A nurse is receiving a telephone prescription from a client's provider. Which of the following actions should the nurse take? (Select all that apply.)
Ask the provider to spell out the name of the medication.
Withhold the medication until the provider signs the prescription.
Request that the provider confirm the read-back of the prescription.
Record the date and time of the telephone prescription.
Instruct another nurse to record the prescription in the medical record.
Correct Answer : A,C,D
Receiving and transcribing a telephone prescription requires strict adherence to medication safety and communication protocols to prevent errors. A telephone order is considered a high-alert communication process that requires verification steps to ensure accuracy of the prescribed medication, dose, and route. The nurse acts as a critical safety checkpoint by using read-back verification and proper documentation. These measures are essential to reduce medication errors and maintain patient safety.
Rationale:
A. Asking the provider to spell out the name of the medication is essential to prevent misinterpretation of sound-alike or unclear drug names during verbal communication. This reduces the risk of medication errors caused by mishearing or pronunciation differences. It is a standard safety practice during telephone prescriptions.
B. Withholding the medication until the provider signs the prescription is not appropriate because telephone prescriptions are considered valid orders once properly received, read back, and documented. While providers must sign the order within the facility’s policy timeframe, immediate withholding is not required if the order has been correctly verified. Delaying administration could compromise patient care.
C. Requesting that the provider confirm the read-back of the prescription is a critical safety step in medication verification. The nurse repeats the order back to the provider to ensure accuracy, and the provider must confirm correctness. This closed-loop communication reduces transcription and interpretation errors in high-risk verbal orders.
D. Recording the date and time of the telephone prescription is required for legal and clinical documentation purposes. It ensures traceability and accountability of the order and helps maintain an accurate medical record. Proper documentation is essential for continuity of care and regulatory compliance.
E. Having another nurse record the prescription in the medical record is not appropriate because the nurse receiving the order is responsible for documenting it. Delegating transcription to another nurse increases the risk of communication errors and breaks accountability in the medication ordering process. The receiving nurse must ensure accurate documentation and verification.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D","E","F"]
Explanation
Preoperative nursing care for a client scheduled for laparoscopic management of a confirmed Ectopic pregnancy focuses on stabilizing the client, ensuring surgical readiness, and preventing perioperative complications such as hemorrhage and aspiration. The client has a tubal pregnancy confirmed by ultrasound with declining β-hCG levels, requiring urgent surgical intervention. Nursing priorities include airway safety, vascular access for rapid fluid or blood administration, verification of informed consent, and baseline laboratory evaluation to guide intraoperative management.
Rationale:
A. Reminding the client to remain NPO is essential to reduce the risk of aspiration during general anesthesia. Laparoscopic surgery requires sedation or general anesthesia, which depresses protective airway reflexes. Ensuring an empty stomach decreases the likelihood of regurgitation and aspiration pneumonia during induction of anesthesia.
B. Administering Rh immune globulin prior to surgery is not appropriate at this time without provider order and timing consideration. Rh immune globulin is typically given after delivery or significant fetal-maternal hemorrhage, not preoperatively. The priority is surgical stabilization rather than prophylactic administration at this stage.
C. Explaining the surgical procedure to the client is not the nurse’s role because informed consent and procedural explanation are the responsibility of the provider. The nurse may reinforce understanding but should not introduce or explain the procedure in detail. This could interfere with the legal consent process
D. Preparing for insertion of an 18-gauge peripheral IV is critical because ectopic pregnancy surgery carries a risk of sudden hemorrhage. A large-bore IV line allows rapid administration of fluids, medications, and blood products if needed. This ensures immediate vascular access for hemodynamic stabilization during surgery.
E. Verifying that the consent form is signed is a key legal and safety requirement before any surgical procedure. The nurse ensures that informed consent has been obtained, properly documented, and matches the planned procedure. This confirms patient understanding and protects autonomy before anesthesia is initiated.
F. Obtaining a complete blood count is necessary to establish baseline hematologic status before surgery. The client already demonstrates mild anemia, which may worsen if intraoperative bleeding occurs. Hemoglobin, hematocrit, and platelet levels guide perioperative planning and readiness for possible transfusion.
G. Administering AB positive blood products is inappropriate due to ABO and Rh incompatibility. The client is B negative, and transfusion with incompatible blood could trigger a severe hemolytic reaction. If transfusion becomes necessary, properly matched B negative or O negative blood must be used instead.
Correct Answer is A
Explanation
Neonatal jaundice is commonly evaluated using serum bilirubin testing because newborns frequently have elevated bilirubin levels in the early days of life. This occurs due to increased breakdown of fetal red blood cells combined with immature liver function, which limits the conjugation and excretion of bilirubin. Nurses must understand the physiologic basis of jaundice to provide accurate parent education and ensure timely monitoring. Serum bilirubin testing helps assess the severity of hyperbilirubinemia and guide treatment decisions such as phototherapy.
Rationale:
A. This statement correctly explains that newborns have immature hepatic function, which reduces their ability to conjugate and eliminate bilirubin. As a result, bilirubin from the breakdown of fetal red blood cells accumulates in the blood, leading to physiologic jaundice. This is the most accurate explanation for why a serum bilirubin test is ordered in newborns.
B. Breastfeeding can be associated with early or late-onset jaundice, but it is not the primary reason for routine serum bilirubin testing. Additionally, supplementation with formula is not routinely recommended unless medically indicated, as breastfeeding should be supported when possible.
C. Congenital dermal melanocytosis (Mongolian spots) is a benign skin finding and is not related to bilirubin metabolism or jaundice risk. It does not affect liver function or red blood cell breakdown and therefore is not a reason for bilirubin testing.
D. Increased bowel movements actually help reduce bilirubin levels by promoting excretion of conjugated bilirubin through stool. Therefore, having multiple bowel movements is not a risk factor for hyperbilirubinemia but rather a protective factor against it.
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