While receiving a telephone verbal order for a high-alert medication, what is the most critical action the nurse should take?
Administer the medication as soon as you receive the order to prevent delay in treatment.
Write down the order immediately and verify it with the prescriber by reading it back.
Document the order in the electronic health record without verifying it with the prescriber.
Request a colleague to double-check the verbal order before documenting it
The Correct Answer is B
A. Administer the medication as soon as you receive the order to prevent delay in treatment: Administering a high-alert medication without verification increases the risk of errors and potential harm. Prompt action should not bypass safety checks.
B. Write down the order immediately and verify it with the prescriber by reading it back: For high-alert medications, the nurse must accurately transcribe the order and perform a read-back verification with the prescriber. This ensures clarity, prevents errors, and aligns with patient safety standards.
C. Document the order in the electronic health record without verifying it with the prescriber: Entering a verbal order without confirmation risks transcription errors and compromises safety, particularly for high-alert medications.
D. Request a colleague to double-check the verbal order before documenting it: Peer verification may help catch errors, but it does not replace the critical step of read-back verification with the prescriber, which is required by safety protocols.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Following the pathway strictly, regardless of patient changes: Strict adherence without considering the patient’s evolving condition can compromise safety and individualized care. Critical pathways are guides, not rigid protocols.
B. Adjusting the care plan when a patient's condition deteriorates unexpectedly: Deviating from a critical pathway is appropriate when a patient’s clinical status changes. The nurse must use clinical judgment to modify interventions to meet the patient’s immediate needs while documenting and communicating the changes.
C. Documenting a pathway deviation only if it improves the patient's condition: All deviations, whether positive or negative, must be documented to maintain accountability, track outcomes, and inform future care planning. Selective documentation is not appropriate.
D. Using the critical pathway as a rigid schedule for patient interventions: Treating the pathway as a fixed schedule ignores patient variability. Effective use of critical pathways involves flexibility and adaptation based on individual patient responses.
Correct Answer is B
Explanation
A. Formulate a nursing diagnosis related to impaired gas exchange: Developing a nursing diagnosis is an important step in the planning phase but does not immediately address acute hypoxemia. Immediate intervention to improve oxygenation takes priority.
B. Administer bronchodilator medication: The patient is exhibiting signs of respiratory distress, including tachypnea, hypoxemia, and wheezing. Administering a prescribed bronchodilator can relieve airway constriction, improve oxygenation, and prevent further deterioration. This is the priority action in the acute phase.
C. Evaluate the effectiveness of previous interventions: Evaluation occurs after interventions have been implemented. Since the patient is currently experiencing hypoxemia and respiratory distress, immediate intervention is required before evaluation.
D. Reassess the patient's vital signs in 30 minutes: Waiting 30 minutes delays treatment for a patient with low oxygen saturation and respiratory distress. Immediate assessment and intervention are necessary to prevent hypoxic complications.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.