The patient is concerned about confidentiality and asks the nurse not to tell anyone what is said. What is the best response by the nurse?

"What we say can be secret. What I write in the chart is available to the health team."

"I am required to report any intent to hurt yourself or others."

"Conversations between patient and nurse are confidential."

"I can't help you unless you trust me."

Answer and Explanation

The Correct Answer is B

A. "What we say can be secret. What I write in the chart is available to the health team." This response lacks clarity about legal and ethical obligations.
B. "I am required to report any intent to hurt yourself or others." This response clearly communicates the legal and ethical obligation to protect the patient and others from harm, while also acknowledging the importance of patient confidentiality in other situations.
C. "Conversations between patient and nurse are confidential." This is true, but it does not address exceptions such as harm to self or others.
D. "I can't help you unless you trust me." This does not address the patient's concerns about confidentiality directly.

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Correct Answer is D

Explanation

A. Each evening: Turning the patient only once per day is insufficient to prevent pressure injuries.
B. Once every shift: This is also inadequate as it does not provide the frequent repositioning necessary to prevent pressure injuries.
C. Every 4 hours: While better than every shift, every 4 hours may still not be frequent enough to prevent pressure injuries in at-risk patients.
D. Every 2 hours: Frequent repositioning, such as every 2 hours, is essential for pressure injury prevention in bedfast patients.

A. Transport victim to hospital. B. Stop, drop, and roll. C. Cover victim with clean cloth or sheet. D. Remove all nonadherent clothing and jewelry.

Correct Answer is B

Explanation

A. Transport victim to hospital: While transport to the hospital is necessary, it is not the immediate priority when the victim is still on fire.

B. Stop, drop, and roll: The first action for someone whose clothing is on fire is to stop, drop, and roll to extinguish the flames and prevent further burns.

C. Cover victim with clean cloth or sheet: Covering with a clean cloth is important after the flames have been extinguished but not the first step when the victim is still burning.

D. Remove all nonadherent clothing and jewelry: Removing clothing and jewelry should be done after the flames are extinguished and initial care has been administered.

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The patient is concerned about confidentiality and asks the nurse not to tell anyone what is said. What is the best response by the nurse?

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Naxlex Comprehensive Predictor Exams

Because thin skin and lack of subcutaneous fat predisposes the older adult to pressure injuries, the nurse alters the care plan to include turning the bedfast patient how often?

Correct Answer is D

Explanation

The nurse arrives to the scene of a house fire. A victim is running out of the house, with flames on the arms. Which is the nurse's first action?

Correct Answer is B

Explanation

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