Which of the following would be true regarding medication reconciliation? Select all that apply.
- A. Medication reconciliation is a Joint Commission National Patient Safety Goal.
- B. Medication reconciliation is designed to obtain and communicate an accurate list of a client's home medications across the continuum of care.
- C. Only nurses or health care providers can be involved in medication reconciliation.
- D. Medications are considered reconciled if a medication order exists that is therapeutically equivalent to the one prior to admission.
- E. A medication is considered to be any medication ordered by a physician.
Correct Answer: A, B, D
Rationale: Medication reconciliation is a Joint Commission goal to ensure accurate medication lists across care transitions. Equivalent medications are reconciled, but not all staff are limited to nurses/providers, and not all medications are physician-ordered.
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A client tells the nurse that she has had sexual contact with someone whom she suspects has genital herpes. Which of the following instructions should the nurse give the client in response to this information?
- A. Anticipate lesions within 25 to 30 days.
- B. Continue sexual activity unless lesions are present.
- C. Report any difficulty urinating.
- D. Drink extra fluids to prevent lesions from forming.
Correct Answer: C
Rationale: Difficulty urinating can indicate herpes-related urinary retention, a serious complication requiring medical attention.
A client with a history of peptic ulcer disease is admitted with abdominal pain. The nurse should include which of the following in the plan of care?
- A. Administer pantoprazole as prescribed.
- B. Encourage a high-fiber diet.
- C. Administer ibuprofen for pain.
- D. Position the client supine.
Correct Answer: A
Rationale: Pantoprazole reduces acid production, promoting ulcer healing.
The nurse is assessing a neonate at 5 minutes after birth. The nurse records the Apgar score based on the findings in the chart A. The nurse compares these findings to the Apgar score obtained at birth, as determined by the findings in the chart B. What should the nurse do next?
- A. Notify the neonatologist on call.
- B. Continue to assess the neonate.
- C. Apply an oxygen mask.
- D. Rub the neonate’s extremities.
Correct Answer: B
Rationale: The neonate’s Apgar score has been improving since birth. (The birth score is 6; the current score is 9.) The nurse should continue to assess the neonate. There is no indication that oxygen is
needed since the color is improving, and stimulating the baby is not necessary as the he is now fl exing his extremities.
The nurse is assessing a client with suspected hyperthyroidism. Which of the following symptoms is most likely to be present?
- A. Weight gain.
- B. Cold intolerance.
- C. Tremors.
- D. Constipation.
Correct Answer: C
Rationale: Tremors are a common symptom of hyperthyroidism due to increased metabolic rate and nervous system stimulation.
A nulliparous client says that she and her husband plan to use a diaphragm with spermicide to prevent conception. Which of the following should the nurse include as the action of spermicides when teaching the client?
- A. Destruction of spermatozoa before they enter the cervix.
- B. Prevention of spermatozoa from entering the uterus.
- C. A change in vaginal pH from acidic to alkaline.
- D. Slowing of the movement of the migrating spermatozoa.
Correct Answer: A
Rationale: Spermicides destroy spermatozoa before they can enter the cervix, preventing fertilization.
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