A nurse is caring for patients with electrolyte imbalances on a medical-surgical unit. Which common causes are correctly paired with the corresponding electrolyte imbalance?

Choice A reason:
Assessing the operative site is important to monitor for signs of bleeding, infection, or other complications. However, it is not the most critical, high-priority assessment immediately after surgery. While the condition of the surgical site can provide valuable information about the patient’s recovery and potential complications, it does not take precedence over ensuring the patient’s airway is clear and they are breathing adequately. The operative site can be assessed once the patient’s airway, breathing, and circulation are stable.
Choice B reason:
Airway assessment is the most critical, high-priority assessment in the PACU. Ensuring that the patient’s airway is clear and they are breathing properly is paramount because anesthesia can depress the central nervous system, leading to compromised airway patency and respiratory function. The primary goal in the immediate postoperative period is to ensure that the patient is ventilating adequately to prevent hypoxia and other respiratory complications. This involves checking for airway obstruction, monitoring respiratory rate, and ensuring that oxygen saturation levels are within normal ranges (typically 95-100% for healthy individuals). Any issues with the airway must be addressed immediately to prevent life-threatening complications.
Choice C reason:
Assessing the pulse is crucial for monitoring the patient’s cardiovascular status, including heart rate and rhythm. This can help detect arrhythmias, hypovolemia, or other cardiovascular issues that may arise postoperatively. However, while important, it is secondary to ensuring that the patient’s airway is clear and they are breathing adequately. The pulse can be assessed once the airway and breathing are confirmed to be stable. Normal pulse rates for adults typically range from 60 to 100 beats per minute.
Choice D reason:
Assessing skin integrity is important for identifying signs of pressure ulcers, infection, or other skin-related issues. However, this assessment is not the highest priority immediately after surgery. Ensuring the patient’s airway, breathing, and circulation are stable takes precedence. Skin integrity can be assessed once the patient is stable and other critical assessments have been completed. Maintaining skin integrity is essential for overall patient care, but it does not supersede the need to ensure the patient is breathing properly and has a clear airway.

The correct answer is A. Gather information on the patient’s current medications, including prescription drugs, over-the-counter drugs, herbal supplements, and vitamins. To ensure accuracy, nurses verify the medication list with the patient, family, caregivers, or community pharmacies and document the information in the patient’s EMR.

Choice A: Gather information on the patient’s current medications, including prescription drugs, over-the-counter drugs, herbal supplements, and vitamins. To ensure accuracy, nurses verify the medication list with the patient, family, caregivers, or community pharmacies and document the information in the patient’s EMR.
This choice accurately describes the comprehensive process of medication reconciliation. Nurses play a crucial role in gathering detailed information about all medications a patient is currently taking, including prescription drugs, over-the-counter medications, herbal supplements, and vitamins. This information is then verified with various sources such as the patient, their family, caregivers, or community pharmacies to ensure its accuracy. Finally, the verified information is documented in the patient’s Electronic Medical Record (EMR). This process helps prevent medication errors, ensures continuity of care, and enhances patient safety.
Choice B: Review the patient’s medication list to verify its accuracy and completeness. They also compare the list of current medications with new orders or prescriptions to detect any discrepancies or potential issues.
While this choice describes an important aspect of medication reconciliation, it is not as comprehensive as Choice A. Verifying the accuracy and completeness of the medication list and comparing it with new orders or prescriptions is a critical step in identifying discrepancies or potential issues. However, it does not encompass the initial gathering of information from various sources or the documentation process, which are essential components of medication reconciliation.
Choice C: Review the medication history provided by the patient and make changes in the medications based on the patient’s current health status. They communicate any medication changes to the patient and the healthcare team.
This choice focuses on reviewing the medication history and making changes based on the patient’s current health status. While this is an important aspect of patient care, it does not fully capture the scope of medication reconciliation. Medication reconciliation involves not only reviewing and updating medications but also gathering comprehensive information from multiple sources and ensuring accurate documentation. This choice lacks the emphasis on verification and documentation that is central to the medication reconciliation process.