Before administering a medication to a client, the nurse must identify the client. Which of the following methods of identification should the nurse use?

Ask the client's full name and date of birth.

Ask a family member to verify the client's identity.

Verify the client's room number.

Check the client's name on the medication administration record (MAR).

Answer and Explanation

The Correct Answer is A

A.   This is the correct method for identifying the client before administering medication.
Asking for the client's full name and date of birth is a standard and effective way to ensure that the right medication is given to the right person.
B.   Depending solely on a family member to verify the client's identity is not considered a reliable method. While involving family members can be helpful in certain situations, the primary responsibility lies with the nurse to directly confirm the client's identity.
C.   Verifying the client's room number is not a sufficient method of client identification.
Room numbers can change, and it's possible for clients to be moved, so relying on this alone is not considered safe practice.
D.   Checking the client's name on the medication administration record (MAR) is an important step in medication administration, but it is not the initial method of identifying the client. It's used to confirm that the right medication is being administered to the right person after the client's identity has been established through direct interaction and confirmation.

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Correct Answer is A

Explanation

A. Observing the client's respiratory status is the priority action because a decreased level of consciousness can potentially lead to compromised airway and respiratory function. It's crucial to monitor for signs of respiratory distress or compromise, such as changes in respiratory rate, depth, and effort.
B. Monitoring intake and output every 8 hr is an important nursing responsibility, but it is not the top priority when the client's respiratory status is in question.
C. Elevating the head of the client's bed 30° to 45° is a standard practice to prevent aspiration and promote optimal digestion during enteral feedings. While important, it is not the immediate priority in this situation.
D. Checking residual volume every 4 to 6 hr is a part of enteral feeding management, but it is not the priority when the client's respiratory status is a concern.

A. Elevate the bed to a position of comfort for the nurse. B. Acquire the help of several people to lift the client. C. Place the wheelchair at a 90° angle to the bed. D. Lock the wheels of the bed and the wheelchair.

Correct Answer is D

Explanation

A. Elevating the bed for the comfort of the nurse does not address the safety and comfort of the client during the transfer.
B. While it's important to have assistance if needed, using several people to lift the client may not always be necessary or appropriate.
C. This positioningis not optimal, as it makes it harder for the client to pivot and sit on the wheelchair.
D. Ensuring the wheels of both the bed and the wheelchair are locked helps maintain stability and safety during the transfer process, reducing the risk of accidental movement and potential falls.

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Before administering a medication to a client, the nurse must identify the client. Which of the following methods of identification should the nurse use?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who has a decreased level of consciousness. The client is receiving continuous enteral feedings via a gastrostomy tube due to an inability to swallow. Which of the following is the priority action by the nurse?

Correct Answer is A

Explanation

A nurse is assisting with transferring a client from the bed to a wheelchair. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is planning care for a client who has a decreased level of consciousness. The client is receiving continuous enteral feedings via a gastrostomy tube due to an inability to swallow. Which of the following is the priority action by the nurse?

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A nurse is caring for a client who receives intermittent enteral feedings through an NG tube. Before administering a feeding, the nurse should measure the gastric residual for which of the following purposes?

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