A nurse receives a telephone order for medication. Which action is most appropriate?
Wait until the end of the shift to write the order
Ask another nurse to write it down later
Skip allergy verification because the provider already knows
Write the order immediately and perform a read-back
The Correct Answer is D
A. Wait until the end of the shift to write the order: Delaying the documentation of a verbal or telephone order increases the risk of memory decay and subsequent medication errors. Inaccurate dosing or timing can occur if the order is not captured immediately in the medical record. Clinical standards require real-time documentation to ensure patient safety and maintain an accurate chronological record of care.
B. Ask another nurse to write it down later: Delegating the documentation of an order you received introduces a significant risk of communication breakdown and error. The nurse who heard the order is the only individual who can verify its accuracy during the initial encounter. Transferring this responsibility to a third party violates basic principles of accountability and safe nursing practice.
C. Skip allergy verification because the provider already knows: Relying on the assumed knowledge of another provider bypasses a critical safety barrier in the medication administration process. The nurse must independently verify the patient allergy status before documenting or administering any new pharmacological agent to prevent anaphylaxis. Allergy verification is a non-negotiable step in maintaining patient safety during order entry.
D. Write the order immediately and perform a read-back: This action follows the National Patient Safety Goals for improving the effectiveness of communication among caregivers. Performing a read-back allows the provider to confirm that the nurse has transcribed the medication name, dose, and frequency correctly. This immediate verification step is essential for reducing transcription errors and ensuring the patient receives the correct therapy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Begin CPR to restore circulation: Cardiopulmonary resuscitation is indicated for sudden cardiac or respiratory arrest in patients with full-code status. In a patient nearing death, mottled and cool extremities represent expected physiological changes as blood shunts to vital organs. This intervention contradicts the goals of palliative care and focuses on reversing an expected part of the natural dying process.
B. Apply hot packs tightly around the legs: Thermal applications pose a significant risk for integumentary injury due to decreased peripheral perfusion and sensory perception. Vasoconstriction in the distal vasculature prevents effective heat dissipation, leading to localized tissue necrosis or burns. Maintaining warmth should be achieved through non-thermal means like blankets to prevent thermal trauma to fragile skin.
C. Call the provider to report circulatory failure: This clinical manifestation is a predictable sign of the active phase of dying rather than an acute medical emergency requiring immediate intervention. While documentation is necessary, a sudden report to the provider for expected physiological decline may cause unnecessary alarm. The priority is managing the environment and supporting the stakeholders present at the bedside.
D. Reassure the family and keep the client warm: This action addresses the psychosocial needs of the family while ensuring the physical comfort of the patient. Mottling is a common cardiovascular sign of impending death that can be distressing for observers to witness. Providing blankets and education regarding the natural physiological progression allows for a peaceful environment during the final stages of life.
Correct Answer is A
Explanation
A. Non-maleficence: This principle dictates the obligation to do no harm to the patient. By implementing fall precautions, the nurse proactively mitigates environmental hazards to prevent physical trauma. This duty focuses on the avoidance of negligent care and the prevention of adverse events that could lead to injury.
B. Beneficence: While this involves taking positive actions to help others, it is more focused on promoting good and providing benefits. Non-maleficence is the specific duty to prevent harm, which is the primary intent of fall safety measures. Beneficence is often the "doing good" side of the same coin, but prevention of injury is non-maleficence.
C. Justice: This ethical concept refers to the fair and equitable distribution of healthcare resources and treatments among all patients. It ensures that every individual has access to the same level of care regardless of their background. Fall precautions for a single patient do not primarily address the systemic allocation of medical goods.
D. Veracity: This principle refers to the nurse's obligation to tell the truth and be honest with patients. It is fundamental to the informed consent process and the establishment of a trusting therapeutic relationship. While honesty is vital, it does not directly relate to the physical safety interventions used to prevent patient falls.
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