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?

Choice A rationale

A physician's license is primarily concerned with their medical practice, diagnosis, and treatment of patients. While medication security is important in patient care, the direct responsibility for the secure storage and accurate documentation of narcotics in a facility, according to its policies, falls on the nursing staff. Disciplinary actions related to these specific failures would typically target those directly involved in the lapse of protocol.

Choice B rationale

A pharmacist's license governs the dispensing and management of medications within a pharmacy setting. While pharmacists play a crucial role in the supply chain and providing information about medications, the day-to-day secure storage and inventory control of narcotics within a long-term care facility, as per the facility's policies, is the responsibility of the nurses on duty.

Choice C rationale

A facility's license pertains to the operational standards and overall compliance of the healthcare institution. While the failure to secure narcotics and maintain proper documentation could potentially lead to issues with the facility's licensing if it reflects systemic problems, the initial disciplinary actions for direct violations of nursing policies regarding medication handling would likely target the individual nurses involved.

Choice D rationale

Nurses are directly responsible for adhering to the policies and procedures of the healthcare facility regarding the handling and documentation of medications, especially controlled substances like narcotics. Failing to keep narcotics in a locked, secure location and neglecting to document counts before and after each shift are direct violations of these professional responsibilities and institutional guidelines, potentially leading to disciplinary actions against their nursing licenses.

Choice A rationale

Playing music chosen by the client can promote relaxation by providing a familiar and comforting auditory stimulus. Music can help to reduce anxiety and create a calming environment, thus minimizing sensory overload in a client recovering from a stroke in the intensive care unit. This personalized approach respects the client's preferences and can positively influence their emotional state, fostering a more restful atmosphere conducive to healing.

Choice B rationale

Encouraging frequent visitors throughout the day can contribute to sensory overload for a client recovering from a stroke. While social support is important, excessive stimulation from multiple visitors can be overwhelming and disrupt the client's rest and recovery process in the intensive care unit, potentially increasing agitation and hindering relaxation.

Choice C rationale

Sitting in a chair next to the client and talking can be stimulating and may not promote relaxation, especially for a client who has recently experienced a stroke. Depending on the content and tone of the conversation, this interaction could increase sensory input and potentially cause agitation or fatigue rather than fostering a calm and restful environment needed for recovery in the intensive care unit.

Choice D rationale

Turning on the television to the Super Bowl would likely exacerbate sensory overload due to the bright lights, loud noises, and fast-paced visual stimulation. This type of environment is counterproductive to promoting relaxation and can be particularly overwhelming for a client recovering from a stroke in the intensive care unit, potentially increasing anxiety and hindering rest.