A nurse on a medical-surgical unit is accepting a telephone prescription for a client who requires medication for insomnia. Which of the following actions should the nurse take?

Repeat the complete prescription back to the provider.

Have a provider who is on site sign the prescription.

Have the unit secretary enter the prescription on the provider's order form.

Verify the accuracy of the prescription with the pharmacist.

Answer and Explanation

The Correct Answer is A

A. Repeat the complete prescription back to the provider – This is the correct action to ensure accuracy and prevent medication errors. The nurse must read back the prescription, including the medication name, dosage, route, and frequency, for verification.

B. Have a provider who is on site sign the prescription – The prescribing provider must sign the order within a specific timeframe, but this step occurs after verifying and documenting the prescription.

C. Have the unit secretary enter the prescription on the provider's order form – Only licensed personnel (nurses, pharmacists, or providers) can transcribe and verify medication orders. The unit secretary cannot enter prescriptions.

D. Verify the accuracy of the prescription with the pharmacist – The nurse should first confirm the order with the provider, not the pharmacist. The pharmacist’s role comes after the order is documented and entered.

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Correct Answer is C

Explanation

A. Sore throat – A sore throat is expected following a tonsillectomy due to the surgical site trauma. It is not an immediate concern unless accompanied by other abnormal findings such as severe pain or difficulty breathing.

B. Blood-tinged mucus – Small amounts of blood-tinged mucus are normal after surgery. However, active bleeding would present as bright red blood rather than a small amount of tinged mucus.

C. Frequent swallowing – This is the priority finding because it may indicate active bleeding at the surgical site. Children may not always report bleeding but may swallow frequently as blood drips into their throat. If left undetected, excessive bleeding can lead to hemorrhage and airway compromise. The nurse should inspect the throat immediately and notify the provider.

D. Dark brown emesis – Vomiting old blood (which appears dark brown) may occur if the child swallowed some blood postoperatively. While this should be monitored, it is not as concerning as active bleeding, which presents as bright red blood.

A. A nurse should explain surgical risks to a client. B. A client who is unable to write cannot provide informed consent. C. A client can refuse a procedure after signing an informed consent form. D. A client who is blind needs a guardian to provide informed consent.

Correct Answer is C

Explanation

A. A nurse should explain surgical risks to a client. – Incorrect. The provider (physician or surgeon) is responsible for explaining surgical risks, benefits, and alternatives. The nurse only verifies that informed consent was obtained and clarifies questions.

B. A client who is unable to write cannot provide informed consent. – Incorrect. A client who cannot write may provide consent verbally or with an "X" if witnessed appropriately.

C. A client can refuse a procedure after signing an informed consent form. – Correct. Clients have the right to withdraw consent at any time before the procedure is performed.

D. A client who is blind needs a guardian to provide informed consent. – Incorrect. A blind client can provide informed consent as long as they understand the procedure. The consent form can be read aloud if needed.

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A nurse on a medical-surgical unit is accepting a telephone prescription for a client who requires medication for insomnia. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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