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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
A risk nursing diagnosis, such as "risk for impaired skin integrity related to inadequate nutrition," identifies a potential problem that does not currently exist but has a high probability of developing if no preventative nursing interventions are implemented. It focuses on the patient's vulnerability to a specific health problem.
Choice B rationale
All nursing diagnoses, including risk diagnoses, require the development of specific nursing interventions aimed at preventing the potential problem from occurring or minimizing its impact. These interventions are crucial for addressing the identified risk factors and promoting patient well-being.
Choice C rationale
Evaluation is a critical component of the nursing process for all nursing diagnoses. The effectiveness of the nursing interventions implemented for a risk diagnosis must be evaluated to determine if they successfully prevented the problem from developing. This ongoing assessment ensures the plan of care is appropriate and achieving the desired outcomes.
Choice D rationale
Nursing diagnoses, including risk diagnoses, are within the scope of nursing practice and guide independent nursing interventions. While collaboration with the medical team is essential for overall patient care, risk diagnoses do not inherently necessitate medical intervention as the primary focus is on preventative nursing actions.
Correct Answer is C
Explanation
Choice A rationale
Information about the family of a client in a different room (room 107) is not directly relevant to the change-of-shift report for the client in room 108. The report should focus on information pertinent to the care of the assigned client.
Choice B rationale
While the fact that a client in room 105 had a bath might be included in their specific report, it is not essential information to communicate during the change-of-shift report for the client in room 108 who has a new pain medication.
Choice C rationale
The administration of a new pain medication to the client in room 108 is crucial information for the oncoming nurse. It is essential to communicate the name of the medication, the time it was given, the dosage, the route of administration, and the client's response to the medication to ensure continuity of pain management.
Choice D rationale
The dietary preferences of a client in a different room (room 109) are not relevant to the change-of-shift report for the client in room 108. Dietary information is specific to each client and should be communicated within their individual report if pertinent to their current care.
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