Nokea
The nurse is preparing a staff education program about medication reconciliation. Which of the following information should the nurse include? Select all that apply.
- A. Discontinued medications should be included while performing medication reconciliation.
- B. Medications taken on an as-needed basis can be excluded from this process.
- C. New medication orders should be compared with the current list.
- D. Medication reconciliation should be performed after the client has been discharged.
- E. Over-the-counter (OTC) medications should be included in the medication reconciliation.
Correct Answer: A,C,E
Rationale: Medication reconciliation includes discontinued medications, new orders, and OTC medications to ensure a complete and accurate list; it should occur at admission, transfer, and discharge, and PRN medications should not be excluded.
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Which of the following client situations would require the most intensive nursing interventions for immobility?
- A. A 38-year-old woman receiving internal radiation therapy for cervical cancer.
- B. A 7-year-old boy with leukemia hospitalized for induction of high-dose chemotherapy.
- C. A 75-year-old man with metastatic prostate cancer hospitalized for a pathologic fracture of the femur.
- D. A 6-month-old undergoing surgery for placement of a central venous catheter.
Correct Answer: C
Rationale: A 75-year-old man with a pathologic femur fracture requires the most intensive nursing interventions for immobility due to pain, risk of further injury, and need for mobility aids and rehabilitation.
A client receiving TPN reports sudden chest pain and dyspnea. Which action should the nurse take first?
- A. Stop the TPN infusion.
- B. Administer oxygen as ordered.
- C. Notify the physician.
- D. Check the client's blood glucose.
Correct Answer: C
Rationale: Sudden chest pain and dyspnea in a client receiving TPN may indicate a serious complication like an air embolism or infection, requiring immediate physician notification. Stopping the infusion or checking glucose is premature, and oxygen requires an order. CN: Physiological adaptation; CL: Synthesize
Which activity increases the risk of renal calculi?
- A. High fluid intake.
- B. Sedentary lifestyle.
- C. Low-sodium diet.
- D. Frequent urination.
Correct Answer: B
Rationale: A sedentary lifestyle promotes urinary stasis, increasing stone risk.
Which complication should the nurse monitor for in a client with a new ileal conduit?
- A. Stoma prolapse.
- B. Urinary retention.
- C. Bladder spasms.
- D. Renal colic.
Correct Answer: A
Rationale: Stoma prolapse is a potential complication of an ileal conduit, requiring surgical correction if severe.
Which of the following characteristics would put a client at the greatest risk for impaired wound healing after abdominal surgery?
- A. Age 75 years.
- B. Age 30 years, with poorly controlled diabetes.
- C. Age 55 years, with myocardial infarction.
- D. Age 60 years, with peripheral vascular disease.
Correct Answer: B
Rationale: Poorly controlled diabetes impairs wound healing due to high glucose levels affecting immune response and tissue repair, posing a greater risk than age or other conditions listed.