A nurse receives a telephone prescription from a provider for a client who is experiencing pain. Which of the following responses should the nurse make?

Rationale

A. Access the online drug formulary for an unfamiliar medication: Consulting a reliable drug reference ensures the nurse understands the medication’s indications, dosage, contraindications, side effects, and interactions. This step is essential when administering a medication for the first time to promote safe and informed practice.

B. Use one patient identifier prior to medication administration: Safe medication administration requires two patient identifiers (e.g., name and date of birth) to verify the correct client. Using only one identifier increases the risk of medication errors and does not meet standard safety protocols.

C. Read the medication label twice prior to administration: Best practice is to read the medication label three times, when removing it from storage, before preparing it, and before administering it to ensure accuracy. Reading only twice may allow for errors in drug selection or dosage.

D. Ask the client if they have ever taken a similar medication: While obtaining medication history from the client is useful, it does not replace verification of proper dosage, route, or interactions. Client recollection may be incomplete or inaccurate, so relying on a reference is safer for first-time administration.

Rationale

A. Keep the head of the client's bed at 30° or less: Elevating the head of the bed to 30° or less reduces pressure on the sacrum and heels, which are common sites for pressure injury in immobile clients. Maintaining this position helps prevent shear and friction forces that contribute to skin breakdown.

B. Bathe the client with soap and hot water: Using soap and hot water can strip natural oils from the skin, increasing dryness and the risk of breakdown. Gentle cleansing with lukewarm water and mild, pH-balanced soap is recommended to preserve skin integrity.

C. Slide the client up in bed every 2 hr: Sliding the client up in bed creates shear and friction forces on the skin, which can exacerbate pressure injuries. Repositioning should involve lifting or using a draw sheet to move the client safely without dragging the skin.

D. Massage bony prominences four times daily: Massaging bony prominences can damage underlying tissue and worsen skin breakdown. Pressure should be relieved through repositioning and support surfaces rather than direct massage of high-risk areas.