Nokea
A nurse in a long-term care facility is preparing to administer medications to a client who has advanced dementia and does not have an identification band. Which of the following actions should the nurse take to verify the client's identity?
- A. Review the client's photograph in the medical record.
- B. Request an assistive personnel to identify the client.
- C. Ask the client to state their room number.
- D. Have the client state their phone number.
Correct Answer: A
Rationale: A photograph ensures accurate identification, critical for a client with dementia unable to self-identify.
You may also like to solve these questions
A nurse in a long-term care facility is caring for a client who has a gastrostomy feeding tube. Prior to administering medications, which of the following findings should the nurse report to the provider?
- A. Hyperactive bowel sounds are present.
- B. Stomach contents are yellowish green in color.
- C. Aspirated stomach contents' pH measures 6.5.
- D. Residual volume of stomach contents measures 90 mL.
Correct Answer: C
Rationale: A pH of 6.5 suggests possible tube misplacement, requiring immediate reporting.
A nurse is caring for an older adult client who has a hearing aid. Which of the following actions should the nurse take when the client reports hearing a whistling sound from the hearing aid?
- A. Clean the hearing aid with isopropyl alcohol.
- B. Turn the hearing aid off for 5 minutes.
- C. Soak the hearing aid in warm water.
- D. Decrease the volume on the hearing aid.
Correct Answer: D
Rationale: Lowering volume addresses feedback, a common cause of whistling.
A nurse in a provider's office is reviewing data from a client's medical record. Which of the following findings should the nurse identify as a risk factor for cardiovascular disease?
- A. Orthostatic hypotension.
- B. BMI of 24.
- C. Type 1 diabetes mellitus.
- D. Family history of osteoporosis.
Correct Answer: C
Rationale: Type 1 diabetes increases cardiovascular risk due to vascular damage.
A nurse at a long-term care facility is reinforcing teaching with a newly licensed nurse about the proper use of restraints. Which of the following instructions should the nurse include in the teaching? (Select all that apply.)
- A. Pad bony prominences before applying a restraint.
- B. Tie the ends of the restraint to the client's bed rail.
- C. Use a square knot to secure the client's restraint to the bed.
- D. Observe the client's skin integrity every 2 hr.
- E. Ensure that 2 fingers can be placed between the restraint and the client.
Correct Answer: A,D,E
Rationale: A: Protects skin. D: Monitors for issues. E: Prevents overly tight restraints.
A nurse is collecting a urine specimen for culture and sensitivity from a client who has an indwelling urinary catheter. Which of the following actions should the nurse take?
- A. Place the specimen in a clean specimen cup.
- B. Remove 45 mL of urine from the catheter with a syringe.
- C. Clamp the catheter tubing below the needleless port.
- D. Clamp the catheter tubing for 60 min.
Correct Answer: C
Rationale: Clamping below the port ensures a fresh, uncontaminated sample.