A nurse is receiving a provider's prescription for a client via telephone. Which of the following actions should the nurse take to ensure the accuracy of the telephone prescription? (Select all that apply.)

Obtain the provider's signature within 8 hr.

Question any part of the order that is unclear or inappropriate.

Transcribe the order into the client's health record.

Implement a recorded order message if the nurse can hear and understand it clearly.

beat the order back to the provider.

Answer and Explanation

Correct Answer : B,C,E

A.   Obtaining the provider's signature within 8 hours is not applicable to telephone orders.
This action is typically relevant to written orders.
B.   Question any part of the order that is unclear or inappropriate. This helps ensure that the nurse fully understands the prescription and can catch any potential errors or discrepancies.
C.   Transcribe the order into the client's health record. This step is crucial for documentation and to ensure that all members of the healthcare team have access to the prescribed treatment.
D.   Implement a recorded order message if the nurse can hear and understand it clearly.
This is important to have a clear and accurate record of the provider's prescription, especially if there is any ambiguity in the verbal communication.
E.   Repeating the order back to the provider is an effective method to confirm accuracy. This read-back process helps to verify that the nurse has understood the prescription correctly, reducing the potential for errors.

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Correct Answer is A

Explanation

A. False imprisonment occurs when a person is intentionally confined or restrained against their will, and they have not given consent. In this scenario, if the nurse restrains the client against her will, it would be considered false imprisonment.
B. Invasion of privacy involves intruding into a person's private affairs, disclosing private information, or using their name or likeness without their consent. This option is not applicable in this scenario.
C. Assault is the intentional threat of causing harm to another person, which creates a reasonable fear of imminent harmful or offensive contact. It involves the apprehension of harm, but not the actual physical act.
D. Battery is the intentional harmful or offensive touching of another person without their consent. It involves the actual physical act of touching.

A. Observe the client's respiratory status. B. Monitor intake and output every 8 hr. C. Elevate the head of the client's bed 30° to 45°. D. Check residual volume every 4 to 6 hr.

Correct Answer is C

Explanation

A. Observing the client's respiratory status is also important, but it is an ongoing assessment rather than an immediate action.

B. Monitoring intake and output every 8 hours is important for overall fluid balance, but it is not the top priority in this situation.

C. This is crucial to prevent aspiration, which can occur if the feeding formula enters the lungs, leading to pneumonia or other serious complications. Elevating the head of the bed helps keep the esophagus above the stomach, reducing the risk of aspiration.

D. Checking residual volume every 4 to 6 hours is a part of enteral feeding care, but it is not the top priority. Monitoring respiratory status takes precedence due to the potential risk of aspiration.

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A nurse is receiving a provider's prescription for a client via telephone. Which of the following actions should the nurse take to ensure the accuracy of the telephone prescription? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

A nurse is planning care for a client who has a decreased level of consciousness. The client is receiving continuous enteral feedings via a gastrostomy tube due to an inability to swallow. Which of the following is the priority action by the nurse?

Correct Answer is C

Explanation

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