reply was charted.

## 핵심 개념

- **Two-challenge rule** — A safety rule: voice a concern at least twice, then escalate if it is still ignored.
- **Chain of command** — The formal line of authority used to escalate a concern to the next responsible person.
- **Weight-based dosing** — Calculating a drug dose according to the client's body weight.
- **Anticoagulant** — A drug that reduces blood clotting; dosing errors can cause serious bleeding or clotting.

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