A nurse is receiving a telephone order from a physician for a new medication for a client.

Which action should the nurse take to ensure accuracy and safety?

Repeat back the order to the physician verbatim.

Ask another nurse to listen to the order on speakerphone.

Write down the order on a piece of paper before entering it into the computer.

Confirm the order with a pharmacist before administering it to the client.

Answer and Explanation

The Correct Answer is A

Repeat back the order to the physician verbatim.

Rationale: The nurse should repeat back the order to the physician verbatim, as this is a standard practice to verify the accuracy and completeness of the order. Repeating back the order allows the nurse and the physician to check for any errors, omissions, or ambiguities, and to clarify any questions or concerns.

Incorrect options:

B) Ask another nurse to listen to the order on speakerphone. - This is not an appropriate action, as it violates the confidentiality and privacy of the client and the physician. Moreover, it does not ensure that the order is correctly understood and recorded by the nurse who will enter it into the computer.

C) Writing down the order on a piece of paper before entering it into the computer is not an appropriate action as it increases the risk of transcription errors, lost or misplaced orders, or delayed entry. The nurse should enter the order directly into the computer as soon as possible and discard any paper notes after verification.

D) Confirming the order with a pharmacist before administering it to the client is not an appropriate action as it adds an unnecessary step and delays the implementation of the order. The nurse should confirm the order with the physician, not the pharmacist, and administer it to the client according to the prescribed schedule. The pharmacist will review the order for any potential interactions, allergies, or contraindications and alert the nurse if any issues arise.

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Correct Answer is A

Explanation

An air leak in the system

Rationale: Continuous bubbling in the water seal chamber indicates an air leak in the system, which can compromise the negative pressure needed for effective drainage of air and fluid from the pleural space. The nurse should locate the source of the air leak and take appropriate measures to correct it. Possible sources of air leak include loose connections, cracks or holes in the tubing or drainage container, or a leak in the lung tissue.

Incorrect options:

B) A normal functioning of the system - Intermittent bubbling in the water seal chamber during inspiration, expiration, or coughing is a normal finding that indicates that air is being removed from the pleural space. Continuous bubbling is abnormal and indicates an air leak.

C) A need to empty the collection chamber - The collection chamber is where fluid drained from the pleural space accumulates. The nurse should empty the collection chamber when it is full or according to facility policy. Bubbling in the collection chamber is not a normal finding and does not indicate a need to empty it.

D) A need to clamp the chest tube - Clamping the chest tube is not recommended unless ordered by the provider or necessary for changing the drainage system. Clamping the chest tube can cause a buildup of pressure in the pleural space and lead to complications such as tension pneumothorax.

A. Fever B. Headache C. Nuchal rigidity D. Photophobia

Correct Answer is C

Explanation

Nuchal rigidity

Rationale: Nuchal rigidity, or stiffness of the neck, is a classic sign of meningitis and indicates inflammation of the meninges, the membranes that cover the brain and spinal cord. Kernig's sign is a test that involves flexing the client's hip and knee at 90 degrees and then attempting to straighten the leg. A positive Kernig's sign is when the client experiences pain or resistance in the hamstring muscles, indicating meningeal irritation.

Incorrect options:

A) Fever - This is a nonspecific sign of infection and inflammation and does not indicate meningitis specifically.

B) Headache - This is a common symptom of meningitis, due to the increased intracranial pressure caused by inflammation of the meninges. However, it is not a specific sign that warrants performing a Kernig's sign test.

D) Photophobia - This is a common symptom of meningitis, due to the sensitivity of the optic nerve to light caused by inflammation of the meninges. However, it is not a specific sign that warrants performing a Kernig's sign test.

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A nurse is receiving a telephone order from a physician for a new medication for a client. Which action should the nurse take to ensure accuracy and safety?

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Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has a chest tube connected to a water seal drainage system. The nurse observes continuous bubbling in the water seal chamber. What does this finding indicate?

Correct Answer is A

Explanation

A client is admitted to the hospital with suspected meningitis. Which assessment finding should alert the nurse to perform a Kernig's sign test?

Correct Answer is C

Explanation

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A nurse is receiving a telephone order from a physician for a new medication for a client.

Which action should the nurse take to ensure accuracy and safety?