A nurse is evaluating the documentation of a newly licensed nurse. The nurse should identify that which of the following entries requires intervention?

Client assisted OOB, instructed to splint ABD

Urine collected for UA and C & S

Prescription received for MSO4 4.0 mg PRN pain

12 units of regular insulin administered subcut

Answer and Explanation

The Correct Answer is C

A. "Client assisted OOB, instructed to splint ABD" is clear and uses standard abbreviations (OOB: out of bed, ABD: abdomen).
B. "Urine collected for UA and C & S" is clear and uses standard abbreviations (UA: urinalysis, C & S: culture and sensitivity).
C. "Prescription received for MSO4 4.0 mg PRN pain" is problematic because "MSO4" is an ambiguous abbreviation that can be confused with other medications. It should be written as "morphine sulfate" for clarity. Additionally, the trailing zero in "4.0 mg" can lead to dosing errors; it should be written as "4 mg."
D. "12 units of regular insulin administered subcut" is clear and uses standard terminology (subcut: subcutaneous).

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Correct Answer is A

Explanation

A. Medication reconciliation involves compiling a comprehensive and accurate list of the patient's current medications, which should be provided to the client at discharge to ensure continuity of care.
B. The list obtained from the client should include all medications the client is taking, including over-the-counter medications and supplements, not just those prescribed by the provider.
C. Verbal orders should be transcribed immediately into the medical record and should not be part of the medication reconciliation process.
D. Medication reconciliation should be an ongoing process throughout the patient's hospital stay to ensure that the most accurate list of medications is maintained.

A. At the end of her shift B. Before she enters the room to give the medications C. Immediately following administration of the medications D. Whenever she has time

Correct Answer is C

Explanation

A. Documenting at the end of the shift can lead to inaccuracies due to the delay, potentially causing errors if other staff need up-to-date information. It also increases the risk of forgetting details of the administration, compromising patient safety.
B. Documenting before administering the medications can lead to discrepancies if the medications are not given as planned. This practice could result in serious errors if the patient refuses the medication or if changes occur that affect administration.
C. Documenting immediately ensures that the record is accurate and reflects the current status of the patient’s medication regimen. It also allows other healthcare providers to see up-to-date information, which is crucial for ongoing patient care and safety.
D. Delaying documentation until a convenient time can lead to incomplete or forgotten details, increasing the risk of medication errors. Timely documentation is essential to maintain an accurate and reliable medical record.

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A nurse is evaluating the documentation of a newly licensed nurse. The nurse should identify that which of the following entries requires intervention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing the components of medication reconciliation with a newly licensed nurse. Which of the following information should the nurse include in the teaching?

Correct Answer is A

Explanation

The nurse goes into a patient's room and administers her 0900 medications. When should the nurse document that the medications were given?

Correct Answer is C

Explanation

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