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 B
Explanation
Rationale:
A. Insert a rectal suppository: While a suppository can relieve constipation, abdominal distention after laparoscopic surgery is often caused by retained gas from insufflation rather than stool, so this intervention may not be effective.
B. Assist the client to ambulate: Early ambulation promotes peristalsis and helps the body expel retained carbon dioxide gas from the abdomen, which is a common cause of post-laparoscopic distention. This is a safe and effective first-line intervention.
C. Prepare the client for a paracentesis: Paracentesis is used to remove fluid in cases of ascites, not routine post-surgical gas-related distention. It is unnecessary for uncomplicated laparoscopic procedures.
D. Place the client in the prone position: While repositioning may offer some comfort, it does not significantly facilitate the expulsion of gas or reduce abdominal distention. Ambulation is more effective.
Correct Answer is ["A","D","E"]
Explanation
Rationale:
A. Assess the client's lung sounds prior to the infusion: Baseline lung assessment helps detect early signs of fluid overload or transfusion-associated circulatory overload (TACO), which is especially important in older adults.
B. Prime the infusion tubing with 0.45% sodium chloride: Only 0.9% sodium chloride (normal saline) is compatible with blood products. Hypotonic solutions such as 0.45% sodium chloride can cause hemolysis of red blood cells.
C. Don sterile gloves to prepare the blood administration setup: Clean gloves are sufficient for preparing and administering blood transfusions. Sterile gloves are not required unless performing a sterile procedure.
D. Verify with another nurse that the unit of blood is compatible with the client's blood type: Double verification of the client’s identity and blood compatibility prevents hemolytic transfusion reactions due to mismatched blood.
E. Infuse the blood over 4 hr: Each unit of packed RBCs should be transfused within no more than 4 hours to reduce the risk of bacterial contamination and hemolysis from prolonged infusion.
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