To reduce the risk of error when communicating to a client's healthcare provider via telephone, which action(s) should the nurse take? Select all that apply.
Document the full conversation in the nurses' notes.
Repeat back changes in the treatment plan to the provider.
Use SBAR format when reporting to the provider.
Review the information with the charge nurse before giving it to the provider.
Provide a summary of the changes in the treatment plan to the charge nurse.
Correct Answer : B,C
Telephone communication facilitates critical interprofessional collaboration to address acute physiological changes or diagnostic results. Effective reporting requires structured data and closed-loop feedback to prevent medical errors, especially during high-stress clinical scenarios or transition of care.
Rationale:
A. Thorough documentation of telephone encounters is a legal and professional standard but does not actively reduce the immediate risk of communication errors during the live exchange. The nurse must record the time, participants, and specific medical advice given in the permanent record.
B. Using read-back protocols creates a closed-loop system that confirms the accuracy of verbal instructions. This step allows the provider to verify that the nurse heard and transcribed the intended dosage or intervention correctly, significantly decreasing potential pharmacological errors.
C. The SBAR framework ensures that the nurse provides concise, pertinent data regarding the patient’s clinical status. By organizing the situation, background, assessment, and recommendation, the nurse provides a logical narrative that helps the provider make informed decisions rapidly.
D. Consulting a supervisor is appropriate for complex clinical dilemmas but is not a standard requirement for all provider communications. Delaying a call to a provider for a peer review can result in omissions or delays in urgent care for a deteriorating patient.
E. Informing the charge nurse about plan updates is vital for unit coordination and resource management after the call. However, reporting to a third party does not improve the primary accuracy of the initial data exchange between the nurse and the provider.
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Related Questions
Correct Answer is D
Explanation
Brief introduction:
Schizophrenia is a complex neurobiological disorder characterized by positive symptoms, such as hallucinations, and negative symptoms, including asociality and diminished emotional expression. Social withdrawal and poor interpersonal functioning result from neurocognitive deficits and a profound lack of intrinsic motivation. Effective psychiatric nursing interventions focus on providing structured social interactions that reduce isolation while minimizing the cognitive and emotional demand on the client during periods of acute withdrawal.
Rationale:
A. Encouraging a client to leave the unit for lunch introduces an overwhelming amount of environmental stimuli and social pressure. This can exacerbate symptoms of paranoia or sensory overload, causing the client to retreat further into isolation. Safe interventions must occur within the controlled environment of the psychiatric unit to ensure the client's stability.
B. While assessing social support is a necessary component of the overall nursing process, it is not a direct intervention to address the current problem of social withdrawal. Data collection does not solve the immediate need for peer or staff engagement. The nurse must prioritize active participation over purely diagnostic activities during the shift.
C. Providing a schedule is a supportive measure for orientation, but it does not actively bridge the gap of social alienation. A list of activities remains a passive tool that a withdrawn client is likely to ignore without direct facilitation from the staff. Structure is useful, but it lacks the interpersonal component required to improve social functioning.
D. Engaging the client in a card game provides a low-pressure activity that facilitates social interaction without requiring intense verbal communication. Activities focused on a third object, like a game, decrease the threat of intimacy and allow the client to practice social skills in a non-threatening manner. This is the most effective way to stimulate cognitive engagement and rapport.
Correct Answer is ["B","C","E"]
Explanation
Brief introduction:
Nasogastric enteral nutrition requires strict adherence to safety protocols to prevent pulmonary aspiration and gastrointestinal distress. The nurse must ensure the gastrointestinal tract is ready to receive the bolus while maintaining anatomical positioning that utilizes gravity to facilitate gastric emptying. Precise management of the feeding infrastructure and the physical properties of the formula minimizes the risk of complications such as dumping syndrome or nosocomial pneumonia.
Rationale:
A. Diluting enteral formulas with water is generally contraindicated as it alters the caloric density and osmolality of the prescribed nutrition. Most formulas are designed to be administered at full strength to meet the specific metabolic demands of the patient. Dilution can lead to underfeeding and may introduce microbial contaminants if the water source is not sterile.
B. Elevating the head of the bed (HOB) to 30 to 45 degrees is a primary intervention to reduce aspiration risk. Maintaining this semi-Fowler position during and for 30 to 60 minutes after feeding prevents gastric reflux into the esophagus. This use of gravity is a standard evidence-based practice for any patient receiving nutrition via a gastric tube.
C. Verification of tube placement is the most critical safety step to prevent accidental tracheobronchial administration. The nurse must confirm the distal tip remains in the stomach using pH testing of aspirate or checking external markings against documented insertion lengths. Failure to verify placement before every intermittent feeding can lead to fatal pulmonary complications if the tube has migrated.
D. Enteral feeding is a clean, not sterile, procedure because the gastrointestinal tract is not a sterile environment. While the feeding container and tubing should be changed according to facility policy to prevent bacterial overgrowth, using expensive sterile containers is not clinically indicated. Clean technique is sufficient for the safe delivery of intermittent enteral nutrition.
E. Ensuring the feeding solution is at room temperature prevents gastric cramping and abdominal discomfort. Cold formula can cause rapid contraction of the gastric smooth muscle, leading to increased motility and diarrhea. Administering the solution at a temperate state promotes better tolerance of the bolus and enhances the overall comfort of the patient during the feeding.
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