A nurse is planning to administer medications to a client. Which of the following information should the nurse use to identify the client? (Select all that apply.)
Telephone number
Diagnosis
Date of birth
Room number
Identification bracelet
Correct Answer : A,C,E
A. Telephone number: A telephone number is a valid and unique personal identifier according to Joint Commission standards.
B. Diagnosis: Multiple clients may have the same diagnosis (e.g., "Pneumonia").
C. Date of birth: This is a standard, universally accepted unique identifier.
D. Room number: Room numbers are not person-specific and can change frequently.
E. Identification bracelet: The ID band contains the client's name and a unique medical record number, making it a primary source for verification.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D","E"]
Explanation
A. Allergies: The client is allergic to latex and penicillin. Since surgery involves the use of gloves, tubing, and catheters (latex) and often includes prophylactic antibiotics (penicillin family), these allergies must be communicated and a "latex-free" environment/alternative antibiotics must be established to prevent anaphylaxis.
B. Oxygen saturation: The client's oxygen saturation is 96%, which is within the normal expected range (95% to 100%). This does not require immediate follow-up prior to the procedure.
C. Pain level: While the pain is high (8/10), this is an expected finding for acute appendicitis. It should be managed, but it is not a barrier to surgery in the same way as safety or legal concerns.
D. Dietary intake: The client reported eating toast at 0600. Surgery requires a client to be NPO (nothing by mouth) for a specific period (usually 6–8 hours) to reduce the risk of aspiration under anesthesia. The surgical team and anesthesiologist must be notified of the 0600 intake.
E. Informed consent: Although the surgeon obtained consent, the nurse notes that the client "expresses concerns about potential complications." If a client expresses doubt or a lack of understanding after signing, the nurse must notify the surgeon to return and provide further clarification before the procedure begins.
F. Blood pressure: The client's blood pressure is stable (124/80 mm Hg) and within normal limits; it does not require follow-up.
Correct Answer is D
Explanation
A. Overweight: This classification applies to a BMI of 25.0 to 29.9.
B. Normal weight: This classification applies to a BMI of 18.5 to 24.9.
C. Underweight: This classification applies to a BMI of less than 18.5.
D. Obesity class I: The World Health Organization defines Obesity Class I as a BMI of 30.0 to 34.9. A BMI of 32 falls directly into this category.
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