Question

A nurse is receiving a provider's prescription for a client via telephone. Which of the following actions should the nurse take to ensure the accuracy of the telephone prescription? (Select all that apply.)

Answer 1

Correct Answers:

Repeat the order back to the provider.
Question any part of the order that is unclear or inappropriate.
Transcribe the order into the client's health record..
Obtain the provider's signature within 8 hr.

Rationale :

✅ Repeat the order back to the provider

🔷 Verification step: Repeating the order word-for-word ensures both the nurse and the provider confirm what was intended, preventing transcription errors.

🔷 Clarification: This allows the provider to immediately correct any misheard or misstated portion before the order is entered.

🔷 Patient safety: This practice reduces the risk of medication errors, especially with sound-alike or look-alike drug names.

🔷 Documentation: The nurse documents that the order was read back and verified, which is a requirement under most facility and accreditation policies.

🔷 Standard of care: This step is supported by The Joint Commission as a safety protocol in verbal or telephone orders.

✅ Question any part of the order that is unclear or inappropriate

💠 Critical thinking: If a dose, frequency, or medication does not make sense, the nurse must stop and seek clarification.

💠 Advocacy: The nurse acts as the client’s advocate by preventing the implementation of an order that could be unsafe.

💠 Examples: Questioning unusual dosages (e.g., too high for age/weight), contraindicated medications, or unclear abbreviations.

💠 Legal duty: Failure to clarify may result in nursing liability if harm occurs, since nurses are accountable for carrying out safe orders.

💠 Collaboration: Promotes communication and ensures evidence-based, safe prescribing.

✅ Transcribe the order into the client’s health record

🔶 Permanent record: The order must be placed in the client’s medical record promptly so the entire care team can access and follow it.

🔶 Accuracy: Transcription ensures the order is not lost, miscommunicated, or forgotten.

🔶 Electronic systems: In facilities using EHRs, the nurse enters the order into the computerized provider order entry system, making it visible and trackable.

🔶 Continuity of care: This step supports communication among disciplines (pharmacy, nursing, dietary, etc.).

🔶 Legal evidence: Documentation provides a legal record showing the nurse followed proper process.

✅ Obtain the provider’s signature within 8 hr

🟩 Policy requirement: Telephone/verbal orders are temporary until the provider signs them. Most institutions require signature within 8 to 24 hours; 8 hours is a common standard.

🟩 Legal accountability: The provider’s signature authenticates the order and makes it legally binding.

🟩 Audit protection: Protects the nurse and institution in case of a medication error or adverse event.

🟩 Regulatory compliance: This is required by accrediting bodies and helps prevent misuse of telephone orders.

🟩 Best practice: Encourages providers to confirm orders promptly, reducing risk of lingering errors.

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Answer 2

Correct Answers:

The client holds his breath for 10 seconds after inhaling the medication.

Rationale :

🌟 Proper technique: After inhaling the medication, the client should hold their breath for about 10 seconds (or as long as possible) to allow the medication to reach the lower airways and be absorbed effectively.

🌟 Maximizes drug effect: Holding the breath prevents the medicine from being exhaled too quickly and increases its bronchodilatory effect.

🌟 Asthma management: This ensures optimal delivery of the short-acting beta agonist (albuterol), which relieves bronchospasm and promotes airway opening.

🌟 Key teaching point: Clients should also exhale fully before inhaling, take a slow, deep breath when pressing the inhaler, and wait 1–2 minutes (not 10 minutes) between puffs if multiple doses are prescribed.

🌟 Safety reinforcement: Overuse of albuterol may lead to tachycardia, tremors, and hypokalemia, so correct inhaler use is critical for safe asthma control.

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Answer 3

Correct Answers:

Nausea

Rationale :

🌟 Subjective data are what the client reports or feels, not what the nurse can observe or measure.

🌟 Nausea is a client’s personal sensation that cannot be directly observed, only described by the client.

🌟 By contrast, blood pressure, petechiae, and cyanosis are objective findings, as they are measurable or observable signs.

🌟 Collecting subjective data helps guide further assessment, diagnostic testing, and individualized care planning.

🌟 Nurses should document subjective data in quotation marks when possible to reflect the client’s exact words.

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Answer 4

Correct Answers:

Urticaria

Rationale :

🌟 Mild allergic transfusion reactions are typically mediated by recipient sensitivity to plasma proteins in donor blood.

🌟 Manifestations include urticaria (hives), pruritus, and flushing, usually without fever or hemolysis.

🌟 Diphenhydramine (an antihistamine) is given before the transfusion to block histamine release and prevent or reduce allergic symptoms.

🌟 Hemolysis is a serious acute immune-mediated reaction and is not prevented by antihistamines; it requires immediate discontinuation of transfusion.

🌟 Fluid overload (TACO) and fever (febrile non-hemolytic reaction) are unrelated to allergic responses, so diphenhydramine is not appropriate prophylaxis for those.

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Answer 5

Correct Answers:

Document the client's allergies in the electronic medical record.

