A nurse is assisting in the care of a client receiving IV fluids. The nurse identifies that the IV pump has been infusing the fluids at double the rate of the prescribed order. After stopping the infusion, which of the following actions is the nurse's priority?

Rationale:

A. Recommend the client spend time alone in his room: Isolation can worsen depressive symptoms by reducing social interaction and support. Clients with major depressive disorder benefit more from structured, supportive environments that encourage engagement.

B. Encourage the client to use positive self-talk: Promoting positive self-talk helps challenge negative thought patterns common in depression. This cognitive-behavioral strategy can improve mood, self-esteem, and overall coping ability.

C. Offer the client low-protein snacks throughout the day: Nutritional support is important, but there is no specific reason to offer low-protein snacks for depression. A balanced diet with adequate protein may better support brain function and mood regulation.

D. Suggest the client exercise before going to bed: Regular exercise is beneficial for managing depression, but exercising before bedtime can disrupt sleep patterns. Physical activity is better scheduled earlier in the day to promote restfulness at night.

Rationale:

A. Withhold the medication until the provider signs the prescription: Waiting for the provider's signature before administering a telephone order may delay critical care. Verbal or telephone orders can be acted upon immediately if clearly understood, documented, and later signed by the provider within the facility’s required timeframe.

B. Record the date and time of the telephone prescription: Accurate documentation includes noting the date and time the telephone order was received. This ensures clarity, legal compliance, and proper sequencing of medical events in the client's record.

C. Request that the provider confirm the read-back of the prescription: A read-back process reduces the risk of medication errors by confirming that the nurse correctly heard and understood the provider’s order. It is a Joint Commission-recommended safety practice.

D. Ask the provider to spell out the name of the medication: Asking the provider to spell out high-risk or sound-alike medications helps avoid transcription errors. This step is especially important when communication clarity is compromised over the phone.

E. Instruct another nurse to record the prescription in the medical record: The nurse receiving the order is responsible for documenting it. Delegating this task to another nurse increases the chance of miscommunication and errors, and violates proper protocol.