Level: Clinical
Difficulty: Medium
Subtopic: Scope of practice
NCLEX: A nurse receives a telephone order for a new IV opioid. What is the nurse’s best action?
Ethics, legal nursing, delegation, prioritization Management of Care
Case Study
A nurse receives a telephone order for a new IV opioid. What is the nurse's best action?
Question
A. Follow facility policy for verbal/telephone orders, clarify the order, and document it correctly.
B. Administer the medication immediately because the provider is busy.
C. Ask UAP to confirm the dose with the pharmacy.
D. Refuse all telephone orders without written confirmation within 24 hours regardless of policy.
B. Administer the medication immediately because the provider is busy.
C. Ask UAP to confirm the dose with the pharmacy.
D. Refuse all telephone orders without written confirmation within 24 hours regardless of policy.
Rationale
Correct answer: A. Follow facility policy for verbal/telephone orders, clarify the order, and document it correctly.
Rationale: Telephone orders require verification per facility policy; the RN does not independently prescribe or skip required safeguards.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Telephone orders require verification per facility policy; the RN does not independently prescribe or skip required safeguards.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.