A nurse on a medical-surgical unit receives a telephone call from an individual who identifies himself as the client's employer.
The employer asks the nurse about the client's condition.
Which of the following is an appropriate response by the nurse?

"The client's condition is stable right now.”.

"I will tell him you called.”.

"I cannot confirm or deny that we have a client by that name.”.

"He is here in the hospital, but I cannot tell you anything else.”. . .

Answer and Explanation

The Correct Answer is C

Choice A rationale

Stating that the client's condition is stable right now is a breach of patient confidentiality and does not comply with privacy regulations.

Choice B rationale

Telling the employer that the nurse will inform the client about the call is also a breach of confidentiality, as it implies that the client is indeed there.

Choice C rationale

Responding with "I cannot confirm or deny that we have a client by that name" is an appropriate and professional way to protect patient confidentiality and comply with privacy laws.

Choice D rationale

Stating that the client is in the hospital but not providing further details still reveals the client's location, which breaches patient confidentiality and privacy regulations. .

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Correct Answer is A

Explanation

Choice A rationale

Asking if there are any problems taking care of feet directly assesses the client’s ability to perform foot self-hygiene. It opens up discussion about specific difficulties the client may face, such as flexibility, vision, or dexterity issues.

Choice B rationale

Asking if the client goes barefoot at home is related to foot safety but does not directly assess their ability to perform foot self-hygiene. It's important for preventing injuries and infections, especially in clients with diabetes.

Choice C rationale

Inquiring about foot swelling helps identify potential complications related to diabetes but does not address the client's ability to perform foot self-care.

Choice D rationale

Asking about problems with ingrown toenails is specific to a common issue in diabetic foot care but does not provide a comprehensive assessment of the client’s ability to maintain foot hygiene.

A. A. Assess the pain level of a client who has received acetaminophen. B. Check a client's peripheral IV site for redness or swelling. C. Measure the intake and output of a client who has received furosemide. D. Reinforce teaching with a client about crutch-gait walking.

Correct Answer is C

Explanation

Choice A rationale

Assessing pain levels is a nursing task requiring clinical judgment, which is beyond the scope of an assistive personnel's duties.

Choice B rationale

Checking an IV site for redness or swelling also requires clinical assessment skills, which are tasks for the nurse.

Choice C rationale

Measuring intake and output is a routine task that can be safely delegated to an assistive personnel. It involves straightforward measurement and recording.

Choice D rationale

Reinforcing teaching about crutch-gait walking requires specific patient education, which falls under the nurse's responsibilities.

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A nurse on a medical-surgical unit receives a telephone call from an individual who identifies himself as the client's employer.The employer asks the nurse about the client's condition.Which of the following is an appropriate response by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who has diabetes mellitus.The nurse should ask which of the following to determine the client's ability to provide foot self-hygiene?

Correct Answer is A

Explanation

A nurse is coordinating care of a group of clients with an assistive personnel (AP). Which of the following tasks should the nurse assign to the AP?

Correct Answer is C

Explanation

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A nurse on a medical-surgical unit receives a telephone call from an individual who identifies himself as the client's employer.
The employer asks the nurse about the client's condition.
Which of the following is an appropriate response by the nurse?