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.

Answer and Explanation

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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Correct Answer is C

Explanation

Rationale:
A. The nurse positions a client who is postoperative in a semi-Fowler's position: Semi-Fowler’s promotes lung expansion and comfort postoperatively, especially after abdominal or thoracic surgery, making this an appropriate nursing action.

B. The nurse uses clean gloves when administering an enema: Clean gloves are sufficient for enema administration since it is a clean (not sterile) procedure, and this reflects correct practice.

C. The nurse performs auscultation of the lungs without lifting the gown: Clothing or gowns interfere with accurate transmission of breath sounds, leading to possible misinterpretation. The gown should be lifted or moved aside to properly auscultate.

D. The nurse applies a cold compress to reduce localized swelling: Cold therapy decreases blood flow and inflammation, making this an appropriate intervention for localized swelling or injury.

A. Obtain a culture specimen of the lochia from the client's perineal pad using a sterile swab. B. Instruct the client to wash her hands before and after changing her perineal pad. C. Initiate contact precautions. D. Encourage the client to maintain a semi-Fowler's position to enhance uterine drainage. E. Monitor the height and tone of the client's fundus. F. Request a prescription for terbutaline from the provider. G. Inform the client she will need to formula feed her newborn until she has received antibiotics for 24 hr.

Correct Answer is ["A","B","D","E"]

Explanation

Rationale:
A. Obtain a culture specimen of the lochia from the client's perineal pad using a sterile swab: The client exhibits signs of postpartum infection, including foul-smelling lochia, fever, and elevated WBC count. Collecting a culture helps identify the causative organism and guide antibiotic therapy.

B. Instruct the client to wash her hands before and after changing her perineal pad: Hand hygiene reduces the risk of introducing additional pathogens to the uterine or perineal area, supporting infection control and client safety.

C. Initiate contact precautions: Contact precautions are typically used for highly contagious or multidrug-resistant infections. Standard precautions, including hand hygiene, are sufficient for most postpartum infections like endometritis.

D. Encourage the client to maintain a semi-Fowler's position to enhance uterine drainage: Semi-Fowler’s positioning promotes drainage of lochia, reduces uterine stasis, and helps prevent further infection or discomfort.

E. Monitor the height and tone of the client's fundus: Regular assessment of fundal height and tone is essential postpartum to detect uterine atony, retained tissue, or infection. Monitoring ensures early intervention if complications develop.

F. Request a prescription for terbutaline from the provider: Terbutaline is a tocolytic used to suppress preterm labor. There is no indication for its use in this postpartum client with uterine infection.

G. Inform the client she will need to formula feed her newborn until she has received antibiotics for 24 hr: Most antibiotics, including clindamycin, are compatible with breastfeeding. The client does not need to discontinue breastfeeding unless specifically contraindicated.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse preceptor is observing a newly licensed nurse caring for a client on a medical-surgical unit. Which of the following actions by the newly licensed nurse requires further instruction by the nurse preceptor?

Correct Answer is C

Explanation

A nurse reviews the provider prescriptions and reassesses the client. Exhibits The nurse is continuing to care for the client. Which of the following actions should the nurse take? Select all that apply.

Correct Answer is ["A","B","D","E"]

Explanation

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