A nurse is performing blood glucose monitoring on a client. Which of the following actions should the nurse take?

A. Active movement is present: The presence of active movement in the fingers and toes of the affected arm indicates that nerve and muscle function are intact, which is a positive finding. It indicates there is no impairment in function of the affected arm.

B. Pain is 4 on scale of 0 to 10: A pain level of 4 is moderate pain and might be expected after a fracture. As long as pain is being managed appropriately with prescribed medications and no other concerning symptoms are present, it does not necessarily require immediate reporting.

C. Capillary refill is less than 2 seconds: A capillary refill time of less than 2 seconds is normal. This suggests good blood flow to the affected arm and is not an issue that needs reporting.

D. Skin is cool to the touch: A cool skin temperature on the affected arm could indicate impaired circulation, possibly due to swelling or tightness of the cast, which could lead to compartment syndrome—a serious condition that requires immediate intervention. Therefore, this finding should be reported to the provider immediately.

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.