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

Reviewing the client's photograph in the medical record is an effective method to ensure accurate identification. This practice aligns with patient safety protocols and minimizes the risk of medication errors by confirming the patient's identity through a visual match with a documented image.

Choice B rationale

Requesting an assistive personnel to identify the client might be unreliable if the personnel is unfamiliar with the client or makes an error. This approach does not provide a secure verification method and could lead to mistakes.

Choice C rationale

Asking the client to state their room number is not reliable since a client with advanced dementia may not remember their room number accurately. This method does not ensure proper identification and can lead to errors.

Choice D rationale

Having the client state their phone number is inappropriate for clients with advanced dementia, who may struggle to recall such information. This method is not a secure or accurate way to verify identity.

A. Place one hand over the other against the part of the gown covering their upper body. B. Clasp their hands together in a relaxed position behind their body at their waist. C. Keep their arms at the sides of their body with their hands in a relaxed position. D. Interlock their fingers and hold their hands away from their body above their waist.

Correct Answer is D

Explanation

Choice A rationale

Placing one hand over the other against the upper body of the gown increases the risk of contamination. The sterile field must be maintained by keeping hands in a position where they are less likely to come into contact with non-sterile surfaces.

Choice B rationale

Clasping hands behind the body at the waist can also lead to contamination, as the hands may inadvertently touch the gown, which may not be sterile in that area. It’s essential to keep hands in a position where they are less likely to become contaminated.

Choice C rationale

Keeping arms at the sides with hands in a relaxed position might cause hands to brush against non-sterile surfaces or clothing, leading to contamination. Therefore, this position is not recommended for maintaining sterility.

Choice D rationale

Interlocking fingers and holding hands away from the body above the waist is the proper technique for maintaining sterility. This position ensures that the hands are kept in the sterile field and away from non-sterile surfaces, reducing the risk of contamination.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse in a long-term care facility is preparing to administer medications to a client who has advanced dementia and does not have an identification band.Which of the following actions should the nurse take to verify the client's identity?

Correct Answer is A

Explanation

A nurse is wearing sterile gloves in preparation for assisting with a client's sterile procedure.While waiting for the procedure to begin, how should the nurse position their hands?

Correct Answer is D

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?