A nurse in a long-term care facility is preparing to administer medications to a client who has advanced dementia and does not have an identification band. Which of the following actions should the nurse take to verify the client's identity?
Ask the client to state their room number.
Have the client state their phone number.
Request an assistive personnel to identify the client.
Review the client's photograph in the medical record.
The Correct Answer is D
Choice A Reason:
Asking the client to state their room number is incorrect. A client with advanced dementia might not reliably remember or be able to state their room number, so this might not be a reliable method for identification.
Choice B Reason:
Having the client state their phone number is incorrect. Similar to the room number, relying on the client to state their phone number might not be feasible or reliable in cases of advanced dementia.
Choice C Reason:
Requesting an assistive personnel to identify the client is incorrect. While asking another staff member might seem practical, it might not ensure accurate identification, especially if the personnel is not directly involved in the client's care or isn't familiar enough with the client's identity due to frequent rotations or duties.
Choice D Reason:
Reviewing the client's photograph in the medical record is correct. Reviewing the client's photograph in the medical record is a reliable method to confirm the client's identity, especially in cases where the client might have difficulty providing other personal information due to advanced dementia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason:
"I will rinse the contaminants from a bedpan with hot water." Is incorrect. Rinsing contaminants with hot water might not be sufficient for proper disinfection and could potentially contribute to the spread of infection. Proper disinfection methods involve using appropriate cleaning agents or disinfectants.
Choice B Reason:
"I will double-bag a client's linens each day." Is incorrect. While containing soiled linens is important, double-bagging might not necessarily be a standard practice for managing linens unless there's a specific protocol or contamination issue. It might not be directly related to infection control principles.
Choice C Reason:
"I will wear sterile gloves when bathing a client who is incontinent." Is incorrect. Wearing sterile gloves for routine bathing of an incontinent client is not typically necessary. Using clean gloves or standard precautions would generally be appropriate unless there's a specific medical procedure requiring sterile technique.
Choice D Reason:
"I will use disinfectant to clean the blood pressure cuff after use on a client." Is correct. Using a disinfectant to clean equipment, especially after use on a client, is a key infec
Correct Answer is B
Explanation
Choice A Reason:
The stoma bleeds lightly when touched is incorrect. Some minor bleeding during the initial postoperative period is expected due to surgical trauma. Light bleeding when touched might not be unusual in the immediate days following colostomy placement.
Choice B Reason:
The stoma appears dark in color is correct. A dark-colored stoma could indicate compromised blood supply or ischemia, which is a concerning finding postoperatively. It's crucial to report this change in color promptly to the provider for further evaluation and intervention.
Choice CReason:
The stoma is draining a small amount of liquid stool is incorrect. In the early postoperative period, drainage of liquid stool from the stoma is normal. The digestive system needs time to adapt to the new anatomy created by the colostomy, and initially, the stool consistency might be liquid before it starts to normalize.
Choice DReason:
The stoma protrudes slightly from the abdomen is incorrect. A slightly protruding stoma is a common and expected finding after colostomy surgery. It's often a normal part of the healing process as the stoma settles and adjusts.
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