A nurse enters a client's room to perform a focused assessment. Which of the following client information should the nurse use to properly identify the client?
Telephone number
Diagnosis
Provider's name
Room number
The Correct Answer is A
Rationale
A. Telephone number: Using the client’s unique identifiers, such as name and date of birth, is standard practice, but if multiple identifiers are required, asking the client to confirm information like a telephone number helps ensure correct identification. Proper identification prevents errors in assessment, medication administration, and procedures.
B. Diagnosis: A client’s diagnosis does not uniquely identify them because multiple clients may share the same condition. Relying on diagnosis alone could lead to misidentification and errors in care.
C. Provider's name: The healthcare provider’s name is not a reliable client identifier. Multiple clients may be under the care of the same provider, so using this information cannot ensure the correct patient is being assessed.
D. Room number: Room numbers are temporary and can change; several clients may share a room at different times. Using room number alone is insufficient to confirm identity and does not meet safety standards for patient identification.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale
A. Add yogurt to enteral feedings: While yogurt contains probiotics, adding it directly to enteral feedings can alter the formula’s consistency and increase the risk of tube clogging. It is not a standard intervention for diarrhea associated with enteral nutrition.
B. Change to an enteral formula that has added fiber: Formulas with added fiber are beneficial for managing chronic diarrhea or constipation, but switching formulas should be guided by the provider or dietitian rather than implemented independently.
C. Add water during tube flushes: Adding water helps maintain hydration and prevent tube clogging but does not directly address the underlying cause of diarrhea. While important for overall care, it is not the primary intervention to manage diarrhea.
D. Slow down the instillation flow rate: Rapid administration of enteral feedings can overwhelm the gastrointestinal system and contribute to diarrhea. Slowing the flow rate allows for better tolerance, reduces osmotic load, and often resolves diarrhea associated with high-volume or fast feedings.
Correct Answer is C
Explanation
Rationale
A. Lethargy: Lethargy is more commonly associated with hypercalcemia, which depresses the central nervous system. In hypocalcemia, neuromuscular excitability is increased, so clients are more likely to experience irritability or paresthesia rather than lethargy.
B. Constipation: Constipation is a manifestation of hypercalcemia due to decreased smooth muscle contractility. Hypocalcemia typically increases neuromuscular excitability and does not generally cause constipation.
C. Positive Chvostek's sign: A positive Chvostek's sign indicates facial muscle twitching in response to tapping over the facial nerve and is a hallmark sign of hypocalcemia. It reflects increased neuromuscular excitability due to low calcium levels and is commonly used in assessment.
D. Muscle flaccidity: Muscle flaccidity occurs with hypercalcemia or decreased neuromuscular activity. In hypocalcemia, muscles are more likely to exhibit tetany, spasms, or cramping due to heightened excitability, rather than flaccidity.
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