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?
Request that the caller contact the client’s provider directly for information.
Ask the caller to contact the client directly for information.
Gather additional information from the caller to verify their identity.
Provide the caller with a brief update about the client’s condition.
The Correct Answer is C
Choice A reason: Requesting that the caller contact the client’s provider directly for information is not the best action. The nurse should first determine if the caller has the client’s consent to receive information and if the caller is authorized to do so.
Choice B reason: Asking the caller to contact the client directly for information is not appropriate. The client may not be able to communicate or may not want to share information with the caller. The nurse should respect the client’s privacy and confidentiality.
Choice C reason: Gathering additional information from the caller to verify their identity is the most appropriate action. The nurse should ask the caller for their name, relationship to the client, and other details that can confirm their identity. The nurse should also check the client’s record for any written or verbal consent to disclose information to the caller.
Choice D reason: Providing the caller with a brief update about the client’s condition is not advisable. The nurse should not share any information without verifying the caller’s identity and the client’s consent. The nurse should also follow the provider’s office policy and the Health Insurance Portability and Accountability Act (HIPAA) guidelines for disclosing information.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: This is not the correct answer because greenish-yellow drainage is a normal color for gastric secretions and does not indicate a problem.
Choice B reason: This is not the correct answer because a report of hunger is common for a client with an NG tube and does not require intervention.
Choice C reason: This is the correct answer because gastric contents in the air vent mean that the NG tube is clogged or kinked and needs to be flushed or replaced. This is the correct answer because it indicates that the NG tube is not functioning properly and could cause aspiration or infection. The other findings are expected or normal for a client with an NG tube.
Choice D reason: This is not the correct answer because abdominal distention is a common reason for placing an NG tube and should improve with gastric decompression.

Correct Answer is B
Explanation
Choice A reason: Client instructed on self-care needs is not a specific or accurate documentation. The nurse should include the details of the instruction, such as the topics covered, the teaching methods used, the client's response, and the evaluation of learning.
Choice B reason: Oral temperature elevated at 0800 is a specific and accurate documentation. The nurse should include the vital signs and any abnormal findings, such as fever, in the client's health record. The nurse should also report the elevation to the provider and monitor the client for signs of infection.
Choice C reason: Episiotomy approximated, 3 cm (1.18 in) in length is not a specific or accurate documentation. The nurse should include the type, location, and degree of the episiotomy, as well as the condition of the wound, the presence of edema, erythema, or drainage, and the interventions performed.
Choice D reason: Client drank adequate amounts of fluid with meals is not a specific or accurate documentation. The nurse should include the exact amount and type of fluid intake, as well as the output, in the client's health record. The nurse should also assess the client for signs of dehydration or fluid overload.
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