A nurse is performing a medication reconciliation while admitting an older adult client transferred from a long-term care (LTC) facility. Which of the following should the nurse identify as part of the medication reconciliation process?
Medications from the LTC facility
Recommendation for prescribed medications
Discontinuation of medications
Medications for another pharmacy
The Correct Answer is A
A. Medication reconciliation involves compiling a complete list of a patient's medications from all sources, including those from the LTC facility, to ensure continuity and accuracy of care.
B. Recommendations for prescribed medications are part of ongoing treatment planning, not specifically the reconciliation process.
C. Discontinuation of medications may occur after reconciliation but is not a primary step in the process.
D. Medications from another pharmacy should be included, but the nurse must focus on all current medications, primarily from the LTC facility for accurate reconciliation.
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Correct Answer is C
Explanation
A. Documenting at the end of the shift can lead to inaccuracies due to the delay, potentially causing errors if other staff need up-to-date information. It also increases the risk of forgetting details of the administration, compromising patient safety.
B. Documenting before administering the medications can lead to discrepancies if the medications are not given as planned. This practice could result in serious errors if the patient refuses the medication or if changes occur that affect administration.
C. Documenting immediately ensures that the record is accurate and reflects the current status of the patient’s medication regimen. It also allows other healthcare providers to see up-to-date information, which is crucial for ongoing patient care and safety.
D. Delaying documentation until a convenient time can lead to incomplete or forgotten details, increasing the risk of medication errors. Timely documentation is essential to maintain an accurate and reliable medical record.
Correct Answer is A
Explanation
A. Planning involves setting goals and desired outcomes for the client's care.
B. Data collection, or assessment, involves gathering information about the client’s health status.
C. Evaluation involves determining if the goals have been met.
D. Implementation involves carrying out the interventions to achieve the goals.
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