A nurse is preparing to administer an antibiotic to a client who has pneumonia. After confirming that the client's assigned identification number matches the medication administration record, the nurse should use which of the following as a second identifier?

Home telephone number

Medical diagnosis

Date of admission

Facility room number

Answer and Explanation

The Correct Answer is A

Rationale:

A. Home telephone number: A home telephone number is an acceptable second client identifier under The Joint Commission's guidelines, as it is specific to the individual and can help prevent medication errors when used alongside another unique identifier.

B. Medical diagnosis: A medical diagnosis is not a unique identifier and may be shared by multiple clients in the same facility. It does not provide adequate confirmation of a client's individual identity.

C. Date of admission: Admission dates are not unique and may be the same for several clients. This information is insufficient as a reliable identifier for ensuring safe medication administration.

D. Facility room number: Room numbers can change during hospitalization and are not considered safe identifiers. Clients may be transferred, making room number an unreliable and non-permanent method of identification.

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Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}

Explanation

Rationale:

• Contact the provider for an antibiotic prescription: Contacting the provider ensures the client receives prompt intervention for a likely surgical site infection. The wound is inflamed and draining yellow pus, and the client has a fever and leukocytosis. Early treatment can prevent the progression to severe sepsis.

• Increase the volume on the television: Increasing the volume on the television can heighten sensory overload and worsen the client’s confusion. Delirium management involves reducing noise and visual stimuli, not adding to it. This approach does not promote orientation or calmness.

• Ask the client's partner to leave the room: Asking the client's partner to leave may remove a critical source of comfort and familiarity. Familiar people help reorient clients with delirium or confusion. Their presence often reduces agitation and promotes emotional security.

• Dim the lights: Dimming the lights reduces environmental overstimulation that may worsen delirium. The client is experiencing hallucinations and disorientation, which are often intensified in bright ICU settings. A calm setting supports cognitive clarity and comfort.

• Assist with elimination: Assisting with elimination is appropriate if the client shows signs of distress or discomfort. However, this need is not emergent compared to infection and altered mental status. Treating the underlying cause of delirium should take precedence.

• Place the client in 4-point restraints: Placing the client in 4-point restraints is a last resort when other safety measures fail. Restraints can escalate agitation and lead to injury or trauma. Delirium should be managed first with environmental and medical interventions.

A. "Go to bed at least 2 hours earlier than usual. B. "Have a snack before bedtime." C. "Drink a cup of chamomile tea at bedtime." D. "Take regular rest periods during the day."

Correct Answer is D

Explanation

Rationale:

A. "Go to bed at least 2 hours earlier than usual.": Going to bed earlier may increase total sleep time, but it does not directly address the cause of nighttime awakening—frequent urination. Earlier bedtime alone is unlikely to improve the client’s quality of sleep.

B. "Have a snack before bedtime.": A bedtime snack may help prevent nausea or maintain blood sugar levels but does not reduce nighttime urinary frequency. In some cases, it might lead to increased fluid intake, potentially worsening nocturia.

C. "Drink a cup of chamomile tea at bedtime.": While chamomile may promote relaxation, it is also a fluid, which can increase bladder activity during the night. Encouraging tea before bed may worsen the client's urinary frequency and sleep disruption.

D. "Take regular rest periods during the day.": Taking rest periods throughout the day can help reduce overall fatigue and minimize sleep disruption caused by nocturia. Resting during the day compensates for nighttime interruptions and supports maternal well-being in early pregnancy.

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A nurse is preparing to administer an antibiotic to a client who has pneumonia. After confirming that the client's assigned identification number matches the medication administration record, the nurse should use which of the following as a second identifier?

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Naxlex Comprehensive Predictor Exams

The nurse is reviewing the nurses' notes, admission assessment, vital signs, and laboratory data. Exhibits Complete the following sentence by using the list of options. The nurse should first plan to dropdown and then dropdown.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}

Explanation

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Correct Answer is D

Explanation

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