Nokea
To improve the accuracy of client identification, the nurse must use at least two identifiers when providing care, treatment, or services. Which of the following are appropriate? Select all that apply.
- A. Room number.
- B. Bed number.
- C. Medical record number.
- D. Name band.
- E. Social security number.
Correct Answer: C,D,E
Rationale: Appropriate identifiers include medical record number, name band, and social security number, as they are unique to the client. Room and bed numbers are not reliable identifiers.
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A nulliparous client visiting the clinic tells the nurse that she stopped taking oral contraceptives 6 months ago but doesn't think she is ovulating. Which of the following should the nurse anticipate that the physician would order if the client is anovulatory?
- A. Denestrol (Ortho Dienestrol)
- B. Clomiphene citrate (Clomid)
- C. Medroxyprogesterone (Depo-Provera)
- D. Norgestrel (Ovrette)
Correct Answer: B
Rationale: Clomiphene citrate is commonly prescribed to stimulate ovulation in anovulatory clients. Denestrol is an estrogen, medroxyprogesterone is a progestin for contraception or other uses, and norgestrel is a contraceptive, not for inducing ovulation.
The nurse recognizes that a client with pain disorder is improving when the client says which of the following?
- A. I need to have a good cry about all the pain I've been in and then not dwell on it.'
- B. I need to find another physician who can accurately diagnose my condition.'
- C. The pain medicine that you gave me helps me to relax.'
- D. I'm angry with all of the doctors I've seen who don't know what they're doing.'
Correct Answer: A
Rationale: Expressing a desire to process emotions and move forward indicates improved coping, a sign of progress in managing pain disorder.
The nurse is preparing to administer a measles, mumps, and rubella (MMR) vaccine to a 15-month-old. Where should the nurse administer the injection?
- A. Deltoid muscle
- B. Vastus lateralis muscle
- C. Gluteal muscle
- D. Subcutaneous tissue of the abdomen
Correct Answer: B
Rationale: The vastus lateralis is the preferred site for intramuscular vaccines like MMR in toddlers due to adequate muscle mass and low risk of nerve damage.
The best way to determine whether or not a medication is compatible with a particular intravenous fluid is to:
- A. Mix a small amount of the medication in a small amount of the intravenous fluid and then examine this mixture for color changes
- B. Refer to a compatibility chart
- C. Call the doctor and ask if the medication is compatible with the particular intravenous fluid
- D. Mix a small amount of the medication in a small amount of the intravenous fluid and then examine this mixture for any precipitates
Correct Answer: B
Rationale: A compatibility chart provides standardized, evidence-based information on medication and IV fluid compatibility, ensuring safety.
Which type of legal consent is indirectly given by the client by the very nature of their voluntary acute care hospitalization?
- A. An opt out consent
- B. An implicit consent
- C. An explicit consent
- D. No consent at all is given
Correct Answer: B
Rationale: Implicit consent is given by the client's voluntary admission to an acute care facility, implying agreement to routine treatments and procedures necessary for their care, unless explicitly refused.