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
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. New onset of hearing loss: Hearing loss is not a typical adverse effect of 0.9% sodium chloride infusion. It may occur with high-dose loop diuretics like furosemide but is unrelated to isotonic fluid administration or hyperparathyroidism management.
B. Kussmaul respirations: These are deep, rapid respirations seen in metabolic acidosis, particularly diabetic ketoacidosis. They are not associated with isotonic fluid infusion or calcium disturbances in hyperparathyroidism.
C. Hyperthermia: Elevated body temperature is not linked to 0.9% sodium chloride infusion. Hyperthermia may occur with infections or neurologic injury, but not as a direct consequence of isotonic fluid therapy.
D. Chvostek's sign: Chvostek's sign is a clinical indicator of hypocalcemia, which can occur as an adverse effect of 0.9% sodium chloride infusion in clients with hyperparathyroidism. Large volumes of saline increase calcium excretion, potentially leading to low serum calcium levels.
Correct Answer is B
Explanation
Rationale:
A. Administer haloperidol via the intramuscular route: Medication may be necessary for agitation, but administering it before assessing the client’s emotional state and safety is premature and could escalate distress.
B. Collect data regarding the client’s feelings: Assessing the client’s emotional state and reasons for pacing and clenched fists helps identify triggers, enabling the nurse to choose the least restrictive intervention and promote de-escalation.
C. Obtain assistance to apply wrist restraints: Restraints are a last resort to ensure safety and should only be used after less restrictive interventions have failed and when the client poses an immediate risk to self or others.
D. Move the client into the seclusion room: Seclusion is also a restrictive intervention requiring assessment of necessity. Moving the client without first gathering data and attempting de-escalation may violate client rights and worsen agitation.
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