What is the priority action of the nurse immediately after receiving a medication telephone order from a physician?

Read back the order to the physician for confirmation.

Double-check the order with another registered nurse.

Authorize the physician's order with the pharmacy.

Withhold the medication until the physician signs the order.

Answer and Explanation

The Correct Answer is A

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.

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Correct Answer is A

Explanation

Choice A rationale

Assessing the patient's respiratory status with auscultation of lung sounds and pulse oximetry provides immediate and critical information about the severity of the shortness of breath and the patient's oxygenation. This data is essential for guiding immediate interventions and further assessment. Normal pulse oximetry is typically 95-100%.

Choice B rationale

Telling the patient the physician will be in shortly does not address the immediate distress of acute shortness of breath and delays necessary assessment and intervention. It offers false reassurance without taking any immediate action.

Choice C rationale

While ensuring patient privacy is important, it is not the priority action in a situation of acute shortness of breath. Addressing the immediate physiological compromise takes precedence over privacy concerns at the initial moment of assessment.

Choice D rationale

Reassuring the patient that the shortness of breath will be relieved shortly, without any assessment or intervention, is inappropriate and potentially dangerous. It does not address the underlying cause and may delay necessary treatment.

A. The patient's respiratory rate and pulse will remain within normal limits. B. The patient's airway will remain clear throughout the night. C. The patient will be resting comfortably by the morning. D. The patient will not experience any feelings of shortness of breath or anxiety.

Correct Answer is B

Explanation

Choice A rationale

Maintaining a normal respiratory rate (typically 12-20 breaths per minute for adults) and pulse rate (typically 60-100 beats per minute for adults) are general indicators of stable physiological function but do not directly confirm airway clearance. While improved airway clearance can contribute to these stable vital signs, other factors can also influence them.

Choice B rationale

A clear airway directly addresses the nursing diagnosis of ineffective airway clearance. If the patient's airway remains unobstructed, thick sputum can be expectorated or managed, and narrowed airways will not impede airflow. This outcome specifically targets the problem identified in the nursing diagnosis.

Choice C rationale

Resting comfortably by the morning is a desirable outcome reflecting overall well-being, but it is not a direct measure of airway clearance. While improved breathing can contribute to comfort, other factors like pain or anxiety can also affect rest.

Choice D rationale

Absence of shortness of breath (dyspnea) and anxiety suggests improved respiratory function, but it doesn't definitively confirm the airway is clear of thick sputum or that narrowed airways are no longer a problem. The patient could still have airway issues without experiencing these symptoms consistently.

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What is the priority action of the nurse immediately after receiving a medication telephone order from a physician?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a patient who came to the hospital with acute shortness of breath.What is the priority action of the nurse as the assessment process is started?

Correct Answer is A

Explanation

The nurse is caring for a patient with the nursing diagnosis of ineffective airway clearance related to narrowed airways and thick sputum.Which is an appropriate expected outcome for this patient?

Correct Answer is B

Explanation

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