A nurse receives a telephone call from a client's family member, who asks the nurse for an update on the client's condition. Which of the following actions should the nurse take to maintain the client's confidentiality?
Request additional information about the caller's relationship to the client.
Provide a general update about the client's condition over the telephone.
Refer the family member to the client's provider for the update.
Encourage the family member to contact the client directly for information.
The Correct Answer is C
Choice A rationale:
Request additional information about the caller's relationship to the client. Rationale: While understanding the caller's relationship to the client is important for confirming the legitimacy of the request, it doesn't address the core concern of maintaining client confidentiality. Sharing information with individuals solely based on their relationship can still lead to breaches in privacy.
Choice B rationale:
Provide a general update about the client's condition over the telephone. Rationale: Providing a general update over the telephone is not a secure method of maintaining client confidentiality. General updates can inadvertently disclose sensitive information and should only be communicated through secure and private channels.
Choice C rationale:
Refer the family member to the client's provider for the update. Rationale: This choice is the correct answer as it ensures that the family member receives accurate and appropriate information from the authorized source, which is the client's healthcare provider. This approach maintains the confidentiality of the client's medical information and adheres to privacy regulations.
Choice D rationale:
Encourage the family member to contact the client directly for information. Rationale: Encouraging direct contact between the family member and the client for information sharing can potentially compromise the client's privacy. The client might not want their condition disclosed to certain individuals, and it's the responsibility of the healthcare provider to ensure that sensitive information is shared appropriately and securely.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
During bladder irrigation, the nurse should instill a specific volume of the prescribed irrigation solution into the bladder to facilitate the removal of clots, mucus, or other debris from the urinary catheter and bladder. The recommended volume to instill is usually 400 to 500 mL, which helps to effectively flush out the bladder without overdistending it.
Choice B rationale:
Clamping the drainage tubing distal to the injection port during bladder irrigation is incorrect. The drainage tubing should remain unclamped to allow the irrigation solution to flow into the bladder and facilitate the removal of debris. Clamping the tubing would prevent the solution from entering the bladder and hinder the irrigation process.
Choice C rationale:
Using a syringe with a 19-gauge needle is not relevant to the process of bladder irrigation. Bladder irrigation is typically performed using a specific irrigation kit that includes appropriate tubing and components, not a syringe and needle.
Choice D rationale:
Withdrawing the irrigation solution into the syringe is not a standard procedure during bladder irrigation. The purpose of bladder irrigation is to instill a specific volume of solution into the bladder and then allow it to drain out, flushing the bladder in the process. Drawing the solution back into a syringe after instillation would disrupt the intended irrigation process.
Correct Answer is B
Explanation
Choice A rationale:
1 cup of shredded lettuce is low in potassium and is not the best source of potassium for a client with heart failure. While vegetables like lettuce are generally healthy, they do not provide a significant amount of potassium.
Choice B rationale:
1 cup of cantaloupe is the best source of potassium among the given options. Cantaloupe is a fruit that contains a moderate amount of potassium. Including this fruit in the client's diet can help maintain a balanced potassium level, which is important for heart health.

Choice C rationale:
1 oz of tuna is a source of protein but is not particularly rich in potassium. While protein intake is important for overall health, other choices on the list provide more potassium, which is specifically needed for clients with heart failure.
Choice D rationale:
1 cup of raspberries is a good source of fiber and antioxidants, but it is not as rich in potassium as cantaloupe. While raspberries can be a healthy addition to the diet, they are not the best choice for addressing potassium needs in this scenario.
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