Nokea
The Joint Commission for Accreditation of Hospital Organizations (JCAHO) specifies that two client identifiers are to be used before administering medication. Which method is best for identifying patients using two patient identifiers?
- A. Take the medication administration record (MAR) to the room and compare it with the name and medical number recorded on the armband.
- B. Compare the medication administration record (MAR) with the client's room number and name on the armband.
- C. Request that a family member identify the client and then ask the client to state his name.
- D. Ask the client to state his full name and then to write his full name.
Correct Answer: A
Rationale: Comparing the MAR with the client's armband name and medical number ensures accurate identification using two reliable identifiers.
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A client diagnosed with hepatitis B asks the nurse how the virus is transmitted. Which of the following is the correct response?
- A. by infectious blood or needles
- B. by infectious blood, sexual contact, and needles, and from mother to newborn
- C. by contaminated food and water
- D. by contaminated water only
Correct Answer: B
Rationale: Hepatitis B is transmitted via blood, sexual contact, needles, and perinatally from mother to newborn.
A client who has glaucoma is to have miotic eyedrops instilled in both eyes. The nurse knows that the purpose of the medication is to:
- A. Anesthetize the cornea
- B. Dilate the pupils
- C. Constrict the pupils
- D. Paralyze the muscles of accommodation
Correct Answer: C
Rationale: Miotics constrict the pupils, increasing aqueous humor outflow to reduce intraocular pressure in glaucoma.
The nurse on the inpatient memory care unit is caring for a client with Alzheimer's who exhibits wandering behavior. The 24-hour observer calls the nurse to report that the client left the unit. It would be most appropriate for the nurse to take which of the following actions?
- A. notify the family
- B. notify security along with a description of the client
- C. ask the observer in what direction the client headed
- D. ask other staff on the unit to assist in finding the client
Correct Answer: B
Rationale: Notifying security with a description ensures a rapid, coordinated response to locate the client and ensure safety.
A 57-year-old male with a history of vasculitis has purple discolorations on his legs, each approximately 0.3 cm to 1 cm in size. He asks the nurse what these discolorations are called, and the nurse correctly calls them
- A. ecchymosis.
- B. purpura.
- C. petechia.
- D. bruises.
Correct Answer: B
Rationale: Purpura are purple discolorations 0.3-1 cm, often seen in vasculitis due to small vessel bleeding. Petechiae are smaller (<0.3 cm), and ecchymosis is larger (>1 cm).
A client diagnosed with Alzheimer's disease initiates the same conversation repeatedly, becomes aggressive when stressed, needs reminders to perform ADLs, and is easily lost in his neighborhood. This client is likely in what stage of Alzheimer's disease?
- A. pre-Alzheimer's
- B. early/mild
- C. moderate
- D. late to severe
Correct Answer: C
Rationale: Moderate Alzheimer's involves repetitive behaviors, aggression, ADL dependence, and disorientation, as described, indicating significant cognitive decline.