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 complete list of a patient's medications from all sources, including those from the LTC facility, to ensure continuity and accuracy of care.
B. Recommendations for prescribed medications are part of ongoing treatment planning, not specifically the reconciliation process.
C. Discontinuation of medications may occur after reconciliation but is not a primary step in the process.
D. Medications from another pharmacy should be included, but the nurse must focus on all current medications, primarily from the LTC facility for accurate reconciliation.

A. Ask a family member to verify the client's identity. B. Check the client's name on the medication administration record (MAR) C. Verify the client's room number D. Ask the client's full name and date of birth.

Correct Answer is D

Explanation

A. Family members are not reliable sources for verifying patient identity.
B. Checking the client's name on the MAR is a part of the process but alone is not sufficient for identification.
C. Room numbers can change or be occupied by different patients; they do not verify patient identity.
D. Asking the client's full name and date of birth ensures direct confirmation from the patient, which is the most reliable method of identification.

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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 performing a medication reconciliation while admitting an older adult client transferred from a long-term care (LTC) facility. Which of the following should the nurse identify as part of the medication reconciliation process?

Correct Answer is A

Explanation

Before administering client medications, the nurse must identify the client. Which of the following methods of identification should the nurse use?

Correct Answer is D

Explanation

A nurse is working in a pediatric special care unit. She recently transferred to this unit from an adult intensive care unit. The nurse is very cautious in administering medications because children are especially vulnerable to medication errors. Why is this true?

A nurse is caring for a group of clients. Which of the following clients should the nurse identify is at the greatest risk of developing medication toxicity?

A nurse is preparing to enter a prescription from a provider. Which of the following formats should the nurse use?

A nurse is collecting data from a client who has heart failure, prior to the administration of furosemide. For which of the following findings should the nurse withhold the medication?

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?

A woman has been prescribed a daily Benadryl for allergy symptoms by her health care provider. She recently began have difficulty staying awake at work, most likely this is related to the Benadryl. Which of the following best describes this response?

A nurse is preparing to administer a client's antihypertensive medication. When using clinical judgment, which of the following findings indicates the nurse should collect further data from the client before administering medication?

A nurse is working with an RN to admit a new client. Which of the following steps of the nursing process is the nurse using when assisting to formulate goals for a positive outcome?