A nurse is preparing to identify a client prior to medication administration.
Which of the following questions should the nurse ask to determine the client's identity?

"What is your home phone number?”

"Can you tell me your room number?”

"Is your name Sarah Jones?”

"Are you 65 years of age?”

Answer and Explanation

The Correct Answer is C

Choice A rationale:

Asking for a home phone number is not an effective method for identifying a patient. Phone numbers can be easily forgotten or mixed up, especially in a hospital setting where a patient may be under stress or experiencing health issues.

Choice B rationale:

Room numbers can change if the patient is moved, and other patients may have previously occupied the same room. Therefore, room numbers are not reliable identifiers.

Choice C rationale:

Asking the patient to confirm their own name is one of the most direct and reliable ways to verify their identity. This method respects patient autonomy and privacy while ensuring accurate identification.

Choice D rationale:

Age alone is not a reliable identifier because it does not distinguish between different patients of the same age.

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Correct Answer is A

Explanation

Choice A rationale:

A respiratory rate of 10/min is lower than the normal range (12-20 breaths per minute for adults), indicating respiratory depression, which is a serious side effect of morphine and should be reported immediately.

Choice B rationale:

Facial flushing is a common side effect of morphine due to histamine release but it’s not life-threatening.

Choice C rationale:

Constipation is a common side effect of morphine and can be managed with laxatives and diet.

Choice D rationale:

Blood pressure 88/56 mm Hg is lower than the normal range (90/60mmHg to 120/80mmHg), indicating hypotension, which can be a side effect of morphine but it’s not as immediately life-threatening as respiratory depression.

A. Aspirate prior to injecting the medication. B. Gently massage the site following the injection. C. Expel the air bubble before injecting the medication. D. Inject the medication into abdominal tissue.

Correct Answer is D

Explanation

Choice Arationale:

Aspiration (pulling back on the syringe before injection) is not recommended when administering enoxaparin. This could cause bruising.

Choice Brationale:

You should not massage the site following the injection as this could cause bruising.

Choice Crationale:

With enoxaparin and other low molecular weight heparins, you do not need to expel the air bubble before injecting the medication. The air bubble ensures that all the medication is delivered.

Choice D rationale:

Enoxaparin should be injected into abdominal tissue. This helps ensure proper absorption and reduces the risk of bruising.

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A nurse is preparing to identify a client prior to medication administration. Which of the following questions should the nurse ask to determine the client's identity?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting in the care of a client who is receiving morphine via a continuous epidural infusion.Which of the following findings should the nurse report to the provider immediately?

Correct Answer is A

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Correct Answer is D

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A nurse is preparing to identify a client prior to medication administration.
Which of the following questions should the nurse ask to determine the client's identity?