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 A
Explanation
A. Recheck the blood pressure after 5 minutes of rest: Blood pressure can be temporarily elevated due to stress, activity, or anxiety (“white coat effect”). Reassessing after the patient has rested ensures an accurate measurement before making clinical decisions or initiating treatment.
B. Immediately administer antihypertensive medication: Initiating medication without confirming persistent elevation and evaluating for underlying causes is inappropriate. Accurate assessment is needed before starting therapy.
C. Schedule follow-up in 6 months: Waiting six months without reassessment risks missing persistent hypertension, which can lead to cardiovascular complications. Follow-up should be sooner after confirming the measurement.
D. Advise the patient to lower salt intake immediately: Dietary counseling is important for hypertension management, but it is not the priority initial action. Confirming the elevated blood pressure first guides appropriate interventions.
Correct Answer is A
Explanation
A. Watery and clear or slightly yellow: Serous drainage is typically thin, watery, and clear or slightly yellow in color. It is composed primarily of serum and is a normal finding in the early stages of wound healing, indicating that the inflammatory phase is progressing appropriately.
B. Pale and pink: Pale pink drainage is usually described as serosanguineous, which contains both serum and small amounts of blood. It is not the same as purely serous drainage.
C. Reddish and thick: Thick, red drainage is indicative of sanguineous or hemorrhagic drainage, suggesting active bleeding or trauma to the wound. This differs from serous drainage and may require closer assessment.
D. Thick, yellow, and foul-smelling: This description corresponds to purulent drainage, which indicates infection. Serous drainage is clear and non-purulent, making this inconsistent with the client’s presentation.
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