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. Speech therapy referral: Referral to speech therapy is appropriate for a client with dysphagia, as a speech-language pathologist can assess swallowing ability and provide strategies to reduce aspiration risk. This supports safe oral intake and rehabilitation.

B. Clear liquids: Prescribing a clear liquid diet may be unsafe for a client with dysphagia, particularly if the client has difficulty swallowing thin liquids, which can increase the risk of aspiration. The nurse should clarify this prescription and consider thickened liquids or alternative feeding methods based on the speech therapist’s assessment.

C. Oral suction at the bedside: Having oral suction available is appropriate for a client with dysphagia to quickly manage secretions or prevent choking and aspiration during oral intake. This intervention promotes safety.

D. Dietitian consult: Consulting a dietitian is appropriate to ensure the client receives adequate nutrition and a safe texture-modified diet. The dietitian can recommend consistency adjustments and nutrient-dense options tailored to the client’s swallowing abilities.

Rationale

A. Encourage the oncoming shift nurse to contact the provider with any questions: While the oncoming nurse may need to contact the provider, relying on this step alone does not ensure a comprehensive or standardized handoff. Important information may be missed if the report is informal or incomplete.

B. Record a verbal report on a recorder for the oncoming nurse to listen to: Using a recording is not ideal because it prevents real-time clarification and questions. Direct communication is necessary to address immediate concerns and confirm understanding for safe continuity of care.

C. Use a standardized approach to giving the handoff report: Utilizing a standardized method, such as SBAR (Situation, Background, Assessment, Recommendation), ensures that essential information is communicated clearly, consistently, and completely. This approach reduces errors and promotes continuity of care between shifts.

D. Provide the handoff report at the nurses' station: Providing a report at the nurses’ station may compromise privacy and lead to distractions. Bedside handoff or a private setting allows for a more thorough and interactive exchange of information, supporting safety and continuity.