A nurse is caring for a client on a medical-surgical unit. Which of the following actions should the nurse take to maintain the client's confidentiality?
List the client's name and condition on board at the nurses' station.
Fax client information with a cover sheet.
Discuss the client's condition with a nurse on another unit.
Post client diagnosis on message board in their room.
The Correct Answer is B
Rationale
A. List the client's name and condition on board at the nurses' station: Displaying client information in a public area can be seen by unauthorized personnel or visitors, violating confidentiality. Sensitive information should never be visible to others not involved in the client’s care.
B. Fax client information with a cover sheet: Using a cover sheet when faxing ensures that client information is protected from unauthorized viewing. This method complies with privacy regulations and maintains confidentiality during necessary communication.
C. Discuss the client's condition with a nurse on another unit: Sharing client information with staff not involved in the client’s care can violate confidentiality. Discussions should be limited to team members directly responsible for the client or conducted through secure channels.
D. Post client diagnosis on message board in their room: Posting sensitive information where others might see it, including visitors or other clients, breaches confidentiality. Personal health information should only be accessible to authorized caregivers.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale
A. Ask the client to occlude one ear with a finger: Occluding one ear is part of the Rinne test, not the Weber test. The Weber test assesses lateralization of sound and does not require the client to block either ear initially.
B. Place a vibrating tuning fork against the midline vertex of the client's head: In the Weber test, the vibrating tuning fork is placed on the midline of the skull, usually the forehead or vertex. This allows the nurse to assess whether sound is heard equally in both ears or lateralizes to one, helping differentiate between conductive and sensorineural hearing loss.
C. Whisper words for the client to identify: Whispered voice testing evaluates the client’s ability to hear and repeat words, but it is a separate assessment from the Weber test and does not determine lateralization.
D. Have the client repeat a phrase spoken by the nurse while the nurse's mouth is hidden: This describes the whispered voice or speech discrimination test, not the Weber test. The Weber test focuses on bone conduction and sound lateralization rather than speech comprehension.
Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"D"}
Explanation
Rationale for Correct Choices
- Thrombophlebitis: The client has a red streak along the vein, palpable cord, warmth, tenderness, and pain at the IV site, which are classic signs of thrombophlebitis. This condition involves inflammation of the vein often accompanied by a thrombus.
- Infection: Presence of purulent drainage at the IV insertion site along with fever (38.6° C / 101.5° F) indicates a local IV-related infection. Infection can occur secondary to thrombophlebitis or as an independent complication of IV therapy.
Rationale for Incorrect Choices
- Extravasation: Extravasation involves leakage of vesicant medication into surrounding tissue causing tissue damage, which is not described here.
- Infiltration: Infiltration is the leakage of nonvesicant IV fluid into surrounding tissue, typically causing swelling, pallor, and coolness, not the red streak and purulent drainage seen in this client.
- Circulatory overload: Circulatory overload presents with dyspnea, hypertension, and edema, none of which are noted in this client.
- Phlebitis: Phlebitis involves vein inflammation and pain but does not usually include purulent drainage. Thrombophlebitis better describes the combination of inflammation with a palpable cord.
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