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?”
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
An apical pulse of 54/min is below the normal range for adults. Digoxin, a cardiac medication, can lower the heart rate. Therefore, it’s crucial to hold the medication if the resting pulse for an adult is less than 60 bpm. This is to prevent further lowering of the heart rate which could lead to bradycardia, a potentially dangerous condition.
Choice B rationale:
A respiratory rate of 14/min is within the normal adult range of 12-20 breaths per minute. This would not be a reason to withhold digoxin.
Choice C rationale:
A blood pressure (BP) of 179/89 mm Hg indicates hypertension, which is not a direct contraindication for digoxin. However, it’s important to monitor BP levels in clients taking digoxin as the medication can affect blood pressure.
Choice D rationale:
A temperature of 37.8° C (100° F) is slightly elevated but would not be a reason to withhold digoxin unless it’s indicative of an underlying infection that needs to be addressed first.
Correct Answer is A
Explanation
Choice A rationale:
Dissolving the medication in 30 mL of water is the correct action. This ensures that the medication is in a suitable form for administration via an NG tube and helps prevent the tube from becoming blocked.
Choice B rationale:
Maintaining the client in the supine position during medication administration is not recommended. This position increases the risk of aspiration. Instead, the client should be in an upright position during medication administration and for at least 30 minutes afterward.
Choice C rationale:
Adding the medication to the enteral feeding formula is not recommended. This can alter the effectiveness of the medication and can also clog the feeding tube.
Choice D rationale:
Flushing the tube with 5 mL of water after administering the medication is not enough. The tube should be flushed with at least 15-30 mL of water before and after medication administration to ensure that the entire dose has been administered and to prevent clogging of the tube.
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