A nurse is assisting with the plan of care for a client who has burns to his lower extremities. Which of the following actions should the nurse include in the plan?

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.

Rationale:

A. Thoracotomy set: A thoracotomy set is used for emergency chest procedures, such as to relieve a pneumothorax or drain the pleural space. It is not relevant to a thyroidectomy, which involves the neck and airway rather than the thoracic cavity.

B. Vacuum assisted wound device: A vacuum-assisted wound device is used for chronic or large open wounds requiring negative pressure therapy. It is not indicated for fresh surgical incisions or preventive airway management following thyroid surgery.

C. Tracheostomy kit: A tracheostomy kit should be readily available at the bedside following thyroid surgery because of the risk of airway obstruction from swelling, bleeding, or damage to the recurrent laryngeal nerve. Immediate airway access may be needed in case of respiratory distress.

D. Tuning fork: A tuning fork is used in auditory and vibration assessments, such as during Rinne and Weber tests. It has no relevance to the immediate post-operative care of a client undergoing a thyroidectomy.