A client states “I have something to tell you in confidence.” Which response by the nurse would be appropriate?

“I don’t want to know this. Tell your health care provider.”.

“I’m your nurse and you can tell me anything.”.

“I’ll close the door first so that no one will hear you.”.

“I can’t promise that the information won’t be shared if your health or safety is involved.”.

Answer and Explanation

The Correct Answer is D

“I can’t promise that the information won’t be shared if your health or safety is involved.” This response by the nurse would be appropriate because it respects the client’s confidentiality while also acknowledging its limits of it. The nurse has a duty to report any information that may indicate a risk of harm to the client or others.

Choice A is wrong because it dismisses the client’s need to share something and implies that the nurse is not interested or trustworthy.

Choice B is wrong because it gives a false assurance of confidentiality and may lead to ethical dilemmas if the client reveals something that requires reporting.

Choice C is wrong because it does not address the issue of confidentiality and may give the impression that the nurse is trying to avoid the conversation.

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Correct Answer is C

Explanation

This is because it shows a normal pH, pCO2, HCO3 and pO2, indicating that the treatment has been effective in restoring normal gas exchange and acid- base balance.

Choice A is wrong because it shows a low pH, high pCO2 and high HCO3, indicating a mixed respiratory and metabolic acidosis.

Choice B is wrong because it shows a low pH, high pCO2 and low HCO3, indicating a combined respiratory and metabolic acidosis.

Choice D is wrong because it shows a high pH, low pCO2 and low HCO3, indicating a mixed respiratory and metabolic alkalosis.

The normal ranges for arterial blood gas (ABG) are:

pH: 7.35 – 7.45
pO2: 10 – 14 kPa or 75 – 105 mmHg
pCO2: 4.5 – 6 kPa or 34 – 45 mmHg

A. Call the rapid response team. B. Move the client to the bed. C. Call the primary care provider. D. Assess client for unresponsiveness.

Correct Answer is D

Explanation

This is because the nurse should always follow the ABC (airway, breathing, circulation) priority when dealing with a client who suddenly slumps over. The nurse should check if the client is conscious and breathing before calling for help or moving the client.

Choice A is wrong because calling the rapid response team should not be done before assessing the client’s condition and ensuring a patent airway.

Choice B is wrong because moving the client to the bed may cause further harm or aspiration if the client has food in the mouth or airway.

Choice C is wrong because calling the primary care provider is not a priority action in this situation. The nurse should first assess and stabilize the client before notifying the provider.

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A client states “I have something to tell you in confidence.” Which response by the nurse would be appropriate?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

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