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.
Request that the provider confirm the read-back of the prescription.
Withhold the medication until the provider signs 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,B,D
The nurse should take the following actions when receiving a telephone prescription from a client's provider:
- Ask the provider to spell out the name of the medication: This is important to ensure accurate transcription of the medication name. Spelling out the name helps prevent errors due to similar-sounding medications or confusion with abbreviations.
- Request that the provider confirm the read-back of the prescription: This step ensures that the nurse and the provider are on the same page and that the prescription has been accurately transcribed. It allows for verification and correction if any discrepancies are identified.
- Record the date and time of the telephone prescription: Documenting the date and time of the telephone prescription is essential for tracking and reference purposes. It helps establish a clear timeline of events and ensures proper documentation of the medication order.
It is not necessary to withhold the medication until the provider signs the prescription, as telephone prescriptions are typically followed up with a written prescription or electronic verification.
Instructing another nurse to record the prescription in the medical record may not be necessary, as the nurse who received the telephone prescription is responsible for accurately documenting the order in the medical record. However, if necessary, the nurse can delegate the task of documentation to another qualified staff member under their supervision, ensuring accuracy and completeness.
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Correct Answer is A
Explanation
Monitoring the infant's lymphocyte count is important in evaluating the immune function of the infant. HIV primarily affects the immune system, including lymphocytes. Monitoring the lymphocyte count helps assess the progression of the disease and the effectiveness of treatment.
Exchange transfusions are not typically used in the management of HIV. They are primarily performed in conditions like severe neonatal jaundice or blood disorders, but not for the treatment of HIV.
Granulocyte colony-stimulating factor (G-CSF) is a medication used to stimulate the production of white blood cells called granulocytes. While G-CSF can be used in certain situations, such as to counteract the side effects of certain chemotherapy drugs, it is not a standard treatment for HIV in infants.
Droplet precautions are typically implemented for infectious diseases that spread through respiratory droplets, such as influenza or respiratory syncytial virus (RSV). HIV does not spread through respiratory droplets, so initiating droplet precautions would not be necessary in the care of an infant with HIV.
Correct Answer is B
Explanation
Lowering the side rails of the bed could lead to the client falling from the bed. Instead raise the side rails and place padding on them.
Measuring the seizure duration is a crucial step for medical evaluation afterwards necessary for determining intervention.
Inserting an oral airway into the client's mouth is not indicated during a tonic-clonic seizure. It is generally not recommended to place any objects or devices into the mouth of a person having a seizure, as it can potentially cause injury to the person or damage to the airway.

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