A nurse on a medical-surgical unit is caring for a patient who is a hospital employee. Several nurses have called seeking information about the patient.
What action should the nurse take in response to inquiries from the nurses?
Refer Questions to the nursing supervisor.
Transfer calls directly to the patient’s room.
Acknowledge that the person is a patient on the unit, but give no specific details about the patient’s condition.
Contact the patient’s provider.
The Correct Answer is A
The correct answer is Choice A: Refer questions to the nursing supervisor.
Choice A rationale: By referring inquiries from other nurses to the nursing supervisor, the nurse maintains patient privacy and upholds healthcare privacy regulations, such as the Health Insurance Portability and Accountability Act (HIPAA). These regulations mandate that patient information should only be disclosed on a need-to-know basis. Referring questions to the nursing supervisor ensures that any information released is managed through the appropriate channels and protects the patient's confidentiality.
Choice B rationale: Transferring calls directly to the patient's room could infringe on their privacy and disrupt their care or rest. It is not the nurse's role to decide if the patient should be disturbed, and doing so may potentially compromise patient care and satisfaction.
Choice C rationale: Acknowledging that the person is a patient on the unit can violate confidentiality rules, as it confirms the individual's presence in the hospital and could lead to speculation about their condition. Nurses must maintain patient privacy by refraining from sharing any information, even if it seems harmless.
Choice D rationale: Contacting the patient's provider does not directly address the issue of handling inquiries from other nurses and could breach confidentiality if the provider discloses information without the patient's consent. Additionally, the provider may not be immediately available, which would delay addressing the inquiries and potentially expose the patient's privacy further.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice B rationale:
Phlebitis is the inflammation of a vein, often caused by an IV catheter. It's characterized by redness, swelling, warmth, and pain along the vein.
Promptly discontinuing the IV infusion is crucial to prevent further irritation and potential complications such as: Thrombophlebitis (inflammation with clot formation)
Infection
Infiltration (leakage of fluids into surrounding tissues) Extravasation (leakage of vesicant or damaging medications)
Continuing the infusion could exacerbate the inflammation and increase the risk of these complications.
Choice A rationale:
Elevation of the extremity can help reduce swelling, but it does not address the underlying inflammation. It's often used as an adjunct measure after discontinuing the IV.
Choice C rationale:
Warm, moist compresses can provide some comfort and potentially promote blood flow, but they are not recommended as a first-line treatment for phlebitis. They may even worsen inflammation in some cases.
Choice D rationale:
Inserting an IV catheter in the opposite extremity is necessary if the patient still requires IV therapy, but it should not be done before addressing the phlebitis in the current site. This could lead to multiple sites of inflammation and increased risk of complications.
Correct Answer is A
Explanation
Choice A rationale:
Hypovolemic shock is a life-threatening condition that occurs when the body loses a significant amount of blood or fluids, leading to a decrease in circulating blood volume. This can result in inadequate perfusion of organs and tissues, which can cause damage and even death if not treated promptly.
In this case, the athlete's symptoms and vital signs are consistent with hypovolemic shock. The athlete has been practicing twice a day in the heat, which can lead to significant fluid loss through sweating. The athlete is also dizzy, which is a common symptom of hypovolemia due to decreased blood flow to the brain. The athlete's blood pressure is low (100/2 mm Hg), pulse rate is elevated (100 beats/minute), and respiratory rate is increased (26 breaths/minute), all of which are compensatory mechanisms to try to maintain blood pressure and perfusion in the setting of hypovolemia. The athlete's skin is cool to touch
and pale in color, which is due to decreased blood flow to the skin. The athlete also does not remember the last voiding time, which may indicate decreased urine output, another sign of hypovolemia.
Key points supporting hypovolemic shock:
Significant fluid loss due to exercise in the heat Dizziness
Low blood pressure Elevated pulse rate Increased respiratory rate Cool, pale skin
Decreased urine output Additional details:
Hypovolemic shock can be caused by various factors, including:
Hemorrhage (blood loss) Severe dehydration Burns
Severe vomiting or diarrhea
Treatment for hypovolemic shock typically involves:
Intravenous fluid replacement to restore circulating blood volume Blood transfusion if the shock is due to hemorrhage
Oxygen therapy to support breathing
Medications to support blood pressure and heart function
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