A nurse is assisting in the care of a client receiving IV fluids. The nurse identifies that the IV pump has been infusing the fluids at double the rate of the prescribed order. After stopping the infusion, which of the following actions is the nurse's priority?

Rationale:

A. "Playing music will increase my husband's alertness.": Music therapy is not primarily used to increase alertness in hospice clients. Soothing music may promote relaxation and even drowsiness, especially in clients receiving sedating medications for or end-of-life comfort.

B. "I will discontinue music therapy when my husband is no longer responsive": Music therapy can still provide comfort even when a client is unresponsive. Familiar or calming music may have soothing effects and contribute to emotional peace, making it appropriate throughout all stages of hospice care.

C. "My husband won't need medication for breakthrough pain while using music therapy.": Music therapy is a complementary technique, not a replacement for pharmacologic pain management. Clients may still require medications for breakthrough pain.

D. "Music will distract my husband's awareness of the pain.": Music therapy helps reduce the perception of pain by providing sensory distraction and promoting relaxation. This cognitive diversion is one of the key benefits of using music as part of holistic pain management in hospice care.

Rationale:

A. Withhold the medication until the provider signs the prescription: Waiting for the provider's signature before administering a telephone order may delay critical care. Verbal or telephone orders can be acted upon immediately if clearly understood, documented, and later signed by the provider within the facility’s required timeframe.

B. Record the date and time of the telephone prescription: Accurate documentation includes noting the date and time the telephone order was received. This ensures clarity, legal compliance, and proper sequencing of medical events in the client's record.

C. Request that the provider confirm the read-back of the prescription: A read-back process reduces the risk of medication errors by confirming that the nurse correctly heard and understood the provider’s order. It is a Joint Commission-recommended safety practice.

D. Ask the provider to spell out the name of the medication: Asking the provider to spell out high-risk or sound-alike medications helps avoid transcription errors. This step is especially important when communication clarity is compromised over the phone.

E. Instruct another nurse to record the prescription in the medical record: The nurse receiving the order is responsible for documenting it. Delegating this task to another nurse increases the chance of miscommunication and errors, and violates proper protocol.