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The nurse is developing a hospital policy on guidelines for telephone and verbal prescriptions. Which guidelines should the nurse include in the policy? Select all that apply.
- A. Avoid using all abbreviations.
- B. Verbal prescriptions are rarely acceptable.
- C. Clarify any questions with the primary health care provider.
- D. Repeat the prescribed prescriptions back to the primary health care provider.
- E. Cosigning the prescription by the primary health care provider is not necessary.
- F. If the prescriber is the client's primary health care provider, documentation is unnecessary.
Correct Answer: C,D
Rationale: To avoid misunderstandings, the nurse would always clarify a telephone or verbal prescription with the health care provider (HCP) if he or she had any questions about the prescription and would repeat any prescribed prescriptions back to the HCP. A telephone order (TO) or prescription involves a primary HCP stating a prescribed therapy over the phone to the nurse. TOs are frequently given at night or during an emergency and need to be given only when absolutely necessary. Likewise, a verbal order (VO) or prescription is acceptable when there is no opportunity for the HCP to write the prescription such as in an emergency situation. Additional guidelines for telephone and verbal prescriptions include the following: clearly determine the client's name, room number, and diagnosis; indicate TO or VO, including the date and time, name of the client, complete prescription, name of the HCP giving the prescription, and nurse taking the prescription; and have the HCP cosign the prescription within the time frame designated by the health care agency (usually 24 hours).
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The nurse provides home care instructions to the mother of a child with a diagnosis of chickenpox about preventing the transmission of the virus. Which is the best statement for the nurse to include in the instructions?
- A. Isolate the child until the skin vesicles have dried and crusted.
- B. Ensure that the child uses a separate bathroom for elimination.
- C. Bring all household members to the clinic for a varicella vaccine.
- D. Request a prescription for antibiotics for all household members.
Correct Answer: A
Rationale: Chickenpox is caused by the varicella-zoster virus. The communicable period is from 1 to 2 days before the onset of the rash to 6 days after the first crop of vesicles, when crusts have formed. Transmission occurs by direct contact with secretions from the vesicles or contaminated objects, and via respiratory tract secretions. It is not transmitted via urine or feces. The recommended preventative schedule for receiving the varicella vaccine is at 12 to 15 months of age (first dose) and 4 to 6 years of age (second dose). It is not administered at the time of exposure to the virus. Antibiotics are not used to treat a viral infection. Rather, they are used for treating bacterial infections.
The nurse is admitting a 56-year-old client with a diagnosis of exacerbation of chronic obstructive pulmonary disease (COPD) and learns that the client received immunization for pneumococcal pneumonia 6 years ago. Which consideration is essential to include in the plan of care during the client's hospital admission?
- A. Offer revaccination to the client.
- B. Document the previous immunization on the client record.
- C. Instruct the client that this vaccine provides lifelong immunity.
- D. Explain to the client that he can be revaccinated only during the fall months.
Correct Answer: A
Rationale: During the history-taking of a client diagnosed with a respiratory disorder, the nurse should ask if the client had been previously vaccinated for influenza (flu) and had received pneumococcal pneumonia vaccine. Revaccination with pneumococcal pneumonia vaccine is currently advised in a client with COPD if the client received the vaccine more than 5 years previously and if the client was younger than 65 years of age at the time of vaccination. Although documentation would be done, this is not the essential action at this time. This vaccine does not provide lifelong immunity in a 56-year-old client who received the vaccine 6 years ago. The pneumococcal pneumonia vaccine is administered any time during the year.
At the scene of a train crash, the nurse triages the victims. Which clients should be coded for triage as most urgent or the first priority? Select all that apply.
- A. Is dead
- B. Has chest pain
- C. Has a leg sprain
- D. Has a chest wound
- E. Has multiple fractures
- F. Has full-thickness burns over 30% of the body
Correct Answer: B,D,F
Rationale: In a disaster situation, saving the greatest number of lives is the most important goal. During a disaster the nurse would triage the victims to maximize the number of survivors and sort the treatable from the untreatable victims. First priority victims (most urgent and coded red) have life-threatening injuries and are experiencing hypoxia or near hypoxia. Examples of injuries in this category are shock, chest wounds, internal hemorrhage, head injuries producing loss of consciousness, partial- or full-thickness burns over 20% of the body surface, and chest pain. Second priority victims (urgent and coded yellow) have injuries with systemic effects but are not yet hypoxic or in shock and can withstand a 2-hour wait without immediate risk (e.g., a victim with multiple fractures). Third priority victims (coded green) have minimal injuries unaccompanied by systemic complications and can wait for more than 2 hours for treatment (leg sprain). Dying or dead victims have catastrophic injuries, and the dying victims would not survive under the best of circumstances (coded black).
The nurse observes a client looking frightened and reporting, 'feeling out of control.' Which therapeutic approach by the nurse is most appropriate to maintain a safe environment?
- A. Administer a PRN antianxiety medication immediately.
- B. Provide isolation for the client in the unit's 'time-out' room.
- C. Observe the client in an ongoing manner but do not intervene.
- D. Encourage the client to talk about her or his feelings in a quiet setting.
Correct Answer: D
Rationale: The anxiety symptoms demonstrated by this client require some form of intervention. Moving the client to a quiet setting decreases environmental stimuli. Talking provides the nurse an opportunity to assess the cause of the client's feelings and identify appropriate interventions. Medication is used only when other noninvasive approaches have been unsuccessful. Isolation is appropriate if a client is a danger to self or others.
The nurse should implement which safety measures to prevent an electrical shock when using electrical equipment? Select all that apply.
- A. Use a two-prong outlet.
- B. Check the electrical cord for fraying.
- C. Keep the electrical cord away from the sink.
- D. Place the excess electrical cord under a small carpet.
- E. Grasp the electrical cord when unplugging the equipment.
- F. Disconnect the electrical cord from the wall socket when cleaning the equipment.
Correct Answer: B,C,F
Rationale: The nurse needs to implement measures to prevent an electrical shock when using electrical equipment. These measures include using a three-prong plug that is grounded, checking the electrical cord for fraying or other damage, keeping the electrical cord away from the sink or other sources of water, using electrical tape to secure the excess electrical cord to the floor where it will not be stepped on (the cord should not be placed under carpet), grasping the plug (not the electrical cord) when unplugging the equipment, and disconnecting the electrical cord from the wall socket when cleaning the equipment.