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:
Intractable pain is pain that is persistent and does not respond to usual pain management methods. While angina can be intractable in some cases, it does not typically manifest as pain in the arm and jaw. Moreover, the patient in this scenario has not yet undergone pain management efforts, so it's premature to classify the pain as intractable.
Choice B rationale:
Phantom pain is pain that is felt in a part of the body that has been amputated or is no longer there. The patient in this scenario has not experienced any amputations, so phantom pain is not a valid explanation for the arm and jaw pain.
Choice C rationale:
Referred pain is pain that is felt in a part of the body that is different from the source of the pain. This is the most likely explanation for the arm and jaw pain in this patient. The heart and the arm and jaw share nerve pathways, so pain signals from the heart can be misinterpreted by the brain as coming from these other areas. This is a common phenomenon in patients with angina.
Choice D rationale:
Cramping pain is a type of pain that is often described as a muscle tightening or squeezing sensation. It is not typically associated with angina. While angina can sometimes cause chest tightness, it's not characterized by cramping in the arm and jaw.
Correct Answer is B
Explanation
Choice A rationale:
Metabolic alkalosis is characterized by a high pH (above 7.45), high bicarbonate (HCO3-) levels, and normal or low PaCO2. The patient's ABGs show a low pH (7.26), low bicarbonate (14 mEq/L), and low PaCO2 (30 mm Hg), which are not consistent with metabolic alkalosis.
Choice C rationale:
Respiratory alkalosis is characterized by a high pH (above 7.45), low PaCO2, and normal or slightly elevated bicarbonate levels. The patient's ABGs do show a low PaCO2, but the pH is low (acidic) and the bicarbonate is low, which are not consistent with respiratory alkalosis.
Choice D rationale:
Respiratory acidosis is characterized by a low pH (below 7.35), high PaCO2, and normal or slightly elevated bicarbonate levels. The patient's ABGs do show a low pH, but the PaCO2 is also low, which is not consistent with respiratory acidosis.
Rationale for the correct answer, B:
Metabolic acidosis is characterized by a low pH (below 7.35), low bicarbonate levels, and normal or low PaCO2. The patient's ABGs are consistent with metabolic acidosis because they show a low pH (7.26), low bicarbonate (14 mEq/L), and low PaCO2 (30 mm Hg).
Acute kidney injury is a common cause of metabolic acidosis. The kidneys play a vital role in regulating acid-base balance by excreting acids and reabsorbing bicarbonate. When the kidneys are damaged, they are unable to excrete acids effectively, leading to an accumulation of acids in the blood and a decrease in bicarbonate levels.
Additional Information:
It's important to note that the patient's low PaCO2 is likely a compensatory mechanism for the metabolic acidosis. In response to acidosis, the respiratory system tries to increase ventilation to blow off more carbon dioxide, which helps to raise the pH. However, this compensatory mechanism is often not enough to fully correct the acidosis.
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