A nurse on a medical-surgical unit is performing medication reconciliation for a newly admitted client. Which of the following actions should the nurse take?
Compare the client's list of home medications to the admission prescriptions written for the client.
Compare a list of common medications to treat a condition to the actual prescriptions.
Compare the medication label to the provider's prescription on three occasions before administration.
Compare the prescription to the allergy history of the client.
The Correct Answer is A
Rationale:
A. Medication reconciliation involves reviewing all medications the client was taking at home and comparing them with the prescriptions ordered on admission. This process helps identify discrepancies, prevent omissions, duplications, or potential interactions, and ensures continuity of care.
B. Comparing a standard list of medications for a condition is not part of medication reconciliation because it may not reflect the individual client’s needs, allergies, or previous therapy. The focus should be on the client’s actual home medications.
C. This step refers to the “three checks” of medication administration, which is different from the initial reconciliation process. Reconciliation focuses on matching home medications with admission orders, not verifying labels prior to each dose.
D. While checking for allergies is a critical safety step, it is only one component of safe medication administration. Medication reconciliation is broader, ensuring that all home medications are considered and that any changes or omissions are intentional and documented.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. Perform range-of-motion exercises once per shift: While ROM exercises help maintain joint mobility, they are not a priority in the acute management of bacterial meningitis. The immediate focus is on preventing complications such as seizures and managing neurological status.
B. Place the client in high-Fowler's position: Although elevated head positioning can reduce intracranial pressure slightly, there is no strict requirement for high-Fowler’s positioning in bacterial meningitis. Comfort and safety are more important, with frequent neurological monitoring.
C. Implement seizure precautions: Bacterial meningitis increases the risk of seizures due to inflammation and increased intracranial pressure. Implementing seizure precautions—such as padding side rails, having suction available, and ensuring rapid access to emergency equipment—is a key safety measure.
D. Monitor the client for hypoglycemia: Hypoglycemia is not typically a complication of bacterial meningitis. Instead, monitoring focuses on neurological status, vital signs, fluid balance, and signs of increased intracranial pressure.
Correct Answer is C
Explanation
Rationale:
A. Mottled skin: Mottling is typically a late sign of poor perfusion or approaching death and does not indicate pain. It reflects circulatory changes rather than discomfort requiring analgesia.
B. Constricted pupils: Constricted pupils may result from certain medications or neurological changes, but they are not a reliable indicator of pain. Pupillary changes alone do not guide pain management.
C. Restlessness: Restlessness is a common manifestation of pain in clients receiving palliative care, especially when verbal communication is limited. Administering prescribed pain medication can help alleviate discomfort and improve comfort.
D. Cheyne-Stokes respirations: This irregular breathing pattern occurs in advanced illness or near end-of-life and is not an indicator of pain. It reflects neurological or metabolic changes rather than discomfort requiring analgesia.
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