A nurse enters a client's room to perform a focused assessment. Which of the following client information should the nurse use to properly identify the client?
Telephone number
Diagnosis
Provider's name
Room number
The Correct Answer is A
Rationale
A. Telephone number: Using the client’s unique identifiers, such as name and date of birth, is standard practice, but if multiple identifiers are required, asking the client to confirm information like a telephone number helps ensure correct identification. Proper identification prevents errors in assessment, medication administration, and procedures.
B. Diagnosis: A client’s diagnosis does not uniquely identify them because multiple clients may share the same condition. Relying on diagnosis alone could lead to misidentification and errors in care.
C. Provider's name: The healthcare provider’s name is not a reliable client identifier. Multiple clients may be under the care of the same provider, so using this information cannot ensure the correct patient is being assessed.
D. Room number: Room numbers are temporary and can change; several clients may share a room at different times. Using room number alone is insufficient to confirm identity and does not meet safety standards for patient identification.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale
A. Poor skin turgor: Poor skin turgor is typically a sign of fluid volume deficit, not excess. In fluid overload, the skin may appear edematous or stretched rather than dehydrated. Assessing turgor helps differentiate between dehydration and overhydration.
B. Thready pulse: A thready, weak pulse is often associated with hypovolemia due to reduced circulating volume. In fluid volume excess, pulses are usually full and bounding because of increased intravascular pressure. Pulse quality provides insight into circulatory status.
C. Crackles in lung bases: Crackles heard in the lower lung fields indicate pulmonary fluid accumulation, a common finding in fluid volume excess. Excess intravascular fluid can leak into the alveoli, causing impaired gas exchange and respiratory symptoms. Auscultation of crackles helps identify pulmonary edema early.
D. Flat neck veins: Flat neck veins are associated with low central venous pressure, typically seen in dehydration or hypovolemia. In fluid overload, neck veins are often distended due to increased venous pressure. Jugular vein assessment is a key indicator of intravascular volume status.
Correct Answer is C
Explanation
Rationale
A. Educate the client about potential adverse effects: Education is important but is not the immediate priority. Ensuring the client’s physiological stability takes precedence over providing information after an overdose. Education can follow once the client’s condition is assessed.
B. Complete an incident report: Completing an incident report is necessary for documentation and quality improvement, but it does not address the client’s immediate safety. Reporting comes after assessing and stabilizing the client.
C. Obtain the client's vital signs: Assessing vital signs is the first action because it provides critical information about the client’s current physiological status. Monitoring for changes in blood pressure, heart rate, respiratory rate, and oxygen saturation helps identify early signs of adverse reactions and guides urgent interventions.
D. Notify the primary care provider: Notifying the provider is important to determine further medical management, but it should occur after assessing the client’s vital signs to provide accurate and current information about their condition. Immediate assessment ensures timely and appropriate provider guidance.
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