A nurse is admitting a client to a medical-surgical unit.
When performing medication reconciliation for the client, which of the following actions should the nurse take?
A. Compare new prescriptions with the list of medications the client reports
B. Encourage the client to make his own list after he returns to his home
Include any adverse effects of the medications the client might develop
Exclude nutritional supplements from the list of medications the client reports
The Correct Answer is A
The correct answer is choice A. The nurse should compare new prescriptions with the list of medications the client reports. This is part of the medication reconciliation process, which is done to avoid medication errors such as omissions, duplications, dosing errors, or drug interactions. It should be done at every transition of care in which new medications are ordered or existing orders are rewritten.
Choice B is wrong because the nurse should not encourage the client to make his own list after he returns to his home. The nurse should provide the client with an updated and accurate list of medications before discharge and instruct the client to keep it with him at all times.
Choice C is wrong because the nurse should not include any adverse effects of the medications the client might develop. The nurse should include any known allergies or adverse reactions the client has experienced in the past, but not potential adverse effects that have not occurred.
Choice D is wrong because the nurse should not exclude nutritional supplements from the list of medications the client reports. The nurse should include all prescription medications, herbals, vitamins, nutritional supplements, over-the-counter drugs, vaccines, diagnostic and contrast agents, radioactive medications, parenteral nutrition, blood derivatives, and intravenous solutions in the medication reconciliation process.
Some of these products may interact with prescribed medications or affect laboratory results.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C"]
Explanation
The correct answers are B and C.
Choice A Reason: Transferring a client who is receiving radiation therapy involves understanding the precautions and care associated with radiation, which may be beyond the training of assistive personnel (AP). Radiation therapy clients may have specific safety and transport protocols that require the expertise of licensed nursing staff.
Choice B Reason: Measuring vital signs for a client who requires contact precautions is a task that can be delegated to AP. Assistive personnel can be trained in infection control procedures and the use of personal protective equipment (PPE), making them capable of measuring vital signs while adhering to contact precautions.
Choice C Reason: Recording urine output for a client who has a suprapubic catheter can be delegated to AP. This task involves measuring and documenting a quantifiable data point, which does not require the clinical judgment of a nurse. AP can be trained to accurately measure and record urine output.
Choice D Reason: Planning care for a client who has dysphagia is a complex task that involves assessment and clinical judgment, which are responsibilities of the licensed nurse. Dysphagia can have serious complications, and care plans must be tailored to each client’s needs, requiring the expertise of a nurse.
Correct Answer is A
Explanation
The correct answer is choice A. Observe the position of the suspended weight.
This is an intervention that the nurse can delegate to an assistive personnel because it does not require clinical judgment or assessment skills.
The nurse should instruct the assistive personnel to report any changes in the position of the weight or the traction system to the nurse immediately.
Choice B is wrong because checking the client’s pedal pulse on the right leg requires assessment skills and clinical judgment that are beyond the scope of practice of an assistive personnel.
The nurse should perform this intervention to monitor the client’s circulation and nerve function in the affected limb.
Choice C is wrong because asking the client to describe her pain requires communication and assessment skills that are beyond the scope of practice of an assistive personnel.
The nurse should perform this intervention to evaluate the client’s pain level and response to analgesics.
Choice D is wrong because reminding the client to use the incentive spirometer requires teaching and evaluation skills that are beyond the scope of practice of an assistive personnel.
The nurse should perform this intervention to promote effective gas exchange and prevent respiratory complications in the client who is immobile.
Buck’s traction is a type of skin traction that is applied by strapping the client’s affected lower limb and attaching weights. The purpose of traction is to restore and maintain straight alignment and length of bones following fractures, to limit movement and reduce pain, spasms and swelling. Normal ranges for skin traction are 2.3 to 4.5 kg for adults and 0.9 to 2.3 kg for children.
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