A nurse on a medical-surgical unit is caring for a patient who is also a hospital employee. Several nurses have called seeking information about the patient.
What should the nurse do in response to these inquiries?
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
This question addresses HIPAA privacy regulations and professional ethics regarding patient confidentiality. The nurse must identify the correct procedural response to unauthorized inquiries, ensuring that protected health information is not disclosed to staff members who are not involved in the patient's direct care.
Choice A rationale: Referring inquiries to the nursing supervisor is the correct professional action when dealing with potentially inappropriate requests for information. The supervisor ensures that facility policies and privacy regulations are upheld, preventing unauthorized disclosure of protected health information to peers.
Choice B rationale: Transferring calls directly to the patient room violates the patient's privacy and right to confidentiality. The nurse cannot determine if the caller is authorized to receive information, and allowing direct access may expose the patient to unwanted contact or information breaches.
Choice C rationale: Acknowledging that a specific individual is a patient on the unit is a breach of confidentiality under HIPAA. Information regarding a patient's presence or location in a facility is protected, and confirming this status to unauthorized personnel is strictly prohibited.
Choice D rationale: Contacting the provider is unnecessary and inappropriate for managing calls from other staff members. The nurse has a duty to protect patient privacy personally and should not shift the burden of screening these unauthorized inquiries to the healthcare provider.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Tenderness to touch is a common finding in wounds healing by secondary intention. It's often due to inflammation, which is a normal part of the healing process. The inflammation brings in cells and substances that promote healing. However, increased tenderness, especially when accompanied by other signs of infection, should be reported.
Choice B rationale:
A halo of erythema on the surrounding skin is a sign of infection. This is a serious complication that can delay healing and lead to further complications. The erythema indicates that the infection is spreading beyond the wound edges and needs prompt attention.
Choice C rationale:
Drainage of serosanguineous fluid is also common in wounds healing by secondary intention. This fluid is a mixture of serum (clear yellowish fluid) and blood. It's a sign that the wound is cleaning itself and new tissue is forming. While excessive drainage or a change in color or odor could signal a problem, drainage itself is not necessarily a cause for concern.
Choice D rationale:
Pink, shiny tissue with a granular appearance is a sign of healthy granulation tissue. This is a type of tissue that forms during the healing process. It's rich in blood vessels and collagen, which are essential for wound healing. The presence of granulation tissue indicates that the wound is healing well.
Correct Answer is A
Explanation
Choice A rationale:
Paralytic ileus is a common postoperative complication that occurs when the normal movement of the intestines (peristalsis) is slowed or stopped. This can lead to a buildup of gas and fluids in the intestines, causing abdominal distention, nausea, vomiting, and constipation. The absence of bowel sounds, abdominal distention, and the inability to pass flatus are all classic signs of paralytic ileus.
Here are some of the factors that can contribute to paralytic ileus: Manipulation of the intestines during surgery
Anesthesia
Pain medications, especially opioids Electrolyte imbalances
Dehydration
Underlying medical conditions, such as diabetes or kidney disease Treatment for paralytic ileus typically involves:
Resting the bowel by not eating or drinking anything by mouth
Using a nasogastric (NG) tube to suction out gas and fluids from the stomach Providing intravenous (IV) fluids and electrolytes
Encouraging early ambulation
Using medications to stimulate bowel movement, such as metoclopramide or erythromycin
Choice B rationale:
Incisional infection is an infection of the surgical wound. It would typically present with redness, warmth, swelling, and pain at the incision site. The patient may also have a fever. While incisional infections can occur after abdominal surgery, they are not typically associated with the absence of bowel sounds, abdominal distention, and the inability to pass flatus.
Choice C rationale:
Fecal impaction is a severe form of constipation in which a large, hard mass of stool becomes trapped in the rectum. It can cause abdominal pain, bloating, and difficulty passing stool. However, it is not typically associated with the absence of bowel sounds or abdominal distention.
Choice D rationale:
Health care-associated Clostridium difficile (C. difficile) is a bacterial infection that can cause severe diarrhea, abdominal pain, and cramping. It is often associated with antibiotic use. While C. difficile can occur after abdominal surgery, it is not typically associated with the absence of bowel sounds, abdominal distention, and the inability to pass flatus.
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