A nurse is triaging clients injured during a tornado. The nurse assesses a client who has an open fracture of his arm. Which of the following actions should the nurse take?

 

Choice A reason:

Providing a list of the client’s current medications during the change of shift report is important for continuity of care, but it is not the primary focus of medication reconciliation. Medication reconciliation aims to ensure accuracy of the medication list at key transition points, such as admission, transfer, and discharge.

Choice B reason:

Not performing reconciliation for a client at discharge from a health care facility is incorrect. Medication reconciliation is crucial at discharge to ensure that the patient leaves with an accurate and complete list of medications, which helps prevent medication errors and adverse drug events.

Choice C reason:

Providing a list of the client’s current medications during admission to a health care facility is a key component of medication reconciliation. This process involves comparing the patient’s current medications with the new medications ordered upon admission to identify and resolve any discrepancies. This helps ensure that the patient receives the correct medications throughout their stay.

Choice D reason:

Including only prescription medications in the medication reconciliation report is insufficient. The reconciliation process should include all medications the patient is taking, including over-the-counter drugs, supplements, and herbal remedies. This comprehensive approach helps identify potential interactions and ensures safe medication management.

Choice A reason: Apply intermittent ice to the affected ankle for the first 48 hours

Applying ice intermittently to the affected ankle for the first 48 hours helps reduce swelling and inflammation. Ice should be applied for 15-20 minutes every 2-3 hours during the initial phase of injury management. This practice is part of the RICE (Rest, Ice, Compression, Elevation) protocol commonly used for sprains and strains.

Choice B reason: Wrap the affected ankle with an elasticized compression bandage

Wrapping the affected ankle with an elasticized compression bandage helps to minimize swelling and provide support to the injured area. Compression bandages should be snug but not too tight to avoid restricting blood flow. This is another component of the RICE protocol.

Choice C reason: Apply full weight-bearing on the affected ankle

Applying full weight-bearing on the affected ankle is not recommended immediately after a second-degree sprain. The ankle needs time to heal, and weight-bearing should be gradually reintroduced as pain and swelling decrease. Initially, the client should avoid putting weight on the injured ankle to prevent further damage.

Choice D reason: Elevate the affected ankle above the level of the heart

Elevating the affected ankle above the level of the heart helps reduce swelling by promoting venous return and decreasing fluid accumulation in the injured area. This is an essential part of the RICE protocol and should be done as much as possible during the first 48 hours.

Choice E reason: Apply a heating pad intermittently to the affected ankle after 48 hours

Applying a heating pad intermittently to the affected ankle after 48 hours can help increase blood flow and promote healing. Heat therapy should be used after the initial acute phase (first 48 hours) when swelling has subsided. Heat can help relax muscles and reduce stiffness in the injured area.