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 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.

A. right upper sternal border B. left upper sternal border C. left lower sternal border D. 5th intercostal space, midclavicular line

Correct Answer is {"xRanges":[234.765625,254.765625],"yRanges":[107.609375,127.609375]}

Explanation

A. The right upper sternal border is not the correct placement for auscultating the apical pulse. This location is more appropriate for assessing heart sounds related to the aortic valve.
B. The left upper sternal border is not the correct placement for auscultating the apical pulse.
This location is more appropriate for assessing heart sounds related to the pulmonic valve.
C. The left lower sternal border is not the correct placement for auscultating the apical pulse.
This location is more appropriate for assessing heart sounds related to the tricuspid valve.
D. 5th intercostal space, midclavicular line is the correct placement for auscultating the apical pulse. This location corresponds to the apex of the heart, which is where the apical pulse (also known as the point of maximum impulse or PMI) can be best heard.

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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

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

A nurse is performing a cardiac assessment. Identify where the nurse should place the stethoscope to auscultate the client's apical pulse. (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.)

Correct Answer is {"xRanges":[234.765625,254.765625],"yRanges":[107.609375,127.609375]}

Explanation

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