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 A
Explanation
A. Using attentive listening with the client demonstrates the principle of presence by showing that the nurse is fully engaged and invested in the client's experience, fostering a collaborative relationship.
B. While focusing on the client’s present circumstances is important, the personal stories shared by clients can provide context and enhance understanding, so limiting this aspect is not ideal.
C. Offering personal thoughts and beliefs can shift the focus away from the client and is generally not appropriate in professional communication.
D. While verbalizing understanding is a supportive action, it does not fully encapsulate the principle of presence, which emphasizes active engagement and listening.
Correct Answer is D
Explanation
A. Assessing the pedal pulses with a Doppler device is not necessary in this situation; the focus should be on the apical pulse due to the irregularity noted in the radial pulse.
B. Assessing the pedal pulses for a full minute does not address the irregularity of the radial pulse and is not the priority.
C. While assessing the apical pulse is appropriate, using a Doppler device is not required unless there are difficulties in obtaining the pulse normally.
D. Assessing the apical pulse for a full minute is the correct action because it provides a more accurate reflection of the heart's rhythm and rate, especially when there is an irregular radial pulse.