A nurse is about to administer a medication and realizes the client is unable to verbalize their identifiers due to confusion. What is the correct action for the nurse to take?
Skip the identity verification step to avoid delaying medication administration.
Ask a colleague who is familiar with the client to confirm their identity.
Verify the client's identity using the MAR and the client's identification band.
Proceed with the administration as the nurse knows the client well.
The Correct Answer is C
A. Skip the identity verification step to avoid delaying medication administration: Omitting verification increases the risk of medication errors and patient harm. All clients, regardless of cognitive status, require proper identification before medications are administered.
B. Ask a colleague who is familiar with the client to confirm their identity: Colleague verification is not a reliable substitute for objective identifiers such as the ID band. Medication safety relies on standardized verification methods rather than personal familiarity.
C. Verify the client's identity using the MAR and the client's identification band: When a client cannot communicate, checking the identification band against the MAR ensures correct identity. This approach maintains patient safety and adheres to legal and professional standards for medication administration.
D. Proceed with the administration as the nurse knows the client well: Familiarity does not replace formal identification procedures. Administering medication without verification risks errors and violates safe medication administration protocols.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Subcutaneous: Subcutaneous injections deliver medication into the fatty tissue beneath the skin. This route is used for vaccines like MMR or insulin in some cases but is not appropriate for TB skin testing, as it does not produce the localized reaction needed for accurate reading.
B. Intradermal: The TB (Mantoux) test is administered intradermally, just beneath the epidermis, to elicit a localized immune response. Proper placement allows formation of a raised wheal, which can be measured 48–72 hours later to determine exposure to Mycobacterium tuberculosis.
C. Enteral: Enteral routes involve the gastrointestinal tract, such as oral or via feeding tube. This route is not suitable for TB testing, as the immune response must occur locally in the skin for accurate interpretation.
D. Intramuscular (IM): IM injections deliver medication into muscle tissue, providing systemic absorption for vaccines or medications. This route is not used for TB testing because it would not create a localized dermal reaction necessary for evaluation.
Correct Answer is A
Explanation
Calculation:
- Identify the doses of each insulin
Regular insulin: 14 units
NPH insulin: 28 units
- Calculate the total units to prepare
Total Units = Regular insulin + NPH insulin
Total Units = 14 + 28
= 42 units
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