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A nurse in an acute care setting is preparing to administer medications to a client. Which of the following information should the nurse obtain to identify the client?

Room number of the client

Client's telephone number

Client's full medical diagnosis

Name of the client

Answer and Explanation

The Correct Answer is D

A. Room number of the client:

The room number alone is not sufficient for accurate client identification. Room numbers may change, and multiple clients may share the same room. Relying on the room number alone can lead to errors.

B. Client's telephone number:

The client's telephone number is not typically used as a primary identifier for medication administration. It may be part of the client's record, but it is not the primary means of confirming identity before administering medications.

C. Client's full medical diagnosis:

While the client's medical diagnosis is important for understanding their overall health condition, it is not a primary identifier for medication administration. Diagnoses can be complex and may not be unique to a single individual within a healthcare setting.

D. Name of the client:

Matching the client's name with their identification band or other official records is a crucial step in preventing medication errors and ensuring the right medication is given to the right person.

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Correct Answer is C

Explanation

An incident report is a formal document used to report any unexpected or adverse events that occur during patient care. In this case, the administration of an incorrect dosage is an incident that should be documented in the incident report. The incident report serves as a record of the event and helps to ensure that appropriate follow-up actions are taken to prevent similar incidents in the future. It is important to note that an incident report is not part of the client's permanent medical record and is kept separate from other documentation.

The provider's progress notes, nursing care plan, and controlled substance inventory record are not appropriate locations to document this specific incident. The provider's progress notes are typically used to document the client's medical history, examination findings, treatment plans, and progress. The nursing care plan is a document that outlines the client's nursing diagnoses, goals, and interventions. The controlled substance inventory record is used to track and document the dispensing and administration of controlled substances, but it does not typically include incident reporting.

A. Monitor the client's range of motion every 60 min. B. Ensure that the provider has signed a prescription for restraints within 48 hr. C. Plan to remove the restraints as soon as the client is calm. D. Offer the client a nutritious snack every 4 hr.

Correct Answer is C

Explanation

A.While monitoring the client's physical condition, including range of motion, is important, it typically needs to be done more frequently than every 60 minutes. The Joint Commission and other regulatory bodies often recommend continuous observation and checks every 15 minutes.

B.Typically, a provider's order for restraints must be obtained immediately or within a very short time frame (often within an hour), not 48 hours. Regulations vary but generally require prompt notification and authorization.

C.Restraints should only be used as a last resort and for the shortest duration possible. The goal is to ensure the client's safety and the safety of others while minimizing the use of restraints. Removing the restraints as soon as the client is calm and no longer a threat to themselves or others is essential to respecting the client's rights and promoting their dignity.

D.Offer the client a nutritious snack every 4 hr.: While providing nutrition and hydration is important, the primary focus immediately after applying restraints should be on the client's safety and the frequent assessment of their condition. Offering a snack every 4 hours is not the immediate priority in this context.

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A nurse in an acute care setting is preparing to administer medications to a client. Which of the following information should the nurse obtain to identify the client?

Nursing Test Bank

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Correct Answer is C

Explanation

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