Ethics, legal nursing, delegation, prioritization · practice question

A 64-year-old client on a medical-surgical unit is being evaluated for nursing care related to unsafe orders. Assessment data include telephone order received for a high-risk IV medication. Which finding requires the nurse to intervene immediately?

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A comfort request with unchanged vital signs and no new symptoms.Routine data unchanged from the prior assessment.A stable, long-standing finding that matches the expected care plan.The new finding that telephone order received for a high-risk IV medication.

Answer and explanation

Correct answer

D. The new finding that telephone order received for a high-risk IV medication.

Why

Follow-up items test whether the nurse recognizes cues that are new, acute, or inconsistent with stability and need prompt nursing action.

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A 64-year-old client on a medical-surgical unit is being evaluated for nursing care related to unsafe orders. Assessment data include telephone order received for a high-risk IV medication. Which finding requires the nurse to intervene immediately?

Correct answer

Why

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