A nurse receives a phone call from a family member asking for patient information. What should the nurse do?

Ask the family member to provide identification.

Do not provide any information over the phone.

Provide only publicly available information.

Inform the family member that they need to visit in person.

Answer and Explanation

The Correct Answer is B

Choice A rationale
Asking the family member to provide identification does not ensure that the caller is authorized to receive patient information. Even with identification, the nurse cannot verify the caller’s relationship to the patient or their authorization to access confidential information.
Choice B rationale
Not providing any information over the phone is the correct action to protect patient confidentiality. Healthcare providers must ensure that patient information is only shared with authorized individuals, and phone calls do not provide a secure method for verifying the caller’s identity.
Choice C rationale
Providing only publicly available information is not appropriate, as it still involves sharing patient-related details without proper verification. Any disclosure of patient information, even if minimal, must be done with caution and proper authorization.
Choice D rationale
Informing the family member that they need to visit in person is a better approach, but it still does not guarantee that the individual is authorized to receive patient information. The nurse should follow established protocols for verifying authorization before sharing any details.

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Correct Answer is B

Explanation

Choice A rationale
Loosening the restraints and assessing the patient’s skin is important, but it should be done as part of a regular assessment and not as the first action. The nurse should first document the findings to ensure accurate and timely communication of the patient’s condition.
Choice B rationale
Documenting the findings in the patient’s chart is the correct action. Accurate documentation is essential for communicating the patient’s condition and any interventions performed. It ensures continuity of care and provides a legal record of the patient’s status and the care provided.
Choice C rationale
Continuing to monitor the patient without making any changes is not appropriate. The nurse should assess the patient’s condition and document the findings to ensure that any necessary interventions are performed promptly.
Choice D rationale
Applying ice packs to reduce swelling is not appropriate in this context. The nurse should first document the findings and then assess the need for any interventions based on the patient’s condition.

A. Calculating intake and output for the unit. B. Inserting an NGT for a client who is unable to eat. C. Reinforcing teaching with a patient who is learning to walk with a quad cane. D. An unstable client complaining of feeling faint.

Correct Answer is D

Explanation

Choice A rationale
Calculating intake and output for the unit is a task that can be delegated to an LVN or UAP. It does not require the advanced clinical judgment and skills of an RN.
Choice B rationale
Inserting an NGT (nasogastric tube) for a client who is unable to eat is a task that can be performed by an LVN under the supervision of an RN. While it requires skill, it does not necessarily require the advanced clinical judgment of an RN.
Choice C rationale
Reinforcing teaching with a patient who is learning to walk with a quad cane can be done by an LVN or UAP. This task involves providing support and encouragement, but it does not require the advanced clinical judgment of an RN.
Choice D rationale
An unstable client complaining of feeling faint requires the advanced clinical judgment and skills of an RN. The RN is best equipped to assess the client’s condition, identify potential causes of instability, and implement appropriate interventions to stabilize the client.

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A nurse receives a phone call from a family member asking for patient information. What should the nurse do?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse assesses a patient with restraints. The nurse should:

Correct Answer is B

Explanation

A nurse on a medical-surgical unit has received a report on four clients. There is an LVN, RN, and UAP working. Which of the following clients would be best to assign to the RN?

Correct Answer is D

Explanation

A nurse is caring for a group of clients on a medical-surgical unit. Which client should the nurse see first?

What type of research is a nurse conducting if they are using a quasi-experimental design?

Which of the following is NOT a type of advance directive?

A nurse administers the wrong medication to a patient, resulting in harm. This situation primarily involves which legal concept?

A nurse at the clinic is involved in disease surveillance. What level of prevention is this?

In what patient situations would a partial ongoing assessment be best performed?

A home health nurse is assessing an older adult client who reports falling a couple of times over the past month. Which of the following findings should the nurse suspect is contributing to the client’s falls?