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?

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

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

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

"I will tell him you called."

Answer and Explanation

The Correct Answer is A

A.   "He is here in the hospital, but I cannot tell you anything else."- This response respects the client's confidentiality and does not disclose protected health information to unauthorized individuals.

B.   "I cannot confirm or deny that we have a client by that name."- This response is evasive and does not provide any useful information.
C.   "The client's condition is stable right now."- Disclosing the client's condition without their consent is a violation of confidentiality.
D.   "I will tell him you called."- This response breaches the client's confidentiality by confirming their presence in the hospital.

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Correct Answer is B

Explanation

A. Soak the hearing aid in warm water Soaking the hearing aid in warm water can damage the device and is not an appropriate solution for a whistling sound.
B. Decrease the volume on the hearing aid- Whistling sounds from a hearing aid often indicate feedback, which can be reduced by lowering the volume.
C. Clean the hearing aid with isopropyl alcohol- Cleaning the hearing aid with isopropyl alcohol may be part of routine maintenance but is not directly related to addressing a whistling sound.
D. Turn the hearing aid off for 5 min- Turning the hearing aid off temporarily may not address the underlying cause of the whistling sound and may disrupt the client's ability to hear when the device is turned back on.

A. Pour 2.54 cm (1 in) of 0.9% sodium chloride solution into the sterile basin. B. Unlock and remove the inner cannula. C. Scrub the inside and outside of the inner cannula with a small brush. D. Cleanse the stoma site with 0.9% sodium chloride solution. E. Wipe the inside of the inner cannula with a folded pipe cleaner.

Correct Answer is A,B,C,E,D

Explanation

Correct Order of Steps: A. Pour 2.54 cm (1 in) of 0.9% sodium chloride solution into the sterile basin. This step ensures the nurse has a sterile solution ready for cleaning the cannula and stoma site. B. Unlock and remove the inner cannula. Removing the inner cannula is necessary to clean it and prevent the buildup of secretions. C. Scrub the inside and outside of the inner cannula with a small brush. Cleaning the cannula thoroughly removes debris and secretions. E. Wipe the inside of the inner cannula with a folded pipe cleaner. The pipe cleaner is used to dry and clear any residual moisture or secretions inside the cannula. D. Cleanse the stoma site with 0.9% sodium chloride solution. Cleansing the stoma site is essential to maintain skin integrity and prevent infection.

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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 caring for an older adult client who has a hearing aid. Which of the following actions should the nurse take when the client reports hearing a whistling sound from the hearing aid?

Correct Answer is B

Explanation

13. A nurse is preparing to provide tracheostomy care to a client who has a chronic tracheostomy. In which order should the nurse complete the following steps? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Correct Answer is A,B,C,E,D

Explanation

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