# A nurse receives an order for hydromorphone 4 mg IV push every 2 hours as needed for an opioid-naive 75-year-old after minor outpatient surgery. The nurse believes the dose is unsafe. Which actions demonstrate advocacy and proper use of the chain of command? Select all that apply. > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=368304&lang=en > language: en > subject: Assignment/Delegation/Supervision > category: MOC ## Question A nurse receives an order for hydromorphone 4 mg IV push every 2 hours as needed for an opioid-naive 75-year-old after minor outpatient surgery. The nurse believes the dose is unsafe. Which actions demonstrate advocacy and proper use of the chain of command? Select all that apply. 1 Withhold the medication and contact the prescriber to clarify the dose, stating the specific safety concerns 2 Document the order, safety concern, communication with the prescriber, and response according to policy 3 If the concern remains unresolved, escalate through the facility's chain of command before administration 4 Do not administer a medication the nurse reasonably believes is unsafe, recognizing independent accountability for medication administration 5 Administer the dose as written because the prescriber believes it is safe and the prescriber's judgment supersedes the nurse's medication-safety concern 6 File an incident report for the next manager to review instead of contacting the prescriber or using the chain of command for the active medication concern ## Explanation Withhold the dose and clarify it directly with the prescriber using specific safety facts (Choice 1). Document the order, concern, communication, and response in the medical record according to policy (Choice 2). If unresolved, escalate through the facility's chain of command before administration (Choice 3). The nurse remains accountable for safe medication administration and should not give a dose reasonably believed unsafe (Choice 4). A prescriber's order does not remove nursing accountability (Choice 5), and an incident report does not replace immediate communication and escalation for an active hazard (Choice 6). ## In-depth explanation Patient Advocacy & Chain of Command 1. Recognize unsafe order — clarify clinically (age, weight, allergy, kidney/liver, opioid-naive status, total dose, interactions) 2. Withhold medication until clarified 3. Direct call to prescribing provider with specific concern + suggested safer alternative if known 4. Document: order, concern, communication, response 5. If provider declines and concern persists: escalate charge nurse → supervisor → medical director → ethics/risk management 6. Refuse to administer a medication reasonably believed to be unsafe 7. File incident report ALONGSIDE direct action, not instead of it Why "Just Following Orders" Fails Nurses are independently licensed and accountable for what they administer. The Five Rights of medication administration sit with the nurse at the bedside; the prescriber's authority does not override nursing accountability. Opioid-Naive IV Hydromorphone Typical opioid-naive starting dose: 0.2-0.5 mg IV. 4 mg IV is roughly 8-20× the typical starting dose for an older adult — high risk of respiratory depression, hypotension, oversedation. Memory Tip "Hold-Call-Document-Escalate-Refuse" ## Clinical scenario Scenario 75 yo, opioid-naive, minor outpatient surgery. Order: hydromorphone 4 mg IV q2h PRN (typical opioid-naive IV start 0.2-0.5 mg). Advocacy Action Map 1. Hold medication 2. Direct call to prescriber: state safety concern (age, opioid-naive, dose 8-20× typical) 3. Document order, concern, call, response 4. If declined → escalate chain of command 5. Refuse to administer; nurse independently accountable 6. File incident report ALONGSIDE direct action Avoid - Administering "because the provider ordered it" - Anonymous incident report instead of direct action - Postponing safety concerns to the next shift ## Key concepts - **Patient Advocacy (Nursing)** — Active support of the client's right to safe, evidence-based, ethical care. Includes speaking up when an order or plan appears unsafe, providing the client with information to make informed decisions, protecting the client from harm, and ensuring the client's voice is heard. The nurse is often the closest and most consistent member of the care team and bears legal and ethical responsibility for advocating before harm occurs. - **Chain of Command for Clinical Concerns** — Sequential escalation pathway when a clinical safety concern is not resolved at the first level: bedside nurse to charge nurse to nursing supervisor (house supervisor at night) to nurse manager to medical director, then ethics committee or risk management. Used when an unsafe order, refusal of necessary care, or systems failure cannot be resolved with the original prescriber. The chain protects the client and the nurse's license; it must be used BEFORE administering the contested medication or proceeding with the contested action. - **Nurse's Independent Accountability for Medications** — Under each nurse's license and the Five Rights of Medication Administration (right client, drug, dose, route, time — and increasingly right reason and right documentation), the nurse is independently accountable for safe administration. The provider's prescriptive authority does not transfer accountability to the nurse who administers. "I was just following orders" is not a defense in licensure boards or courts; refusing to administer a medication the nurse reasonably believes is unsafe is both protected and expected. ## Related questions - [A 67-year-old client with chronic obstructive pulmonary disease attends a routine primary …](https://mymerci.kr/pages/nclex_q.php?qn_id=360522&lang=en) - [A registered nurse on a medical-surgical unit is delegating tasks at the start of shift. 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