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 C
Rationale for Choice A:
Refer Questions to the Nursing Supervisor:
While it's essential to involve the nursing supervisor in situations that require their expertise or authority, it's not always necessary for basic inquiries about a patient's presence on the unit.
Disadvantages of referring calls to the nursing supervisor in this scenario:
It could delay the dissemination of essential information to concerned colleagues.
It could increase the workload of the nursing supervisor, potentially diverting their attention from more critical tasks. It could create a perception of a lack of transparency or openness among staff members.
Rationale for Choice B:
Transfer calls directly to the patient’s room:
Transferring calls directly to a patient's room without their consent breaches their privacy and confidentiality. It could also place undue stress on the patient, especially if they are not prepared to receive calls or discuss their health status.
Disadvantages of transferring calls directly to the patient’s room:
It violates the patient's right to privacy and confidentiality. It could disrupt the patient's rest and recovery.
It could place the patient in an uncomfortable position of having to answer questions about their health when they may not feel ready to do so.
Rationale for Choice C:
Acknowledge that the person is a patient on the unit, but give no specific details about the patient’s condition:
This approach strikes a balance between protecting the patient's privacy and providing necessary information to concerned colleagues. It verifies the patient's presence on the unit without disclosing any sensitive details about their health, thus adhering to ethical and legal guidelines.
Advantages of acknowledging the patient’s presence without providing details:
Respects the patient's right to privacy and confidentiality. Aligns with ethical and legal principles of healthcare.
Provides basic information to concerned colleagues without compromising patient information. Helps to establish trust and transparency among staff members.
Rationale for Choice D:
Contact the patient’s provider:
Contacting the patient's provider for every inquiry about the patient's presence is not practical or efficient. It could overburden the provider and delay the relay of information to concerned colleagues.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Elevating the head of the bed can promote comfort and ease breathing, but it's not the first priority in this situation. The nurse needs to assess the client's gastrointestinal status before offering any fluids or food.
While elevating the head of the bed may be helpful in some postoperative situations, it doesn't directly address the client's request for something to drink or the need to assess for potential contraindications to oral intake.
It's important to prioritize assessment before intervention to ensure safe and effective care.
Choice B rationale:
Offering apple juice, a clear liquid, might seem appropriate given the postoperative orders, but it's premature without first assessing the client's abdomen.
Auscultation can reveal important information about bowel sounds, which can indicate whether the client's gastrointestinal system is ready to tolerate fluids or food.
Prematurely offering fluids could lead to complications like nausea, vomiting, or aspiration if the client's bowels are not functioning properly.
Choice D rationale:
Ordering a lunch tray is not appropriate at this stage. The nurse needs to first assess the client's tolerance for clear liquids before advancing the diet.
Advancing the diet too quickly could also lead to gastrointestinal complications.
It's important to follow the postoperative orders and progress the diet gradually as tolerated.
Choice C rationale:
Auscultating the client's abdomen is the essential first step in this scenario. It allows the nurse to gather crucial data about the client's gastrointestinal status.
By listening to bowel sounds, the nurse can determine if the client's intestines are active and functioning properly. If bowel sounds are present and normal, it suggests that the client is likely able to tolerate clear liquids.
If bowel sounds are absent or abnormal, it may indicate a potential problem, such as ileus (a temporary paralysis of the intestines), and the nurse would need to hold oral intake and notify the healthcare provider.
This assessment provides essential information to guide the nurse's subsequent actions and ensure the client's safety.
Correct Answer is A
Explanation
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.
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