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 D
Explanation
Choice A rationale
Performing nursing tasks quickly might compromise the quality and thoroughness of care. Unconscious patients still require careful and meticulous attention to their needs, and rushing could lead to errors or omissions in care.
Choice B rationale
Discouraging family members from touching an unconscious patient can be detrimental to the patient's well-being. Even in an unconscious state, patients may benefit from the familiar touch and presence of loved ones, which can provide comfort and potentially aid in sensory processing.
Choice C rationale
Turning the television to a loud volume is unlikely to be beneficial for an unconscious patient and could be overstimulating or even distressing. Sensory stimulation for unconscious patients should be carefully considered and usually involves gentle, controlled inputs rather than loud, indiscriminate noise.
Choice D rationale
Explaining procedures to an unconscious patient in a normal tone of voice is an appropriate action. Although the patient may not consciously understand, they may still have some level of auditory processing. Speaking calmly and explaining actions can also provide a sense of respect and dignity for the patient. .
Correct Answer is D
Explanation
Choice A rationale
Relying solely on written communication can be time-consuming and may not be suitable for all situations or for clients with low literacy. While it can be a useful adjunct, it shouldn't replace verbal communication entirely.
Choice B rationale
Reducing time spent with the client can hinder effective communication and relationship building. It doesn't address the communication barrier and may leave the client feeling unheard and uncared for.
Choice C rationale
Speaking loudly can distort sounds and make it harder for someone with a hearing deficit to understand. It can also be perceived as disrespectful or condescending. The approach should focus on clarity, not volume.
Choice D rationale
Background noise, such as a television, can significantly interfere with a hearing-impaired person's ability to understand speech. Reducing or eliminating such distractions creates a clearer auditory environment, facilitating better comprehension of verbal communication.
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