A nurse is transcribing several telephone prescriptions for clients. Which of the following forms of documentation should the nurse use?
Zolpidem 10 mg PO HS
Heparin 10,000 u subcutaneously TID
Docusate 100 mg PO QD
Lorazepam 2 mg PO BID
The Correct Answer is A
A. Zolpidem 10 mg PO HS: This is the correct and acceptable documentation format. It includes the full drug name, dosage, route, and timing abbreviation ("HS" for bedtime), all of which are permitted and clear in medical documentation.
B. Heparin 10,000 u subcutaneously TID: The abbreviation "u" for units is considered unsafe and prone to misreading (e.g., as a zero). Instead, "units" should be written out to prevent medication errors.
C. Docusate 100 mg PO QD: "QD" is a dangerous abbreviation that can be misread as "QID" (four times daily). The Joint Commission recommends writing "daily" instead to ensure clarity and patient safety.
D. Lorazepam 2 mg PO BID: While mostly acceptable, using "BID" can be risky because it may be misinterpreted. Current best practices encourage writing "twice daily" to reduce ambiguity in documentation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. An assistive personnel arrives for her shift with alcohol on her breath:This situation requires immediate reporting to the supervisor and removal of the staff member from duty, but it does not call for an incident report unless it results in a safety event or client harm.
B. A client’s family member falls in the unit hallway:An incident report is required for any unplanned event that occurs on the premises and poses a risk of injury or liability, including visitor falls. This documentation is important for legal protection and quality improvement.
C. A client does not have advance directives in his medical record:The absence of advance directives is a legal and ethical issue that should be addressed during admission, but it does not represent an error or adverse event requiring an incident report.
D. A client refuses a blood transfusion:Refusal of treatment is a patient’s right and should be documented in the medical record. It is not a mistake or accident, so it does not necessitate an incident report unless a related error or adverse event occurs.
Correct Answer is A
Explanation
A. Omeprazole:Omeprazole is a proton pump inhibitor (PPI) that, with long-term use, can reduce calcium absorption by lowering stomach acid. This decreased calcium absorption contributes to bone demineralization and increases the risk of osteoporosis and fractures.
B. Famotidine:Famotidine is an H2-receptor antagonist that suppresses gastric acid but has not been strongly linked to reduced calcium absorption or osteoporosis. It is generally considered safer than PPIs in terms of long-term bone health.
C. Bismuth:Bismuth compounds are used for gastrointestinal discomfort and to treat Helicobacter pylori infections but are not associated with osteoporosis. They work locally in the stomach and do not significantly affect mineral metabolism.
D. Magnesium hydroxide:This antacid works by neutralizing stomach acid and may cause diarrhea, but it is not known to interfere with calcium absorption or contribute to bone loss. It does not carry a risk of osteoporosis with prolonged use.
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