A nurse is assisting with the care of a client on a medical surgical unit who was admitted from the emergency department.

Exhibits

For each assessment finding on Day 2 click to specify if the finding is due to lisinopril, carvedilol, or furosemide. Each finding may be related to more than 1 medication.

A. Time. The prescription states that erythromycin should be administered four times per day, which is a standard frequency for this medication. No clarification is needed unless there are specific timing concerns, such as administration with or without food.
B. Medication. Erythromycin is a commonly prescribed macrolide antibiotic used for bacterial infections. Since the medication itself is clearly stated, there is no need to clarify this aspect of the prescription.
C. Route. The prescription does not specify the route of administration (e.g., oral, intravenous, or topical). Since erythromycin is available in multiple forms, including oral tablets, capsules, liquid suspension, and intravenous formulations, it is essential to clarify the intended route with the provider before administration.
D. Dosage. A dose of 500 mg four times per day is a typical dosage for erythromycin in treating infections. Unless there are concerns regarding the client’s renal or hepatic function or potential drug interactions, the dosage does not require clarification.

A. Communicate advance directives status via the medical record and shift report. The nurse is responsible for ensuring that all members of the healthcare team are aware of the client’s advance directives. Documenting this information in the medical record and shift report helps guide care in accordance with the client’s wishes.
B. Provide the client with written information about advance directives. Clients have the right to receive information about advance directives, including living wills and do-not-resuscitate (DNR) orders. The nurse should provide educational materials to help the client make informed decisions.
C. Inform the client that an advance directive discontinues further care. An advance directive does not automatically discontinue all medical care. It provides instructions regarding specific interventions the client wishes to accept or decline, such as resuscitation, mechanical ventilation, or artificial nutrition. The nurse should clarify this to avoid misconceptions.
D. Instruct the client that an advance directive is a legal document and must be honored by care providers. Advance directives are legally binding documents that must be followed by healthcare providers. The nurse should reinforce that the client’s wishes, as stated in the directive, will be respected.
E. Document that the provider discussed do-not-resuscitate status with the client. Proper documentation is essential to ensure the client's preferences regarding resuscitation and end-of-life care are acknowledged and followed. The nurse should record discussions regarding advance directives in the medical record.
F. Initiate a power of attorney for health care document. The nurse does not have the authority to initiate a power of attorney for health care. The client must complete this legal document independently or with legal assistance, and it typically requires notarization or witness signatures. The nurse can provide information about it but cannot create or execute it on the client’s behalf.