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?
"I cannot confirm or deny that we have a client by that name."
"I will tell him you called."
"The client's condition is stable right now."
"He is here in the hospital, but I cannot tell you anything else."
The Correct Answer is A
Choice A Reason:
"I cannot confirm or deny that we have a client by that name." is correct. Respecting patient confidentiality is crucial in healthcare. Revealing any information about a patient's condition without proper authorization or consent could breach confidentiality laws, such as HIPAA (Health Insurance Portability and Accountability Act) in the United States. Therefore, providing minimal to no information over the phone to an unidentified caller is the appropriate approach to safeguard the patient's privacy.
Choice B Reason:
"I will tell him you called." Is incorrect. This response implies that the nurse will pass along the information or the fact that the employer called, potentially breaching the patient's confidentiality by confirming the client's presence in the hospital to an unauthorized person.
Choice C Reason:
"The client's condition is stable right now." Is incorrect. Revealing any information about the patient's condition to someone who hasn't been authorized to receive such information can breach patient confidentiality. Even stating that the condition is stable discloses some level of the patient's health status without proper consent.
Choice D Reason:
"He is here in the hospital, but I cannot tell you anything else." Is incorrect. While this response acknowledges the patient's presence in the hospital, it also hints that the nurse has information about the patient. It doesn't adhere to the standard of patient confidentiality, potentially breaching the patient's privacy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason:
"Encourage your partner to eat three large meals each day." Is incorrect. At the end of life, a patient's appetite might decrease, and they may not tolerate large meals. Encouraging large meals can cause discomfort or be inappropriate for their condition.
Choice B Reason:
"We will use an electric blanket to keep your partner warm." Is incorrect. While maintaining comfort is important, the use of an electric blanket might not be suitable as the patient's circulation and ability to regulate body temperature might be compromised.
Choice C Reason:
"Opioids will be restricted if your partner develops respiratory distress." Is incorrect.
Opioids can be appropriate for managing symptoms like pain or dyspnea at the end of life. Restricting opioids solely due to the risk of respiratory distress might hinder adequate symptom management. The use of opioids should be based on individual patient needs and careful assessment by healthcare providers.
Choice D Reason:
"Assume your partner can hear you, even if they do not respond." Is correct. This statement encourages communication and acknowledges the possibility that the patient might still be able to perceive their surroundings, even if they are not responsive. It supports the importance of providing emotional support and communication during the end-of-life process.
Correct Answer is A
Explanation
Choice A Reason:
Removing 45 mL of urine from the catheter with a syringe is correct. To obtain a sterile urine specimen from an indwelling urinary catheter, the nurse should use a sterile syringe to aspirate a specific volume of urine from the catheter tubing. This method ensures minimal contamination and an accurate representation of the urine in the bladder at that moment.
Choice B Reason:
Clamping the catheter tubing for 60 min is incorrect.
Clamping the catheter tubing can lead to potential complications such as urinary retention, backflow of urine, or discomfort for the client. It's not a standard practice and could compromise the client's care.
Choice C Reason:
Clamping the catheter tubing below the needleless port is incorrect.
Clamping the catheter tubing can disrupt the urinary drainage and potentially cause issues like urinary stasis or increase the risk of infection. It's not an appropriate method for collecting a sterile urine specimen.
Choice D Reason:
Place the specimen in a clean specimen cup is incorrect. While placing the specimen in a clean cup is necessary, the method of collecting a urine sample from an indwelling catheter involves using a sterile syringe to aspirate a specific volume of urine directly from the catheter tubing, rather than pouring it into a cup from the collection bag.
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