A nurse is collecting data from a client who has chronic kidney failure. An assistive personnel reports that the client has a blood pressure of 190/110 mm Hg. Which of the following actions should the nurse take first?

Choice A reason: Social workers address psychosocial needs, not drug interactions. Medication queries require clinical expertise beyond their scope in this context.

Choice B reason: Advanced practice nurses have prescribing and pharmacology knowledge, ideal for assessing interactions. They’re the best referral for this clinical question.

Choice C reason: Patient care technicians assist with basic care, lacking drug interaction training. They can’t evaluate complex medication profiles adequately here.

Choice D reason: Psychologists focus on mental health, not pharmacokinetics. They lack the medical expertise to address physical drug interaction concerns effectively.

Choice A reason: Instructing another nurse to record risks errors; the receiving nurse must document directly for accuracy. Scientifically, this violates chain-of-command and transcription protocols, as firsthand recording ensures fidelity to the provider’s intent, reducing miscommunication in medication orders.

Choice B reason: Asking for spelling clarifies the medication, preventing errors like sound-alikes (e.g., Celexa vs. Celebrex). Scientifically, this aligns with safety standards, as precise identification ensures correct drug administration, critical in telephone orders where auditory mistakes are common.

Choice C reason: Withholding until signed delays care; telephone orders allow immediate action with later signature (e.g., 24-48 hours). Scientifically, this contradicts urgent care needs, as timely treatment outweighs procedural lag, provided documentation and verification are complete.

Choice D reason: Recording date and time establishes a legal timeline, ensuring accountability and sequence of care. Scientifically, this is mandatory in telephone orders, supporting traceability and adherence to protocols, critical for auditing and patient safety in medication administration.

Choice E reason: Read-back confirmation verifies accuracy, reducing errors in verbal orders. Scientifically, this is evidence-based, as it ensures the provider’s intent matches the nurse’s record, safeguarding against misheard doses or drugs, a key step in safe prescribing practices.