A nurse is performing medication reconciliation for a client newly admitted. Which of the following actions should the nurse take?

Perform the reconciliation only at admission and discharge

Compare only the prescribed home medications to the new prescriptions

Delete new prescriptions that may interact with home medications

Consider the risk for medication interactions

Answer and Explanation

The Correct Answer is D

Choice A reason: Limiting reconciliation to admission and discharge misses medication changes during hospitalization, risking errors or omissions. Effective reconciliation occurs at all care transitions—admission, transfers, discharge—ensuring a current, accurate list. This approach prevents discrepancies, like duplicative therapies or missed doses, that could harm the client. Skipping interim updates undermines safety, as hospital regimens evolve, making this action incomplete and inadequate for proper care.

Choice B reason: Comparing only home medications to new prescriptions excludes drugs given during hospitalization, creating an incomplete profile. Reconciliation requires reviewing all medications—home, inpatient, and discharge—to identify conflicts or redundancies. Focusing solely on prescribed home meds overlooks real-time additions, like painkillers or antibiotics, risking interactions or therapeutic gaps. This narrow scope fails to meet reconciliation’s comprehensive safety goal.

Choice C reason: Deleting new prescriptions with potential home medication interactions exceeds nursing scope and risks altering treatment without provider input. Reconciliation identifies conflicts for collaborative resolution, not unilateral changes. For example, removing a necessary anticoagulant due to an interaction could harm the client. This action bypasses clinical judgment, undermining the process’s intent to flag, not fix, issues independently.

Choice D reason: Considering medication interaction risks is the essence of reconciliation, ensuring safety by identifying conflicts between home and hospital drugs—like warfarin and antibiotics increasing bleeding risk. The nurse compiles a full list, assesses potential adverse effects, and reports to the provider for adjustments. This proactive step prevents harm, aligns with standards, and supports individualized care, making it the correct action.

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Correct Answer is C

Explanation

Choice A reason: A parent with type 2 diabetes indicates a genetic risk for metabolic issues, possibly relevant to liver disease progression, like NAFLD. However, it’s historical data, not an immediate threat to transplant success. The priority lies with factors affecting post-operative care, like adherence, over family history. This statement, while useful, isn’t urgent for reporting now.

Choice B reason: Childhood asthma history suggests past respiratory issues, potentially complicating anesthesia or recovery, but if resolved, it’s low priority. End-stage liver disease focuses on hepatic function, not dormant lung conditions. Without current symptoms, this doesn’t impact transplant candidacy urgently, making it less critical than adherence concerns.

Choice C reason: Poor medication adherence is a red flag for transplant listing, as post-operative immunosuppressants prevent rejection, requiring strict compliance. Non-adherence risks graft failure, a life-threatening outcome in end-stage liver disease. This statement demands immediate provider attention to assess candidacy and plan interventions, prioritizing it over other concerns here.

Choice D reason: Lack of family support affects emotional coping and post-transplant care logistics, potentially stressing recovery, but it’s not an immediate medical risk. Adherence to medications directly impacts survival, outweighing psychosocial factors in urgency. This statement, while relevant, doesn’t necessitate urgent reporting compared to compliance issues.

A. Infuse 0.9% sodium chloride at 150 mL/hr B. Have the client bear down when checking their blood pressure C. Maintain the pressure bag at 300 mm Hg of pressure D. Align the transducer to the level of the client’s radial artery

Correct Answer is C

Explanation

Choice A reason: Infusing 0.9% sodium chloride at 150 mL/hr through an arterial line is excessive and dangerous, risking fluid overload or vessel damage. Arterial lines use a slow flush (1-3 mL/hr) to maintain patency, not high-volume infusion. This rate suits IV hydration, not arterial monitoring, making it an incorrect and harmful action for this setup.

Choice B reason: Having the client bear down (Valsalva maneuver) increases intrathoracic pressure, falsely elevating arterial readings, distorting accuracy. Arterial lines provide continuous, real-time pressure via transducers, not manual checks requiring such actions. This technique applies to venous lines or respiratory tests, not arterial monitoring, rendering it inappropriate and misleading here.

Choice C reason: Maintaining the pressure bag at 300 mm Hg ensures a continuous flush (1-3 mL/hr) of saline, preventing clot formation in the arterial line, which could block it. This pressure exceeds arterial systolic values, keeping the system patent and readings accurate. It’s a standard practice, critical for reliable monitoring, making it the correct action in this scenario.

Choice D reason: Aligning the transducer to the radial artery level is incorrect; it should be at the phlebostatic axis (heart level) for accurate pressure readings. Radial alignment overestimates pressure due to gravitational effects, skewing data. Proper calibration at the heart ensures true arterial values, so this action fails to meet monitoring standards.

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A nurse is performing medication reconciliation for a client newly admitted. Which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

A nurse is caring for a client who has an arterial line inserted in the radial artery. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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