A nurse is receiving a telephone prescription from a client's provider. Which of the following actions should the nurse take? (Select all that apply..

Request that the provider confirm the readback of the prescription.

Instruct another nurse to record the prescription in the medical record.

Withhold the medication until the provider signs the prescription.

Ask the provider to spell out the name of the medication.

Record the date and time of the telephone prescription.

Answer and Explanation

Correct Answer : A,D,E

A.   Correct. Confirming the readback ensures accurate communication and understanding of the prescription.
B.   It's the responsibility of the nurse receiving the prescription to document it in the medical record.
C.   Withholding medication until the provider signs the prescription may delay needed treatment.
D.   Correct. Asking the provider to spell out the medication name prevents errors due to miscommunication.
E.   Correct. Recording the date and time of the telephone prescription is essential for documentation and accountability.

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Correct Answer is D

Explanation

A. In adults insert catheter approximately 16 cm (6.5 inches); in older children, 8– 12 cm (3–5 inches); in infants and young children, 4–7.5 cm (1.5–3 inches). Rule of thumb is to insert catheter distance from tip of nose (or mouth) to angle of mandible.
B. Suction should not be applied while inserting the catheter, as it could cause trauma to the mucosa and increase discomfort. Suction should only be applied while withdrawing the catheter, and it should be done intermittently to avoid injury and reduce the risk of hypoxia.
C. Suctioning should not exceed 10-15 seconds at a time to prevent hypoxia and other complications. Prolonged suctioning can lead to oxygen depletion and potential respiratory distress in the client.
D. Waiting at least 1 minute between suctioning attempts allows the client to recover and helps maintain adequate oxygenation. This pause is essential to prevent hypoxia and to ensure the client has time to breathe normally before the next suctioning attempt.

A. Instruct the client to take a brisk walk. B. Check the client's temperature. C. Provide the client with a glass of orange juice. D. Position the client on their left side.

Correct Answer is D

Explanation

A. Incorrect. Instructing the client to take a brisk walk might exacerbate their symptoms.
B. Incorrect. Checking the client's temperature is not indicated based on the reported symptoms.
C. Incorrect. Providing orange juice might help with low blood sugar but doesn't directly address the reported symptoms.
D. Correct. Positioning the client on their left side can improve blood flow to the heart and uterus, alleviating symptoms of dizziness and racing heart that can occur due to pressure on the vena cava when lying flat on the back.

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