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 D
Explanation
Choice A rationale:
A negative mammogram is not a requirement of the iPLEDGE program. Mammograms are used to screen for breast cancer and are not related to isotretinoin therapy.
Choice B rationale:
Regular Papanicolaou tests, which screen for cervical cancer, are not a requirement of the iPLEDGE program. These tests are not related to isotretinoin therapy.
Choice C rationale:
There is no requirement for clients to begin a daily supplement of vitamin A prior to initiating therapy. In fact, taking additional vitamin A while on isotretinoin can increase the risk of vitamin A toxicity.
Choice D rationale:
Sexually active female clients must use two forms of birth control during treatment. This is because isotretinoin can cause severe birth defects.
Correct Answer is A
Explanation
Choice A rationale:
An apical pulse of 54/min is below the normal range for adults. Digoxin, a cardiac medication, can lower the heart rate. Therefore, it’s crucial to hold the medication if the resting pulse for an adult is less than 60 bpm. This is to prevent further lowering of the heart rate which could lead to bradycardia, a potentially dangerous condition.
Choice B rationale:
A respiratory rate of 14/min is within the normal adult range of 12-20 breaths per minute. This would not be a reason to withhold digoxin.
Choice C rationale:
A blood pressure (BP) of 179/89 mm Hg indicates hypertension, which is not a direct contraindication for digoxin. However, it’s important to monitor BP levels in clients taking digoxin as the medication can affect blood pressure.
Choice D rationale:
A temperature of 37.8° C (100° F) is slightly elevated but would not be a reason to withhold digoxin unless it’s indicative of an underlying infection that needs to be addressed first.
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