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 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.

A. Discontinue supplements containing vitamin C 24 hr. before the test B. Refrain from consuming pork 7 days before the test. C. Place a thick layer of stool on the specimen card. D. Urinate prior to collecting the stool specimen

Correct Answer is D

Explanation

Choice A Reason:

Discontinuing supplements containing vitamin C 24 hr. before the test is incorrect. While high doses of vitamin C might interfere with the accuracy of some laboratory tests, it typically doesn't impact fecal occult blood testing. However, it's always best to follow specific instructions provided by the healthcare provider or laboratory.

Choice B Reason:

Refraining from consuming pork 7 days before the test. There isn't typically a requirement to avoid specific foods, such as pork, before a fecal occult blood test. The test is designed to detect blood in the stool, regardless of the diet. However, some dietary restrictions might be advised based on specific instructions or conditions, but these are not universally applicable.

Choice C Reason:

Placing a thick layer of stool on the specimen card is incorrect. When collecting a sample for a fecal occult blood test, it's important to follow the specific instructions provided by the healthcare provider or laboratory. Generally, a small portion of stool is applied to the designated area on the specimen card as instructed, rather than applying a thick layer. Applying too much stool can affect the accuracy of the test.

Choice D Reason:

Urinating prior to collecting the stool specimen is correct. This instruction ensures that the urine doesn't contaminate the stool sample, which could potentially affect the accuracy of the test results.

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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 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?

Correct Answer is A

Explanation

A nurse is reinforcing discharge teaching about fecal occult blood testing with include in the teaching?

Correct Answer is D

Explanation

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