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. Observing the client is inappropriate as they are demonstrating signs of choking and require immediate intervention.
B. Performing the Heimlich maneuver is appropriate as the guest is unable to talk, which indicates a potential airway obstruction that needs to be relieved promptly.
C. Slapping the client on the back may not be effective and could worsen the obstruction, especially since they are grasping their throat.
D. Assisting the client to the floor and beginning mouth-to-mouth resuscitation is not appropriate in this situation, as the priority is to clear the obstruction, not to provide rescue breaths.
Correct Answer is A
Explanation
A. Dehydration is a common finding in clients who have experienced diarrhea for several days, as they may have lost significant fluid and electrolytes.
B. A rigid abdomen is more characteristic of conditions such as perforation or severe peritonitis rather than diarrhea.
C. Decreased bowel sounds may occur in certain conditions, but diarrhea typically presents with increased bowel sounds due to hyperactivity.
D. Hypothermia is not a common finding associated with diarrhea; instead, clients may have a normal or elevated temperature due to potential underlying infections.