A nurse in a long-term care facility is preparing to administer medications to a client who has advanced dementia and does not have an identification band. Which of the following actions should the nurse take to verify the client's identity?
Ask the client to state their room number.
Have the client state their phone number.
Request an assistive personnel to identify the client.
Review the client's photograph in the medical record.
The Correct Answer is D
Choice A Reason:
Asking the client to state their room number is incorrect. A client with advanced dementia might not reliably remember or be able to state their room number, so this might not be a reliable method for identification.
Choice B Reason:
Having the client state their phone number is incorrect. Similar to the room number, relying on the client to state their phone number might not be feasible or reliable in cases of advanced dementia.
Choice C Reason:
Requesting an assistive personnel to identify the client is incorrect. While asking another staff member might seem practical, it might not ensure accurate identification, especially if the personnel is not directly involved in the client's care or isn't familiar enough with the client's identity due to frequent rotations or duties.
Choice D Reason:
Reviewing the client's photograph in the medical record is correct. Reviewing the client's photograph in the medical record is a reliable method to confirm the client's identity, especially in cases where the client might have difficulty providing other personal information due to advanced dementia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason:
Verifying the bilirubin level of the tube contents is incorrect. Measuring bilirubin levels in the tube contents is not a standard or reliable method for confirming tube placement. It's not an established or recommended technique for this purpose.
Choice B Reason:
Auscultating for air insufflation is incorrect. Auscultation for air insufflation involves injecting air into the tube and listening for bubbling sounds over the stomach area. While this method is commonly used, it can sometimes yield inconsistent or inconclusive results, especially in patients with certain conditions or situations where air movement might not be detectable.
Choice C Reason:
Request a chest x-ray is correct. Obtaining a chest x-ray is the most reliable method to confirm the placement of a feeding tube, especially when the tube is newly inserted or if there are any doubts about its location. A chest x-ray can accurately visualize the position of the tube within the gastrointestinal tract, ensuring it is in the intended location before any feedings or medications are administered.
Choice D Reason:
Checking the pH level of gastric contents is incorrect. Measuring the pH level of aspirated gastric contents can provide information about the acidity of the fluid, indicating gastric placement (pH below 5) in most cases. However, the pH can be influenced by various factors like medications, enteral feeding solutions, or certain medical conditions, making it less reliable than a chest x-ray for definitive confirmation of tube placement.
Correct Answer is C
Explanation
Choice A Reason:
"I can't change my mind about the care I will receive once I sign my living will." Is incorrect.
This statement suggests a misconception that signing a living will locks in a permanent decision, whereas advance directives can usually be updated or modified as long as the individual is competent to do so.
Choice B Reason:
"If I want life support, I'll need to sign a separate consent form first." Is incorrect. While the concept of a consent form for specific treatments is relevant, it might not fully reflect the broader scope of advance directives, which encompass a range of healthcare preferences beyond just life support.
Choice C Reason:
"I'm glad to have the opportunity to choose what kind of care I receive while I still can." Is correct. This statement reflects the understanding that advance directives offer the opportunity to make decisions about the type of care the client wishes to receive or avoid, empowering them to express their preferences while they are still able to do so.
Choice D Reason:
"Once I fill out my living will, there will be a 1-month delay before it is legally binding." Is incorrect. There isn't typically a standardized waiting period before an advance directive becomes legally binding. The legal validity and activation of advance directives vary by region, but they usually become effective immediately upon completion unless stated otherwise or specific requirements apply.
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