A nurse working in a rehabilitation unit is administering medications to two clients who have the same name. Which of the following identifiers should the nurse use to verify the identities of each client?

The telephone numbers of the clients

The room numbers of the clients

The diagnoses of the clients

The names of the clients' nearest relatives

Answer and Explanation

The Correct Answer is A

A. Using the telephone numbers of the clients is correct. According to The Joint Commission's National Patient Safety Goals, at least two unique identifiers, such as date of birth and telephone number, should be used to verify client identity before administering medications to prevent errors.

B. Using the room numbers of the clients is incorrect. Room numbers can change, and relying on them increases the risk of medication errors if a client is moved or misidentified.

C. Using the diagnoses of the clients is incorrect. A diagnosis is not a unique identifier, as multiple clients in a unit may have the same or similar conditions, leading to potential confusion.

D. Using the names of the clients' nearest relatives is incorrect. Family members’ names do not provide a direct, unique way to verify the client’s identity, making them unreliable for medication administration.

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Correct Answer is A

Explanation

A. "A client who has a sodium level of 140 mEq/L after one episode of diarrhea." This is the correct choice. A sodium level of 140 mEq/L is within the normal range, and the client has had only one episode of diarrhea, suggesting that they are stable and could be safely discharged.

B. "A client who is 3 days postoperative following a hip arthroplasty and has a warm, red area on his left calf." This is a concern. The warm, red area on the calf could indicate the presence of a deep vein thrombosis (DVT) or infection, both of which require further evaluation and management.

C. "A client who has atrial fibrillation and an INR of 4." This is concerning. An INR of 4 indicates an increased risk of bleeding, which requires closer monitoring and potentially adjusting the anticoagulation therapy before discharge.

D. "A client who reports chest pain after ambulating." This is an urgent issue that needs immediate attention. Chest pain could indicate a serious cardiac event, such as a myocardial infarction, and the client should not be discharged until further evaluation is performed.

A. Give a dose of alendronate. B. Administer furosemide. C. Apply a cardiac monitor. D. Monitor for Chvostek's sign.

Correct Answer is C

Explanation

A. Give a dose of alendronate is incorrect. Alendronate is a medication used to treat osteoporosis, and it does not address low potassium levels. In this case, the focus should be on correcting the potassium imbalance.

B. Administer furosemide is incorrect. Furosemide is a diuretic that can cause further loss of potassium. In a client with low potassium levels (hypokalemia., administering furosemide could worsen the condition and lead to life-threatening complications.

C. Apply a cardiac monitor is correct. Hypokalemia (potassium level of 2.9 mEq/L) can cause significant cardiac arrhythmias, including ventricular tachycardia or fibrillation. Applying a cardiac monitor is essential for monitoring the client’s heart rhythm and detecting any abnormalities related to the low potassium level.

D. Monitor for Chvostek's sign is incorrect. Chvostek's sign is indicative of hypocalcemia, not hypokalemia. While both hypocalcemia and hypokalemia can cause neuromuscular excitability, monitoring for Chvostek’s sign is not a priority in the management of hypokalemia.

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A nurse working in a rehabilitation unit is administering medications to two clients who have the same name. Which of the following identifiers should the nurse use to verify the identities of each client?

Nursing Test Bank

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