The nurse is caring for an unconscious patient.
The nurse repositions the patient at least every 2 hours and ensures that all of the patient's bony prominences are padded.
What is the rationale for these actions?

Choice A rationale

Performing a physical examination involves the systematic assessment of a patient's body to identify signs of health or illness. Listening to lung sounds, palpating peripheral pulses, and obtaining vital signs are all fundamental components of a physical examination aimed at gathering objective data about the patient's current condition.

Choice B rationale

Establishing priorities for outcomes involves setting goals for patient care based on identified nursing diagnoses and collaborative problems. While the nurse's assessment data will inform the development of outcomes, the initial actions described focus on data collection, not outcome identification.

Choice C rationale

Demonstrating diagnostic reasoning is the cognitive process of analyzing assessment data to arrive at a nursing diagnosis or identify a collaborative problem. While the nurse is gathering data that will contribute to diagnostic reasoning, the actions described are the data collection phase itself, not the analysis.

Choice D rationale

Setting time frames for interventions involves establishing specific schedules for nursing actions aimed at achieving patient outcomes. The nurse's immediate actions upon the patient's arrival are focused on rapid assessment to understand the patient's immediate needs, not on scheduling future interventions.

Choice A rationale

Reading back the order ensures accuracy and allows the physician to immediately correct any misheard or misinterpreted information. This step is crucial for patient safety as it verifies the details of the medication order before it is implemented.

Choice B rationale

While double-checking with another nurse is a good practice, the immediate priority after receiving a telephone order is to confirm the order directly with the prescriber to avoid any initial misunderstanding.

Choice C rationale

Authorizing the order with the pharmacy occurs after the order has been received and verified. The pharmacy then prepares and dispenses the medication based on the confirmed order.

Choice D rationale

Withholding the medication could delay necessary treatment. The priority is to verify the order promptly and then proceed with safe administration. Many institutions allow for a limited time frame for the written order to follow a telephone order.