The nurse is caring for a client and the following sequence of events occur:. 1428: BP: 88/36 mm Hg. 1430: Dr. Jones paged.

1445: No return call from Dr. Jones.

1450: BP 90/40 mm Hg. 1455: Dr. Jones paged and charge nurse notified.

1505: No return call from Dr. Jones.

What should the nurse document in the patient's chart regarding the sequence of events described above?

Choice A rationale:

The nurse is not responsible since the nurse was following the doctor's orders. Rationale: While it is essential for nurses to follow physician orders, they also have a responsibility to assess the appropriateness and safety of those orders. If the nurse administers a medication that is clearly harmful or beyond the normal dosage, they have a duty to question the order and seek clarification from the physician. Administering a medication that is twice the normal dosage without questioning the order would be a breach of the nurse's responsibility.

Choice B rationale:

Only the nurse was responsible since the nurse administered the medication. Rationale: While the nurse did administer the medication, the ultimate responsibility lies with both the nurse and the physician. The nurse should have questioned the order if it appeared to be incorrect or unsafe. Nurses are advocates for their patients and have a duty to ensure the safety and well-being of those under their care.

Choice C rationale:

Both the nurse and the physician are responsible for the error. Rationale: This is the correct choice. Both the nurse and the physician share responsibility for the error. The nurse should have questioned the order, and the physician should have prescribed the correct dosage. Patient safety is a collaborative effort, and both healthcare providers are accountable for ensuring that the patient receives appropriate and safe care.

Choice D rationale:

Only the physician is responsible since he or she ordered the drug. Rationale: While the physician did order the drug, the nurse also has a responsibility to assess the order and question it if necessary. Nurses are trained to use their clinical judgment and critical thinking skills to ensure the safety of their patients. If the nurse administers a medication without questioning a clearly incorrect dosage, they share responsibility for the error.

Choice A rationale:

Making sure the consent is signed and in the patient's chart in a timely manner is an important step in the consent process. However, the most appropriate action for the nurse in this situation is to verify the necessity of the surgical procedure before placing the consent in the chart. This is crucial to ensure that the patient fully understands the procedure they are consenting to and that it is medically necessary. Verifying the necessity of the surgical procedure helps in preventing unnecessary procedures, promoting patient safety, and adhering to ethical principles.

Choice B rationale:

Verifying the necessity of the surgical procedure before placing the consent in the chart is the most appropriate action for the newly licensed nurse. This step ensures that the procedure is medically necessary, aligns with the patient's condition, and promotes informed decision-making. By confirming the necessity, the nurse upholds the principle of beneficence, ensuring the patient's well-being, and autonomy, allowing the patient to make informed decisions about their healthcare.

Choice C rationale:

Asking a family member to translate the consent into the language the patient understands might be helpful in improving the patient's understanding of the procedure. However, the primary concern in this situation is verifying the necessity of the surgical procedure. While communication is essential, it does not address the core issue of confirming the medical need for the surgery.

Choice D rationale:

Explaining the risks and benefits of the surgical procedure prior to getting a signature is a vital step in the consent process. However, the question specifically asks for the most appropriate action, which is to verify the necessity of the procedure. Explaining the risks and benefits is an important follow-up step after ensuring the procedure's necessity.