Before administering a medication to a client, the nurse must identify the client. Which of the following methods of identification should the nurse use?
Verify the client's room number.
Check the client's name on the medication administration record (MAR).
Ask the client's full name and date of birth.
Ask a family member to verify the client's identity.
The Correct Answer is C
A. Verifying the client's room number is not a reliable method of identification, as multiple clients can be in the same room or the client may have been moved.
B. Checking the client's name on the MAR is a good practice but should be combined with a direct method of identification for accuracy.
C. Asking the client for their full name and date of birth is the standard practice for confirming identity before administering medications, ensuring that the nurse is addressing the correct individual.
D. Asking a family member to verify the client's identity is not appropriate, as the nurse must confirm the client's identity personally to maintain safety and accountability.
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Correct Answer is C
Explanation
A. Knowing the client's height can be helpful for ergonomic considerations, but it is not critical for the transfer process.
B. The client's ability to communicate is important for understanding their needs and preferences but does not directly impact the physical safety of the transfer.
C. The client's current weight-bearing status is crucial to determine the safest method of transfer. If the client cannot bear weight, additional assistance or equipment may be necessary to prevent falls or injury.
D. While knowing the type of equipment used in previous transfers can provide insight, it is secondary to understanding the client's current physical capabilities and needs.
Correct Answer is B
Explanation
A. While performing ROM exercises is important for maintaining joint function and circulation, it is not the immediate priority compared to assessing respiratory status.
B. Auscultating breath sounds at least every 2 hours is crucial to monitor for any signs of respiratory compromise, which is a common concern in immobile clients due to the risk of atelectasis and pneumonia.
C. Ensuring adequate fluid intake is important for hydration and preventing complications but is secondary to assessing respiratory function.
D. Applying anti-embolic stockings is important for preventing venous thromboembolism, but respiratory assessment takes precedence in the context of immobility.