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?
Room number
Telephone number
Patient’s name
Diagnosis
The Correct Answer is C
A. Using the room number to identify a patient is not reliable since many clients may share it.
B. The telephone number is not typically used for client identification during assessments.
C. The nurse should use the client's name to properly identify the client before performing any assessment or intervention. This is a standard safety measure that helps to prevent errors and ensure quality care.
D. The diagnosis is important for providing appropriate care but is not used for client identification during assessments.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","E","F"]
Explanation
A. The nurse asks the client when was the last time they ate or drank anything, and verifies that they are fasting according to the preoperative instructions. Dietary intake is important because the client should have an empty stomach to prevent aspiration during anesthesia.
B. The oxygen saturation remains at 96% on room air, which is within the normal range. No immediate follow-up is needed based on this parameter.
C. The client's pain level has increased from 6 to 8 on a scale of 0 to 10. This increase in pain intensity requires further assessment and intervention to ensure adequate pain management before surgery.
D. The client's blood pressure remains relatively stable within normal limits.
However, the increase in pain intensity may impact blood pressure, and it's essential to monitor for any significant changes.
E. The allergies are important to identify because the client is allergic to shellfish, latex, and penicillin, which could cause anaphylaxis or other adverse reactions during surgery or anesthesia. The nurse should ensure that the client is wearing an allergy bracelet and that the surgical team is aware of the allergies.
F. The informed consent is essential to obtain before any invasive procedure. The nurse should verify that the client understands the risks, benefits, and alternatives of the surgery and that the consent form is signed and witnessed.
Correct Answer is D
Explanation
A. This action may increase the risk of injury to both the nurse and the client.
B. This action does not effectively prevent the fall or minimize injury.
C. Moving quickly to a position in front of the client can cause imbalance and increase the risk for falling.
D. Allowing the client to slide down their outstretched leg can help prevent injury to both the client and the nurse.
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