A nurse is preparing to administer a medication based on a telephone verbal order. What step should be taken if the prescribed dose is unusually high?

Question the order and contact the prescriber for clarification

Administer the dose as prescribed to avoid delaying patient care

Consult with a pharmacist to confirm the dosage before proceeding

Document the dose and proceed with administration without verification.

Answer and Explanation

The Correct Answer is A

A. Question the order and contact the prescriber for clarification: When a prescribed dose appears unusually high, the nurse must verify the order with the prescriber to prevent potential medication errors or patient harm. Clarification ensures safe and accurate medication administration.

B. Administer the dose as prescribed to avoid delaying patient care: Administering a dose that seems unsafe without verification risks overdose, adverse reactions, or serious complications. Patient safety takes priority over speed.

C. Consult with a pharmacist to confirm the dosage before proceeding: While consulting a pharmacist is a useful safety step, the primary responsibility is to clarify the order with the prescriber who wrote it. Pharmacist input can supplement, but not replace, prescriber verification.

D. Document the dose and proceed with administration without verification: Administering a questionable dose without verification violates safety standards and professional nursing responsibility. Documentation alone does not protect the patient from potential harm.

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Correct Answer is B

Explanation

A. Following the pathway strictly, regardless of patient changes: Strict adherence without considering the patient’s evolving condition can compromise safety and individualized care. Critical pathways are guides, not rigid protocols.

B. Adjusting the care plan when a patient's condition deteriorates unexpectedly: Deviating from a critical pathway is appropriate when a patient’s clinical status changes. The nurse must use clinical judgment to modify interventions to meet the patient’s immediate needs while documenting and communicating the changes.

C. Documenting a pathway deviation only if it improves the patient's condition: All deviations, whether positive or negative, must be documented to maintain accountability, track outcomes, and inform future care planning. Selective documentation is not appropriate.

D. Using the critical pathway as a rigid schedule for patient interventions: Treating the pathway as a fixed schedule ignores patient variability. Effective use of critical pathways involves flexibility and adaptation based on individual patient responses.

A. Apply a topical ointment and continue with the bath. B. Cover the area with a bandage to prevent infection. C. Document the findings and report to the healthcare provider. D. Ignore it since it is a common issue in bedridden clients.

Correct Answer is C

Explanation

A. Apply a topical ointment and continue with the bath: Applying ointment without further assessment or orders can mask skin changes and delay appropriate intervention. Early pressure injury management requires evaluation and interdisciplinary planning rather than routine topical treatment.

B. Cover the area with a bandage to prevent infection: Covering the area without assessment, staging, or provider notification may be inappropriate and could worsen skin breakdown. Dressing selection depends on the stage of the pressure injury and underlying skin integrity.

C. Document the findings and report to the healthcare provider: Redness over the sacral area may indicate a stage 1 pressure injury and requires prompt documentation and reporting. This allows for early interventions such as pressure redistribution, skin protection, and care plan updates before major damage occurs.

D. Ignore it since it is a common issue in bedridden clients: Pressure injuries are never expected or acceptable findings. Ignoring early signs increases the risk of progression to deeper tissue injury and serious complications.

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A nurse is preparing to administer a medication based on a telephone verbal order. What step should be taken if the prescribed dose is unusually high?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is working in a healthcare facility that uses critical pathways to manage patient care. Which action by the nurse demonstrates an understanding of when to deviate from the critical pathway?

Correct Answer is B

Explanation

During a bath, the nurse notices redness and a potential pressure ulcer on the client's sacral area. What should the nurse do next?

Correct Answer is C

Explanation

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