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 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.
Correct Answer is B
Explanation
A. Using an alcohol rub when hands are visibly soiled is incorrect; hands should be washed with soap and water in such cases.
B. Rubbing all surfaces of the hands with an alcohol rub for 20 to 30 seconds is an appropriate practice for effective hand hygiene when hands are not visibly soiled, ensuring thorough coverage of all hand surfaces.
C. Gloves are not a substitute for hand hygiene; hands should be washed before putting on gloves and after removing them to prevent contamination.
D. Even if an individual does not have an infection, they can still carry pathogens on their hands that may infect others, highlighting the necessity of proper hand hygiene.