The nurse is collecting data from the client following the transfusion of 2 units of packed RBCs.

Exhibits

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Laboratory Results:

1800:

WBC count 6,700/mm (5,000 to 10,000/mm3)

Hemoglobin 12 g/dL (14 to 18 g/dL)

Hematocrit 36% (40% to 52%)

Vital Signs:

1800:

Blood pressure 112/74 mm Hg

Heart rate 95/min

Respiratory rate 18/min

Temperature 37.5°  C (99.5°  F)

O2 saturation 100% 2 L/min O2 via nasal cannula

Assessment:

1800:

Physical Exam

General: no distress

Head, ears, eyes, nose, and throat (HEENT): oropharynx clear, mucous membranes moist and pink

Respiratory: bilateral breath sounds clear

Gastrointestinal: epigastric tenderness to palpation, no rebound tenderness or guarding

Neurologic: awake and alert

A. Ask the provider to spell out the name of the medication. Asking the provider to spell out the name of the medication is important to ensure accuracy and prevent medication errors. This step helps clarify any potential confusion regarding similar-sounding medications or names, reducing the risk of administering the wrong drug.
B. Withhold the medication until the provider signs the prescription. Withholding the medication until the provider signs the prescription is not necessary. Telephone prescriptions are valid and can be administered after being documented appropriately, provided that the nurse follows institutional policies regarding the signing of prescriptions. This means that the nurse should not delay necessary medication administration based on awaiting a signature.
C. Record the date and time of the telephone prescription. Recording the date and time of the telephone prescription is essential for accurate medical documentation. This information is critical for maintaining an accurate medication administration record and for legal purposes, ensuring that there is a clear timeline of the prescription order.
D. Request that the provider confirm the read-back of the prescription. Requesting that the provider confirm the read-back of the prescription is a crucial step in ensuring the accuracy of the prescription. The read-back method helps confirm that the nurse understood the prescription correctly and prevents potential errors by allowing the provider to verify the information relayed.
E. Instruct another nurse to record the prescription in the medical record. Instructing another nurse to record the prescription in the medical record is not appropriate. The nurse who received the telephone prescription should document it to maintain accountability and ensure accurate record-keeping. This promotes responsible practice and avoids miscommunication regarding the prescription details.

A. Communicate advance directives status via the medical record and shift report. The nurse is responsible for ensuring that all members of the healthcare team are aware of the client’s advance directives. Documenting this information in the medical record and shift report helps guide care in accordance with the client’s wishes.
B. Provide the client with written information about advance directives. Clients have the right to receive information about advance directives, including living wills and do-not-resuscitate (DNR) orders. The nurse should provide educational materials to help the client make informed decisions.
C. Inform the client that an advance directive discontinues further care. An advance directive does not automatically discontinue all medical care. It provides instructions regarding specific interventions the client wishes to accept or decline, such as resuscitation, mechanical ventilation, or artificial nutrition. The nurse should clarify this to avoid misconceptions.
D. Instruct the client that an advance directive is a legal document and must be honored by care providers. Advance directives are legally binding documents that must be followed by healthcare providers. The nurse should reinforce that the client’s wishes, as stated in the directive, will be respected.
E. Document that the provider discussed do-not-resuscitate status with the client. Proper documentation is essential to ensure the client's preferences regarding resuscitation and end-of-life care are acknowledged and followed. The nurse should record discussions regarding advance directives in the medical record.
F. Initiate a power of attorney for health care document. The nurse does not have the authority to initiate a power of attorney for health care. The client must complete this legal document independently or with legal assistance, and it typically requires notarization or witness signatures. The nurse can provide information about it but cannot create or execute it on the client’s behalf.