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 A
Explanation
Choice A rationale
The nurse practice act and agency policy provide the legal and organizational framework for nursing practice and delegation. Determining if the delegation of topical medication administration is permissible under these guidelines is the foundational first step to ensure legality and adherence to established protocols.
Choice B rationale
Assessing the UAP's training is crucial for safe delegation, but it's secondary to ensuring that the task is delegable in the first place according to legal and policy guidelines. Training is irrelevant if the task cannot be delegated.
Choice C rationale
Ensuring appropriate supervision is essential for delegated tasks, but again, it's contingent on whether the task can be legally and organizationally delegated. Supervision protocols come into play after the initial permissibility of delegation is established.
Choice D rationale
Evaluating the client's past response to the treatment is important for ongoing care but doesn't determine the initial delegability of the task to a UAP. The focus of the first question is on the legal and policy aspects of delegation. .
Correct Answer is D
Explanation
Choice A rationale
Anticipatory Grieving is a normal response to an expected loss, such as the impending death of oneself or a loved one. While the client is facing death, her statement "Why me, Lord" and inability to pray suggest a struggle with her spiritual beliefs and meaning in the face of this event, rather than primarily focusing on the emotional preparation for loss.
Choice B rationale
Ineffective Coping refers to an inability to manage stressors effectively. While the client's distress indicates difficulty coping with her situation, the specific mention of spiritual questioning and inability to pray points towards a disturbance in her spiritual well-being, which is more accurately described by spiritual distress.
Choice C rationale
Low Self-Esteem involves negative feelings about oneself and one's worth. While facing death can impact self-esteem, the client's direct questioning of her faith and inability to connect spiritually are the more prominent indicators in this scenario, suggesting a conflict or disruption in her spiritual domain rather than primarily a devaluation of self.
Choice D rationale
Spiritual Distress is characterized by a disruption in one's belief or value system that provides strength, hope, and meaning to life. The client's cry of "Why me, Lord" and her inability to pray indicate a struggle with her faith and a potential feeling of abandonment or questioning of her spiritual beliefs in the face of death. This aligns directly with the defining characteristics of spiritual distress.
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