A nurse is reviewing a new order on the Electronic Health Record.
The dose of the medication is abnormally high.
What would be the nurse's best next action?
Refuse to administer the medication.
Administer the medication as ordered.
Document concerns about the order.
Query the physician about the order.
The Correct Answer is D
Choice A rationale
Refusing to administer the medication without further investigation could jeopardize the client's timely treatment. While safety is paramount, the nurse's initial action should be to gather more information rather than outright refusal, which could delay necessary care.
Choice B rationale
Administering a medication that appears to be abnormally high without verifying the order is unsafe and could lead to serious adverse effects for the client. Nurses have a professional responsibility to question orders that seem incorrect or potentially harmful.
Choice C rationale
Documenting concerns is an important step in the process, but it is not the best *next* action. While documentation is crucial for legal and communication purposes, directly addressing the potentially erroneous order with the prescriber takes precedence to ensure patient safety.
Choice D rationale
Querying the physician about the order is the most appropriate immediate action. This allows the nurse to clarify the dosage, route, and rationale for the high dose. It opens a dialogue with the prescriber to confirm the order's accuracy or identify a potential error, directly addressing the safety concern.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Locked-in syndrome is a rare neurological disorder characterized by complete paralysis of all voluntary muscles except for those that control eye movement. The client's reported symptoms of drowsiness, irritability, and decreased attention span do not align with the typical presentation of locked-in syndrome, where cognitive function remains largely intact.
Choice B rationale
Sensory deprivation occurs when there is a reduction in sensory input, leading to various psychological and physiological effects. The client's recent loss of regular visits from her daughter and family, coupled with the reported symptoms of drowsiness, excessive sleeping, decreased attention span, irritability, and signs of depression, strongly suggest sensory deprivation as a contributing factor due to reduced social interaction and stimulation.
Choice C rationale
Residential psychosis is not a recognized or well-defined psychological or psychiatric term. Therefore, it is not an appropriate diagnosis for the client's symptoms.
Choice D rationale
Disturbed sensory perception involves alterations in the processing of sensory stimuli, such as hallucinations or delusions. While the client exhibits changes in her mental state, the reported symptoms are more indicative of a lack of sensory input and social interaction rather than distorted sensory processing.
Correct Answer is ["A","B"]
Explanation
Choice A rationale
Nurse practice acts, established at the state level, delineate the scope of nursing practice. They define the specific actions, duties, and responsibilities that nurses are legally authorized to perform based on their education, licensure, and experience. These acts also outline what activities fall outside the permissible boundaries of nursing practice to protect patient safety and maintain professional standards.
Choice B rationale
A primary objective of state nurse practice acts is to safeguard the public by regulating the practice of nursing. Through licensure requirements, standards of care, and disciplinary procedures, these acts ensure that only qualified and competent individuals provide nursing care. This regulation helps to maintain accountability within the profession and protect patients from potential harm due to unqualified or unethical practice.
Choice C rationale
The regulation of nursing practice primarily falls under the jurisdiction of individual state governments, not the federal government. Each state has its own board of nursing or similar regulatory body that is responsible for developing and enforcing the state's nurse practice act. While federal laws may influence healthcare, the direct oversight and regulation of nursing licensure and practice are state responsibilities.
Choice D rationale
Student nurses are held to the same standards of care as licensed nurses when providing patient care. Although they are still in the learning process and work under supervision, they are expected to adhere to established safety protocols and ethical principles. Their actions can have consequences, and they are accountable for the care they provide, just as licensed nurses are.
Choice E rationale
If a student nurse faces disciplinary action by a state board of nursing due to violations of nursing practice standards or unprofessional conduct, it can indeed impact their eligibility to take the National Council Licensure Examination (NCLEX). State boards have the authority to determine who is eligible for licensure, and disciplinary actions can lead to delays or even prohibition from taking the examination, depending on the severity of the infraction.
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