A nurse in a provider's office receives a telephone call from a client's sibling requesting current information about the client's condition. Which of the following actions should the nurse take?

Gather additional information from the caller to verify their identity.

Request that the caller contact the client's provider directly for information.

Ask the caller to contact the client directly for information.

Provide the caller with a brief update about the client's condition.

Answer and Explanation

The Correct Answer is C

A. Gather additional information from the caller to verify their identity: Even if the caller's identity is verified, HIPAA regulations prohibit disclosing a client's medical information without the client’s explicit authorization. Verifying identity alone does not grant permission to release confidential health information.

B. Request that the caller contact the client's provider directly for information: Redirecting the caller to the provider does not resolve the issue of confidentiality. Healthcare providers are also bound by HIPAA regulations and cannot release information without proper consent, regardless of who is making the request.

C. Ask the caller to contact the client directly for information: This action respects the client’s privacy and autonomy. Under HIPAA, healthcare professionals may not disclose health information without client authorization. Advising the sibling to speak directly with the client is the appropriate response to safeguard confidentiality.

D. Provide the caller with a brief update about the client's condition: Sharing any health information without the client’s express consent is a violation of HIPAA. Even a brief update constitutes a breach of confidentiality and could result in legal and professional consequences.

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Correct Answer is C

Explanation

A. Turn on loud music in client care areas: Loud music can increase noise levels, which contributes to environmental stress and can disrupt clients’ rest and recovery. It is generally contraindicated in acute care settings where reducing stress and promoting healing are priorities.

B. Assign different nurses to provide care for clients each day: Frequent changes in caregivers can increase client anxiety and stress by reducing continuity of care and trust. Consistent assignments promote familiarity, comfort, and better communication between clients and caregivers.

C. Restrict the number of visitors for clients: Limiting visitors helps reduce noise and overcrowding, which are common environmental stressors in acute care units. This strategy supports a calmer environment conducive to client rest and recovery while maintaining essential social support.

D. Offer the clients many choices regarding care: While offering choices can promote autonomy, providing too many options may overwhelm clients, especially those who are ill or stressed. Simplifying decisions helps reduce cognitive overload and environmental stress.

A. Check the client's medical records to see which medications were recently administered. B. Notify the charge nurse of the client's condition. C. Review the client's most recent SaO2 level in the medical record. D. Recheck the client's SaO2 level after having the client cough and clear their throat.

Correct Answer is D

Explanation

A. Check the client's medical records to see which medications were recently administered:
While reviewing medications is important for understanding potential causes of hypoxia, it is not the immediate priority when a client’s oxygen saturation is low. Immediate assessment and intervention to improve oxygenation come first.

B. Notify the charge nurse of the client's condition: Notifying the charge nurse is important but should follow an initial assessment and attempt to address the problem. Immediate client reassessment takes precedence to determine the current status and possible interventions.

C. Review the client's most recent SaO2 level in the medical record: Checking prior oxygen saturation levels can provide context but does not directly address the acute finding of 88% saturation, which requires prompt evaluation and action.

D. Recheck the client's SaO2 level after having the client cough and clear their throat: This action directly addresses a common cause of transient hypoxia such as airway obstruction from secretions. Reassessment after clearing the airway is the priority to determine if oxygenation improves before escalating interventions.

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