A nurse is preparing to administer oral medications to a client. According to the Joint Commission, which are acceptable client identifiers? (Select all that apply.)

Date of birth

Photograph identification

Facility room number

Client’s full name

Answer and Explanation

Correct Answer : A,D

Choice A Reason:

Date of birth is an acceptable client identifier. The Joint Commission specifies that using the date of birth helps ensure accurate identification of the client. This identifier is unique to each individual and is less likely to be duplicated.

Choice B Reason:

Photograph identification is not typically listed as an acceptable identifier by the Joint Commission. While it can be useful in some settings, it is not one of the primary identifiers recommended for ensuring patient safety.

Choice C Reason:

Facility room number is not an acceptable client identifier. The Joint Commission explicitly states that room numbers should not be used as identifiers because they can change and are not unique to the individual.

Choice D Reason:

Client’s full name is an acceptable client identifier. Using the full name helps to accurately identify the client and match them with their medical records and treatment plans.

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Correct Answer is C

Explanation

Choice A Reason:

“I will keep spare crutch tips handy.” This statement is correct and indicates good practice. Keeping spare crutch tips handy ensures that the client can replace worn or damaged tips promptly, maintaining the safety and effectiveness of the crutches.

Choice B Reason:

“I will inspect my crutches every day for signs of wear.” This statement is also correct. Regular inspection of crutches for signs of wear and tear helps prevent accidents and ensures that the crutches remain in good working condition.

Choice C Reason:

“I will bear the weight of my body on my axillas.” This statement is incorrect and indicates that the client needs additional education. Bearing weight on the axillas (armpits) can cause nerve damage and discomfort. The correct technique is to support the body’s weight with the hands and arms, not the axillas.

Choice D Reason:

“I will support most of the weight of my body with my arms.” This statement is correct. Supporting the body’s weight with the arms and hands is the proper technique for using crutches, as it prevents nerve damage and ensures better control and stability.

A. Thrombophlebitis B. Infiltration C. Infection D. Extravasation

Correct Answer is A

Explanation

Choice A reason: Thrombophlebitis is characterized by inflammation of the vein with the formation of a blood clot. The signs and symptoms include erythema, warmth, edema, and a red line traveling up the vessel, which indicates the presence of inflammation and possible clot formation. This condition requires prompt intervention to prevent further complications such as the spread of infection or the clot traveling to other parts of the body.

Choice B reason: Infiltration occurs when IV fluid or medication leaks into the surrounding tissue. Signs of infiltration include swelling, discomfort, and coolness at the IV site, but it does not typically present with erythema, warmth, or a red line traveling up the vessel. Infiltration is less likely to cause the systemic signs seen in this case.

Choice C reason: Infection at the IV site can cause erythema, warmth, and edema, but it usually does not present with a red line traveling up the vessel. The red line is more indicative of thrombophlebitis, where the inflammation follows the path of the vein. Infection would also likely present with additional systemic signs such as fever.

Choice D reason: Extravasation involves the leakage of vesicant drugs into the surrounding tissue, causing severe local tissue damage. Signs include pain, burning, and blistering at the site, but it does not typically present with a red line traveling up the vessel. Extravasation is more localized and does not follow the vein’s path like thrombophlebitis.

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A nurse is preparing to administer oral medications to a client. According to the Joint Commission, which are acceptable client identifiers? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting a client who has received crutches in an urgent care center following a foot injury. Which statement would the nurse identify as an indication that the client needs additional education?

Correct Answer is C

Explanation

A nurse is assessing a client’s peripheral IV during hourly rounding. The nurse notices the site has erythema, warmth, edema, and a red line traveling up the vessel. Which complication would the nurse identify this client has?

Correct Answer is A

Explanation

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