A nurse is speaking with a visitor who asks a question about the status of a relative who is a client on the unit. Which of the following responses by the nurse is appropriate?
"Please ask your relative about this, because I cannot share information about her."
"I'm not taking care of your relative today, so I don't have the latest information."
"I will have your relative's nurse come and talk with you about her care."
"Let me check your relative's medical record to see how she's doing."
The Correct Answer is C
Choice A reason: This response is inappropriate because it violates the client's right to privacy and confidentiality. The nurse should not disclose any information about the client to anyone without the client's consent, unless it is required by law or for the client's safety.
Choice B reason: This response is inappropriate because it shows a lack of accountability and professionalism. The nurse should not dismiss the visitor's concern or pass the responsibility to another nurse. The nurse should either provide the information if they have it or direct the visitor to the appropriate source.
Choice C reason: This response is appropriate because it respects the client's privacy and confidentiality, while also addressing the visitor's concern. The nurse should inform the visitor that they will contact the nurse who is taking care of the client and ask them to come and talk with the visitor.
Choice D reason: This response is inappropriate because it violates the client's privacy and confidentiality. The nurse should not access the client's medical record without a valid reason or the client's consent. The nurse should only check the medical record if they are involved in the client's care or have a need to know the information.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Beneficence is the ethical principle of doing good or acting in the best interest of others. While this is an important principle for nurses to follow, it does not directly apply to the situation of reporting the truth about the incident.
Choice B reason: Nonmaleficence is the ethical principle of avoiding harm or minimizing the risk of harm to others. This principle is relevant to the prevention of falls and the use of gait belts, but it does not address the issue of honesty in documentation.
Choice C reason: Fidelity is the ethical principle of being faithful or loyal to one's commitments and responsibilities. This principle relates to the nurse's duty to provide safe and competent care to the client, but it does not specify the obligation to report the facts accurately.
Choice D reason: Veracity is the ethical principle of telling the truth or being truthful. This principle is the most appropriate for the charge nurse to follow in this case, as it requires the nurse to report the incident honestly and completely, including the omission of the gait belt. This is essential for quality improvement, legal protection, and ethical accountability.
Correct Answer is C
Explanation
Choice A reason: Data collection about specific client needs related to turning is not an assessment that the nurse should make before delegating care, but rather a task that the nurse should perform and communicate to the AP. The nurse should identify the client's risk factors, preferences, and goals for turning and share them with the AP.
Choice B reason: Changing the client's central IV line dressing is not a task that the nurse should delegate to the AP, as it requires sterile technique and infection control. The nurse should perform this task and document the findings and interventions.
Choice C reason: Checking the client's pain level prior to turning her is an assessment that the nurse should make before delegating care, as it affects the client's comfort and safety. The nurse should ensure that the client's pain is adequately managed and that the AP is aware of the client's pain status and medication regimen.
Choice D reason: The presence of the client's family is not an assessment that the nurse should make before delegating care, but rather a factor that the nurse should consider and respect when planning and implementing care. The nurse should involve the client's family in the care process as much as possible and provide them with education and support.
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