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 B
Explanation
Choice A reason: Allowing the AP to document the vital signs prior to logging out is not a correct action, as it violates the principles of confidentiality and accountability. The nurse should not share their login credentials or allow anyone else to use their electronic record.
Choice B reason: Logging out so the AP can log in to document the vital signs is the correct action, as it ensures that the documentation is accurate, timely, and secure. The nurse should log out of the electronic record after completing their charting and allow the AP to log in using their own credentials.
Choice C reason: Offering to chart the vital signs for the AP is not a correct action, as it delays the documentation and increases the risk of errors. The nurse should not chart the vital signs for the AP, as they are not the ones who obtained them.
Choice D reason: Recommending the AP come back later when the record is available is not a correct action, as it also delays the documentation and reduces the availability of the electronic record. The nurse should not make the AP wait for the record, as it may affect the continuity of care.
Correct Answer is A
Explanation
Choice A reason: A nurse places a mask on a client with tuberculosis before transport to the radiology department is a safe handling technique, as it prevents the transmission of airborne pathogens to other clients and staff. The nurse should also wear a respirator and follow the standard and airborne precautions.
Choice B reason: A nurse cleans up a blood spill with hydrogen peroxide is not a safe handling technique, as it can damage the skin and mucous membranes and cause irritation and infection. The nurse should use a bleach solution or an approved disinfectant to clean up blood spills and follow the standard and contact precautions.
Choice C reason: A nurse removes her gown after leaving the client's room is not a safe handling technique, as it can contaminate the environment and expose the nurse to infectious agents. The nurse should remove the gown before leaving the client's room and dispose of it in a designated receptacle.
Choice D reason: A nurse disconnects an indwelling urinary catheter from the drainage bag to collect a specimen is not a safe handling technique, as it can introduce bacteria into the urinary tract and cause infection. The nurse should use a sterile syringe and needle to aspirate the specimen from the sampling port and follow the standard and contact precautions.
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