Correct Answer: A,C,D

Rationale: Date of birth is a commonly used identifier to confirm the client's identity. Diagnosis is not an appropriate identifier for confirming a client's identity. Identification number is a unique identifier assigned to each client helping ensure accurate identification. Name is a fundamental identifier and should be used in combination with other identifiers to verify the client's identity. Room number is not an appropriate identifier for confirming a client's identity.

Correct Answer: B

Rationale: Palpating the abdomen may exacerbate pain or cause discomfort and it is not the first action in the assessment of a client with suspected appendicitis. Auscultating bowel sounds is a more appropriate initial step. Auscultating bowel sounds is the priority to assess for signs of bowel obstruction or ileus which can contribute to the client's symptoms. Offering pain medication can be addressed after the initial assessment and determination of the cause of the symptoms. Administering an antibiotic is premature before a diagnosis is confirmed. The priority is to assess and gather information first.

Correct Answer: A

Rationale: Obtaining apical and radial rates simultaneously allows the nurse to assess for a pulse deficit by comparing the two rates. A pulse deficit is present when the apical rate (heard with a stethoscope) is greater than the radial rate (palpated at the wrist). Palpating pulses in the lower extremities is not specific for assessing a pulse deficit and may not accurately reflect the cardiac output. Checking blood pressure in left and right arms assesses for blood pressure differences but does not specifically address a pulse deficit. Comparing the pulse strength in the upper extremities does not directly assess for a pulse deficit; simultaneous assessment of apical and radial rates is more appropriate.

Correct Answer: A

Rationale: Keeping the client's bed linens dry helps maintain the client's comfort and prevents chilling associated with damp linens. Applying an alcohol-water solution may increase evaporative cooling and is not a standard intervention for fever. Encouraging increased fluid intake is appropriate to promote hydration but the specific amount should be individualized based on the client's condition and needs. Applying ice packs to the groin is not a recommended site for cooling and may cause discomfort. The choice of cooling measures should be appropriate and based on the healthcare provider's orders or institutional protocols.

Correct Answer: B

Rationale: The frequency of previous vital sign measurements may be important but is not the most critical information to communicate during a transfer. The effectiveness of the last dose of pain medication is crucial information for the receiving facility to manage the client's pain appropriately. The number of family members who have visited is important for emotional support but may not be the priority for the receiving facility. The time of the client's last bath is relevant but may not be as critical as information related to pain management during the hand-off report.