A nurse is preparing to identify a client prior to medication administration.
Which of the following questions should the nurse ask to determine the client's identity?
"What is your home phone number?”
"Can you tell me your room number?”
"Is your name Sarah Jones?”
"Are you 65 years of age?”
The Correct Answer is C
Choice A rationale:
Asking for a home phone number is not an effective method for identifying a patient. Phone numbers can be easily forgotten or mixed up, especially in a hospital setting where a patient may be under stress or experiencing health issues.
Choice B rationale:
Room numbers can change if the patient is moved, and other patients may have previously occupied the same room. Therefore, room numbers are not reliable identifiers.
Choice C rationale:
Asking the patient to confirm their own name is one of the most direct and reliable ways to verify their identity. This method respects patient autonomy and privacy while ensuring accurate identification.
Choice D rationale:
Age alone is not a reliable identifier because it does not distinguish between different patients of the same age.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Hanging the antibiotic medication bag above the level of the primary infusion is an important step in administering an antibiotic via intermittent IV bolus. However, it is not the first step. The medication bag is usually hung higher to allow the antibiotic to infuse by gravity once it’s connected.
Choice B rationale:
Wiping the connection port of the primary IV tubing with an antiseptic swab is a crucial step in preventing infection. However, this is typically done just before connecting the secondary line, not as the first step.
Choice C rationale:
Checking the IV site for signs of infiltration is indeed the first step. It’s important to ensure that the IV catheter is still properly placed in the vein and that there are no signs of infection or infiltration, which could cause complications.
Choice D rationale:
Connecting the tubing of the medication bag to the primary tubing is done after cleaning the port and before hanging the bag. It’s not the first step.
Correct Answer is D
Explanation
Choice A rationale:
A Positive Chvostek’s sign is a clinical finding associated with hypocalcemia, or low levels of calcium in the blood. It’s not directly related to glyburide usage or symptoms of anxiety and profuse sweating.
Choice B rationale:
Pitting pedal edema occurs when excess fluid builds up in the body, causing swelling. It’s not directly related to glyburide usage or symptoms of anxiety and profuse sweating.
Choice C rationale:
Decreased deep-tendon reflexes or hyporeflexia happens when your skeletal muscles have a decreased or absent reflex response. It’s not directly related to glyburide usage or symptoms of anxiety and profuse sweating.
Choice D rationale:
Decreased blood glucose level or hypoglycemia occurs when your blood sugar (glucose) level falls too low. Glyburide is an oral diabetes medicine that helps control blood sugar levels. Anxiety and profuse sweating are symptoms of low blood sugar.
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