A nurse is collecting data from a client who has pneumonia and a prescription for cefazolin. Which of the following findings should the nurse report to the provider prior to administering the initial dose? (Click on the exhibit tabs for additional information about the client. There are three tabs that contain separate categories of data.)

A. Withhold the medication until the provider signs the prescription: Telephone prescriptions are considered valid once received and properly documented. Delaying administration until a signature is obtained could compromise timely care. The provider must later sign the prescription, but administration should not be delayed if properly authorized.

B. Ask the provider to spell out the name of the medication: Asking for the spelling of the medication name helps prevent errors, especially with drugs that sound alike or have complex names. Clarification ensures correct medication administration and enhances client safety.

C. Request that the provider confirm the read-back of the prescription: Reading back the prescription and obtaining confirmation is a critical safety step. It verifies that the prescription was accurately understood and recorded, significantly reducing the risk of medication errors.

D. Instruct another user to record the prescription in the medical record: The nurse receiving the prescription must personally document it. Assigning this task to someone else increases the chance of miscommunication or transcription errors and violates professional documentation standards.

E. Record the date and time of the telephone prescription: Proper documentation of the date and time ensures an accurate, complete medical record. It establishes when the prescription was received, which is important for both clinical tracking and legal accountability.

A. Serosanguinous drainage on dressing: Serosanguinous drainage, which is a mixture of clear and blood-tinged fluid, is a common and expected finding in the early postoperative period. It typically indicates normal healing unless the amount becomes excessive or the drainage changes character.

B. Hypoactive bowel sounds: Hypoactive bowel sounds are common within the first 24 to 48 hours following surgery, especially after general anesthesia or abdominal procedures. This finding is expected and does not immediately require provider notification unless accompanied by other concerning signs like severe abdominal distention.

C. Urinary output of 25 mL/hr: Urinary output should be at least 30 mL/hr to indicate adequate kidney perfusion and hydration. An output of 25 mL/hr suggests possible hypovolemia, renal impairment, or urinary retention, and it should be promptly reported to the provider for further evaluation.

D. Pain level of 2 on 0 to 10 scale: A pain score of 2 indicates mild pain, which is manageable and expected after surgery. This level of discomfort does not require urgent reporting to the provider as long as it remains controlled and does not interfere with recovery activities.