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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["D","E"]
Explanation
Rationale:
A. Clamp the chest tube every 2 hr to assess the amount of drainage: Routine clamping of a chest tube is unsafe because it can cause a sudden buildup of pressure in the pleural space, leading to a tension pneumothorax.
B. Maintain the collection chamber above the level of the client's waist: The collection chamber should always be positioned below the level of the client’s chest to allow gravity drainage. Placing it above the waist would prevent proper drainage.
C. Strip the chest tube vigorously to dislodge blood clots: Vigorous stripping or milking of the chest tube can create excessive negative pressure, potentially damaging lung tissue. Current guidelines recommend gentle milking only if ordered and rarely if obstruction is suspected.
D. Add water to the water seal chamber as it evaporates: Maintaining the proper water level in the water seal chamber is essential to preserve the one-way valve function that prevents air from re-entering the pleural space. Evaporation can reduce the seal, so the nurse should routinely check and refill it.
E. Mark the drainage output on the collection chamber: Documenting drainage at regular intervals allows accurate monitoring of the client’s progress and early identification of complications such as increased bleeding or fluid accumulation. It supports timely communication with the healthcare provider.
Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"B"}
Explanation
Rationale for Correct Choices
• Compartment syndrome: The child’s nondisplaced midshaft fracture of the radius and ulna places them at risk for compartment syndrome, whereby increased pressure within the muscle compartments impairs circulation and tissue perfusion. Early recognition is crucial to prevent permanent nerve or muscle damage.
• Paresthesia: The child reports tingling in the fingers, which indicates nerve involvement or compression—an early warning sign of compartment syndrome. Monitoring for paresthesia helps the nurse identify worsening neurovascular compromise promptly.
Rationale for Incorrect Choices
• Osteomyelitis: Infection of the bone is unlikely immediately after a closed nondisplaced fracture without open wounds or surgical intervention. There is no evidence of systemic infection at this stage.
• Nonunion: Fracture nonunion is a long-term complication that occurs if healing fails over weeks to months. The child’s fracture is recent, so immediate risk is low.
• Physical damage: While trauma caused the fracture, “physical damage” is a broad term and does not specify a complication requiring acute monitoring.
• Ecchymosis: Bruising indicates soft tissue injury but does not predict compartment syndrome or other severe complications.
• Type of fracture: While important for diagnosis and treatment planning, the fracture type (nondisplaced) does not directly indicate the acute risk for neurovascular compromise.
• Location of fracture: The midshaft location contributes to fracture management but is not as clinically relevant as the early signs of compartment syndrome, such as paresthesia.
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