A nurse is preparing to administer medication to a client.
Which of the following identifiers should the nurse use to identify the client?
Place of birth.
Room number.
Driver license number.
Telephone number.
The Correct Answer is D
Choice D rationale
The telephone number is considered a reliable client identifier because it is unique to the individual and typically part of their personal health record. Using multiple identifiers, such as the telephone number in conjunction with the client's name and date of birth, is a critical safety measure to prevent medication errors and ensure the right medication is administered to the right client. This process, known as the "two-identifier rule," is a cornerstone of client safety protocols and aligns with guidelines from organizations like The Joint Commission
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Increased head circumference is an unexpected finding in a newborn exposed to cocaine in utero. Cocaine is a potent vasoconstrictor, which reduces blood flow and oxygen to the developing fetus, potentially leading to intrauterine growth restriction, which would more likely result in a smaller head circumference, not a larger one. This is due to compromised fetal oxygenation and nutrient delivery.
Choice B rationale
Hypotonicity, or decreased muscle tone, is not a typical finding. Neonates exposed to cocaine in utero often exhibit hypertonicity and a rigid posture due to central nervous system excitability. This increased muscle tone is a common neurological manifestation resulting from the drug's stimulatory effects on the developing nervous system, leading to hyperirritability and tremors.
Choice C rationale
Irritability is a very common finding in a newborn exposed to cocaine throughout pregnancy. Cocaine is a potent central nervous system stimulant, and its effects on the developing fetal brain can lead to long-term neurological and behavioral issues. After birth, the neonate experiences withdrawal symptoms, resulting in excessive crying, high-pitched cries, tremors, and a state of hypervigilance.
Choice D rationale
A decreased auditory startle response is not an expected finding. Newborns exposed to cocaine often exhibit an increased and exaggerated startle response to various stimuli, including auditory cues. This hyperresponsiveness is a manifestation of the generalized central nervous system excitability caused by the chronic prenatal exposure to the potent sympathomimetic effects of cocaine on the brain. *.
Correct Answer is B
Explanation
Choice A rationale
Visual disturbances are a less common side effect of risperidone and are not typically considered a priority finding. While they can be a nuisance for the client, they do not pose an immediate threat to the client's life. Other side effects require more immediate attention and intervention from the healthcare provider.
Choice B rationale
Risperidone can cause cardiac side effects such as QT prolongation, which can lead to life-threatening arrhythmias like Torsades de pointes. An irregular pulse is a critical finding that could indicate an underlying cardiac issue and requires immediate evaluation. This is a priority finding for the nurse to report to the provider.
Choice C rationale
Constipation is a common side effect of risperidone due to its anticholinergic properties. While it can cause discomfort, it is not an immediate life-threatening condition. The nurse should address this by encouraging fluid and fiber intake and possibly discussing a stool softener with the provider, but it is not the highest priority.
Choice D rationale
Dry mouth is a common and relatively benign side effect of risperidone. While it can cause discomfort and increase the risk of dental caries, it is not an urgent or life-threatening condition. The nurse can advise the client on strategies to manage this symptom, such as using sugar-free candies or chewing gum. *.
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