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 medication label to the provider’s prescription on three occasions before administration.
Compare the client’s list of home medications to the admission prescriptions written for the client.
Administer medications to treat a condition to the actual prescriptions.
Ensure the medication is administered within 3 hours of the scheduled time.
The Correct Answer is B
Choice A reason: Comparing the medication label to the provider’s prescription three times is a safety step during administration, not reconciliation. Reconciliation verifies the client’s home medications against new orders to prevent errors like omissions or duplications. This action occurs post-reconciliation, focusing on administration accuracy, not the initial verification of the medication list.
Choice B reason: Medication reconciliation involves comparing the client’s home medication list to admission prescriptions to ensure continuity and accuracy. This process identifies discrepancies, such as missed medications or incorrect doses, preventing adverse drug events. It requires verifying with the client or family and cross-checking provider orders, making it the cornerstone of safe transitions in care settings.
Choice C reason: Administering medications to treat a condition to the actual prescriptions is unclear and not part of reconciliation. Reconciliation focuses on verifying and documenting medications, not administering them. This option does not align with the systematic process of ensuring all medications are correctly prescribed upon admission, making it incorrect.
Choice D reason: Ensuring administration within 3 hours of the scheduled time relates to medication administration protocols, not reconciliation. Reconciliation verifies the accuracy of the medication list before administration. This step is about timing, not the verification process critical to preventing errors during care transitions, rendering it irrelevant to the task.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Changing the stoma pouch 30 minutes after meals is not recommended, as meal timing does not dictate pouch changes. Pouches are typically changed every 3-7 days or if leaking, to prevent skin irritation. This statement reflects a misunderstanding, as it suggests an incorrect schedule unrelated to stoma care needs.
Choice B reason: Cutting the pouch opening 1/8 inch larger than the stoma ensures a snug fit, preventing leakage while protecting peristomal skin from irritation by digestive enzymes. Proper sizing maintains skin integrity and pouch adherence, supporting effective ostomy management. This statement demonstrates correct understanding of stoma care techniques.
Choice C reason: Cleaning the stoma with moisturizing soap is incorrect, as soaps with oils or fragrances can irritate peristomal skin and impair pouch adhesion. Mild, non-residue soap and water are recommended to maintain skin integrity. This statement indicates a misunderstanding of proper stoma cleaning practices.
Choice D reason: Expecting the stoma to be blistered is incorrect, as a healthy stoma should be pink, moist, and free of irritation. Blistering indicates complications like infection or poor pouch fit. This statement reflects a misunderstanding of normal stoma appearance and care, suggesting potential issues requiring intervention.
Correct Answer is C
Explanation
Choice A reason: Encouraging ambulation only after 48 hours delays recovery, as early ambulation (within 12-24 hours) promotes circulation, prevents thromboembolism, and aids bowel function post-abdominal surgery. This instruction is incorrect, as it contradicts evidence-based protocols for early mobilization to enhance recovery.
Choice B reason: Instructing clients to avoid coughing is inappropriate, as coughing and deep breathing prevent pulmonary complications like atelectasis post-abdominal surgery. Splinting the incision during coughing reduces discomfort and dehiscence risk, making this instruction incorrect as it increases respiratory complications.
Choice C reason: Monitoring for signs of infection, such as fever or redness, is critical post-abdominal surgery to detect complications early. Infections can delay healing and lead to sepsis. Regular assessment ensures timely intervention, aligning with evidence-based postoperative care, making this the correct information to include.
Choice D reason: Removing surgical dressings within 12 hours is not standard, as dressings typically remain for 24-48 hours or per surgeon orders to protect the wound and reduce infection risk. Premature removal increases contamination risk, making this instruction incorrect for postoperative care.
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