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."

Answer and Explanation

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.

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Correct Answer is C

Explanation

Training the bladder by voiding every 5 hr. is incorrect. For individuals experiencing urinary incontinence, scheduled voiding at regular intervals might be a part of the management plan. However, the specific interval of every 5 hours might not suit everyone, as it depends on individual bladder capacity and function. Scheduled voiding should be tailored to the individual's needs and not solely based on a fixed time frame.

Choice B Reason:

Applying adult diapers at bedtime is incorrect. While using protective garments like adult diapers may manage urinary incontinence during sleep, it doesn't address the underlying issue or provide a solution to improve the condition.

Choice C Reason:

Performing pelvic-muscle exercises is correct. Pelvic floor muscle exercises, also known as Kegel exercises, can help strengthen the muscles that support the bladder and control urine flow. This can potentially improve urinary incontinence by enhancing bladder control.

Choice D Reason:

Drinking citrus juice with meals is incorrect. Citrus juices can irritate the bladder and potentially exacerbate urinary incontinence for some individuals. Advising the consumption of citrus juice might not be beneficial and could worsen symptoms in certain cases.

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

Correct Answer is A

Explanation

Choice A Reason:

Measuring the intake and output of a client who has received furosemide is correct. This task involves recording and measuring fluid intake and output, which is typically within the scope of practice for assistive personnel. It requires accurate documentation and doesn't involve making clinical judgments.

Choice B Reason:

Reinforcing teaching with a client about crutch-gait walking is incorrect. Teaching and instructing clients about specific medical procedures or techniques usually require specialized knowledge and assessment skills, typically within the nurse's scope of practice.

Choice C Reason:

Checking a client's peripheral IV site for redness or swelling is incorrect. Assessing for redness or swelling at an IV site involves clinical judgment and assessment skills to identify potential complications. This task is better suited for a licensed nurse who can interpret findings and take appropriate action if needed.

Choice D Reason:

Assessing the pain level of a client who has received acetaminophen is incorrect. Assessing pain levels involves subjective interpretation and understanding of pain scales, which generally falls under the scope of licensed healthcare providers who can evaluate and manage pain interventions based on assessments.

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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 reinforcing teaching with an older adult client who has urinary incontinence. Which of the following instructions should the nurse include? Train the bladder by voiding every 5 hr.

Correct Answer is C

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 A

Explanation

A nurse is preparing to remove an NG tube for a client who is postoperative following colon surgery. In which order should the nurse perform the following steps? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

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A nurse is collecting a urine specimen for culture and sensitivity from a client who has an indwelling urinary catheter. Which of the following actions should the nurse take?

A nurse is preparing to clean a blood spill on a bedside table. Which of the following solutions should the nurse plan to use?

A nurse is collecting data from a client who is 2 days postoperative following the placement of a colostomy. Which of the following findings should the nurse report to the provider?

A nurse is caring for a young adult client who is postoperative and requires physical therapy, pain management, and dietary advancement. The nurse enters the client's room and finds them dressing and stating that they are going home. Which of the following actions should the nurse take?

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?

A nurse is reinforcing teaching with a client about using guided imagery to manage chronic pain. Which of the following statements by the client indicates an understanding of this technique?