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.”. . .
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. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
While checking recent medication administration is important, it is not the immediate priority when a client is experiencing shortness of breath. Immediate actions should focus on assessing and improving the client's oxygenation status.
Choice B rationale
Reviewing the client’s most recent SaO2 level is useful, but not the first action to take when there is an immediate concern for the client’s oxygenation. Addressing the current low SaO2 level takes precedence.
Choice C rationale
Notifying the charge nurse is necessary, but the nurse should first attempt to quickly re-evaluate the client’s condition and try simple interventions to improve oxygenation, such as having the client cough and clear their throat.
Choice D rationale
Rechecking the SaO2 level after having the client cough and clear their throat is the appropriate first action. This can help determine if the low SaO2 reading is due to a temporary obstruction, such as mucus, and allows for a more accurate assessment of the client's respiratory status. .
Correct Answer is D
Explanation
Choice A rationale
Placing the client's arms above her head prior to logrolling can cause discomfort and injury, especially after spinal surgery. Arms should be kept at the sides to maintain alignment.
Choice B rationale
Placing the client in semi-Fowler's position before logrolling is incorrect. The semi-Fowler's position is not stable for logrolling and does not align the spine correctly for safe movement.
Choice C rationale
Placing the bed in the lowest position before logrolling can make the process more difficult and unsafe. The bed should be at a height that allows proper body mechanics for the caregiver.
Choice D rationale
Placing a pillow between the client's legs prior to logrolling helps maintain spinal alignment and prevents twisting of the spine, which is crucial after a laminectomy.
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