A nurse is reviewing a client's medication administration record (MAR) and notes a medication order that is significantly higher than the usual therapeutic dose. The prescribing physician is currently unavailable. What is the nurse's most appropriate action?
- AAdminister half the ordered dose to be safe and document the action.
- BAdminister the medication as ordered, assuming the physician has a reason for the dose.
- CContact the charge nurse or nursing supervisor for clarification.
- DHold the medication and wait for the physician to become available for clarification.
Show answer & explanationAnswer & explanation
Correct answer: C. Contact the charge nurse or nursing supervisor for clarification.
When a drug order is questionable, the nurse has a professional and ethical responsibility to clarify it. If the prescribing physician is unavailable, contacting the charge nurse or nursing supervisor is the most appropriate next step. They can assist in reaching the physician, consulting pharmacy, or making an informed decision about holding or clarifying the order, ensuring client safety without unnecessarily delaying care if clarification can be obtained through other means.
Why the other options are wrong
- A. Administering an altered dose without an order is outside the nurse's scope of practice and can lead to a medication error.
- B. Administering a questionable dose can lead to a medication error and potential harm to the client, violating the 'right dose' principle.
- D. Holding the medication indefinitely might delay necessary treatment; seeking immediate clarification through available channels is preferred over simply waiting.
Questionable Medication Order
A medication order that appears unsafe, unclear, or inappropriate based on the client's condition or standard prescribing guidelines.
- Nurse's responsibility to clarify.
- Prioritize client safety.
- Follow chain of command if prescriber unavailable.
Memory trick: Question the Dose, Consult, and Never Overdose.