A nurse is caring for a client who is flushed and has a temperature of 38.7° C (101.7° F). Which of the following actions should the nurse take?

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.

Choice A reason: Gloves are the first piece of personal protective equipment that the nurse should remove, as they are the most contaminated and can transfer microorganisms to other surfaces. The nurse should remove the gloves by grasping the outside of one glove at the wrist and pulling it off inside out, then holding it in the gloved hand and sliding the fingers of the ungloved hand under the other glove at the wrist and pulling it off inside out over the first glove. The nurse should then discard the gloves in a biohazard container.

Choice B reason: Goggles are the second piece of personal protective equipment that the nurse should remove, as they can protect the eyes from splashes or droplets. The nurse should remove the goggles by grasping the earpieces or headband and lifting them away from the face. The nurse should then discard the goggles in a designated receptacle or place them in a designated area for reprocessing.

Choice C reason: Gown is the third piece of personal protective equipment that the nurse should remove, as it can protect the clothing and skin from contamination. The nurse should remove the gown by untying the neck and waist ties and pulling the gown away from the neck and shoulders, touching only the inside of the gown. The nurse should then turn the gown inside out, fold or roll it into a bundle, and discard it in a biohazard container.

Choice D reason: Mask is the last piece of personal protective equipment that the nurse should remove, as it can protect the nose and mouth from inhalation of microorganisms. The nurse should remove the mask by grasping the bottom ties or elastics and then the top ties or elastics and pulling the mask away from the face. The nurse should then discard the mask in a biohazard container.