Rationale :

🌟 Priority principle: Using Maslow’s hierarchy and safety frameworks, the nurse must address safety before education, planning, or non-urgent tasks.

🌟 Allergies: Documenting allergies ensures the healthcare team avoids administering harmful medications, foods, or products that could cause a life-threatening reaction.

🌟 Immediate risk reduction: Without allergy documentation, the client is at risk for anaphylaxis or other severe adverse events during hospitalization.

🌟 Sequencing of care: Once allergies are documented, the nurse can proceed with teaching, planning care, and providing information to the family.

🌟 Patient safety standard: This is a Joint Commission National Patient Safety Goal, emphasizing accurate and accessible allergy documentation as a critical first step in safe care delivery.

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Answer 6

Correct Answers:

"Information about a client can be disclosed to family members at any time."

Rationale :

🌟 This statement shows a need for further teaching because under HIPAA regulations, client health information cannot be freely shared with family members without the client’s consent (unless the client is incapacitated and disclosure is necessary for care decisions).

🌟 HIPAA protects privacy and ensures that only authorized individuals have access to a client’s health records.

🌟 Family members may only receive information if the client designates them or if disclosure is directly relevant to involvement in the client’s care.

🌟 The other statements are correct: a client’s address is identifiable information, HIPAA covers all forms (verbal, electronic, written), and HIPAA is a federal law that overrides state privacy rules when stricter standards are not in place.

🌟 Teaching should emphasize the nurse’s duty to always verify consent before releasing information to anyone other than the healthcare team directly involved in care.

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Answer 7

Correct Answers:

Shake the inhaler for 3 to 5 seconds.

Rationale :

🌟 Before using a metered-dose inhaler (MDI), the client should shake the canister for 3–5 seconds to properly mix the medication and propellant, ensuring an accurate and effective dose is delivered.

🌟 The inhaler should only be pressed once per inhalation, not twice simultaneously, as multiple sprays at once reduce effectiveness and increase side effects.

🌟 Clients should wait about 1 minute (not 2 minutes) between inhalations of the same medication to allow for maximal bronchodilation and better absorption.

🌟 Rinsing the mouth is important after using an inhaled corticosteroid, not after a short-acting bronchodilator like albuterol, to prevent oral candidiasis.

🌟 Proper technique maximizes medication delivery to the lower respiratory tract and minimizes systemic absorption and side effects.

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Answer 8

Correct Answers:

Malpractice

Rationale :

🌟 Malpractice is professional negligence by a healthcare provider that results in harm to a client. Administering the wrong medication, which caused a severe allergic reaction and prolonged hospitalization, clearly meets this definition.

🌟 The key elements of malpractice are: duty owed, breach of duty, causation, and damages. Here, the nurse had a duty to safely administer the correct medication, breached that duty by giving the wrong drug, which directly caused the client’s injury and extended hospital stay.

🌟 Battery refers to intentional, unauthorized physical contact; assault is the threat of harm; and abuse is the willful infliction of harm. None of these apply because the error was unintentional but negligent.

🌟 Malpractice cases often involve medication errors, failure to monitor, delayed interventions, or inadequate communication/documentation.

🌟 Nurses reduce malpractice risk by following the five rights of medication administration (right client, right drug, right dose, right route, right time), along with documentation and safety checks.

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Answer 9

Correct Answers:

Physicians' Desk Reference
Published journals
Pharmacists

Rationale :

Physicians’ Desk Reference (PDR)

🔷 Authoritative compendium: Provides FDA‑approved indications, dosages, contraindications, warnings, and adverse effects straight from manufacturers.

🔷 Point‑of‑care use: Helpful for quick checks on formulations, routes, and special populations.

🔷 Safety first: Supports safe administration by confirming look‑alike/sound‑alike details and black box warnings.

Published journals (peer‑reviewed)

🔶 Evidence‑based: Offer current research, systematic reviews, and guidelines that inform best practices and clinical updates.

🔶 Quality control: Peer review reduces bias and errors, improving reliability over opinion pieces or marketing materials.

🔶 Clinical relevance: Useful for nuanced issues (e.g., renal/hepatic dosing, new safety signals, drug–drug interactions).

Pharmacists

🟩 Medication experts: Provide real‑time guidance on dosing, interactions, compatibility, monitoring, and patient education.

🟩 Personalized safety: Tailor recommendations to age, organ function, and co‑morbidities, preventing errors.

🟩 Interdisciplinary partner: Essential for high‑alert meds, IV admixture questions, and transition‑of‑care medication reconciliation.

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Answer 10

Correct Answers:

Assessment

Rationale :

🌟 The assessment phase is the first step of the nursing process, where the nurse gathers comprehensive data about the client’s health, including history of allergies to foods, medications, latex, or contrast media.

🌟 Identifying allergies early ensures safe planning of diagnostic tests and treatments by preventing exposure to substances that could trigger reactions.

🌟 If allergies are not assessed at this stage, the client may face serious adverse events such as anaphylaxis, especially during procedures involving dyes, iodine, or medications.

🌟 Once collected, this information is used in the planning phase to create a safe, individualized care plan, in the implementation phase to avoid allergens, and in the evaluation phase to measure effectiveness and safety of care.

🌟 Proper allergy assessment is also a Joint Commission patient safety requirement, ensuring all providers are aware of allergy risks.

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NUR 104 Final Assessment Summer II 2025

No.

1 :
A nurse is receiving a provider's prescription for a client via telephone. Which of the following actions should the nurse take to ensure the accuracy of the telephone prescription? (Select all that apply.)

2 :
Transcribe the order into the client's health record. A nurse is teaching a client who has asthma about how to use an albuterol inhaler. Which of the following actions by the client indicates an understanding of the teaching?

3 :
A nurse is completing a client's history and physical examination. Which of the following information should the nurse consider subjective data?

4 :
A nurse is preparing to transfuse one unit of packed RBC to a client who experienced a mild allergic reaction during a previous transfusion. The nurse should administer diphenhydramine prior to the transfusion for which of the following allergic responses?

5 :
A nurse is completing the initial admission assessment and history for a client. Which of the following is the priority action for the nurse to take?

6 :
A nurse is reviewing information about the Health Insurance Portability and Accountability Act (HIPAA) with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates a need for further teaching?

7 :
A nurse is providing discharge teaching to a client has a new prescription for a metered dose inhaler (MDI). Which of the following instructions should the nurse include in the teaching?

8 :
A nurse accidentally administers the wrong medication to a client, which results in a severe allergic reaction and prolongs the client's hospitalization. The client could rightfully sue the nurse for which of the following?

9 :
A nurse is teaching a class about safe medication administration. The nurse should include in the teaching that which of the following references are acceptable for safe medication administration? (Select all that apply.)

10 :
A nurse in a clinic is interviewing a client who will undergo diagnostic testing. The nurse should ask about a client's potential allergies during which phase of the nursing process?

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NUR 104 Final Assessment Summer II 2025

No.

1 : A nurse is receiving a provider's prescription for a client via telephone. Which of the following actions should the nurse take to ensure the accuracy of the telephone prescription? (Select all that apply.)

2 : Transcribe the order into the client's health record. A nurse is teaching a client who has asthma about how to use an albuterol inhaler. Which of the following actions by the client indicates an understanding of the teaching?

3 : A nurse is completing a client's history and physical examination. Which of the following information should the nurse consider subjective data?

4 : A nurse is preparing to transfuse one unit of packed RBC to a client who experienced a mild allergic reaction during a previous transfusion. The nurse should administer diphenhydramine prior to the transfusion for which of the following allergic responses?

5 : A nurse is completing the initial admission assessment and history for a client. Which of the following is the priority action for the nurse to take?

6 : A nurse is reviewing information about the Health Insurance Portability and Accountability Act (HIPAA) with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates a need for further teaching?

7 : A nurse is providing discharge teaching to a client has a new prescription for a metered dose inhaler (MDI). Which of the following instructions should the nurse include in the teaching?

8 : A nurse accidentally administers the wrong medication to a client, which results in a severe allergic reaction and prolongs the client's hospitalization. The client could rightfully sue the nurse for which of the following?

9 : A nurse is teaching a class about safe medication administration. The nurse should include in the teaching that which of the following references are acceptable for safe medication administration? (Select all that apply.)

10 : A nurse in a clinic is interviewing a client who will undergo diagnostic testing. The nurse should ask about a client's potential allergies during which phase of the nursing process?

1 :
A nurse is receiving a provider's prescription for a client via telephone. Which of the following actions should the nurse take to ensure the accuracy of the telephone prescription? (Select all that apply.)

2 :
Transcribe the order into the client's health record. A nurse is teaching a client who has asthma about how to use an albuterol inhaler. Which of the following actions by the client indicates an understanding of the teaching?

3 :
A nurse is completing a client's history and physical examination. Which of the following information should the nurse consider subjective data?

4 :
A nurse is preparing to transfuse one unit of packed RBC to a client who experienced a mild allergic reaction during a previous transfusion. The nurse should administer diphenhydramine prior to the transfusion for which of the following allergic responses?

5 :
A nurse is completing the initial admission assessment and history for a client. Which of the following is the priority action for the nurse to take?

6 :
A nurse is reviewing information about the Health Insurance Portability and Accountability Act (HIPAA) with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates a need for further teaching?

7 :
A nurse is providing discharge teaching to a client has a new prescription for a metered dose inhaler (MDI). Which of the following instructions should the nurse include in the teaching?

8 :
A nurse accidentally administers the wrong medication to a client, which results in a severe allergic reaction and prolongs the client's hospitalization. The client could rightfully sue the nurse for which of the following?

9 :
A nurse is teaching a class about safe medication administration. The nurse should include in the teaching that which of the following references are acceptable for safe medication administration? (Select all that apply.)

10 :
A nurse in a clinic is interviewing a client who will undergo diagnostic testing. The nurse should ask about a client's potential allergies during which phase of the nursing process?