A nurse is speaking with a visitor who asks a question about the status of a relative who is a client on the unit. Which of the following responses by the nurse is appropriate?
"Please ask your relative about this, because I cannot share information about her."
"I'm not taking care of your relative today, so I don't have the latest information."
"I will have your relative's nurse come and talk with you about her care."
"Let me check your relative's medical record to see how she's doing."
The Correct Answer is C
Choice A reason: This response is inappropriate because it violates the client's right to privacy and confidentiality. The nurse should not disclose any information about the client to anyone without the client's consent, unless it is required by law or for the client's safety.
Choice B reason: This response is inappropriate because it shows a lack of accountability and professionalism. The nurse should not dismiss the visitor's concern or pass the responsibility to another nurse. The nurse should either provide the information if they have it or direct the visitor to the appropriate source.
Choice C reason: This response is appropriate because it respects the client's privacy and confidentiality, while also addressing the visitor's concern. The nurse should inform the visitor that they will contact the nurse who is taking care of the client and ask them to come and talk with the visitor.
Choice D reason: This response is inappropriate because it violates the client's privacy and confidentiality. The nurse should not access the client's medical record without a valid reason or the client's consent. The nurse should only check the medical record if they are involved in the client's care or have a need to know the information.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: The most recent blood glucose reading is not the most important information for the nurse to report at shift change. IV corticosteroids can cause hyperglycemia, which requires monitoring and treatment, but it is not as critical as the client's level of consciousness.
Choice B reason: The laboratory tests scheduled for next shift are not the most important information for the nurse to report at shift change. The nurse should inform the oncoming nurse about the tests, but they are not as urgent as the client's neurological status.
Choice C reason: The reddened area on the coccyx is not the most important information for the nurse to report at shift change. The nurse should document and report any signs of skin breakdown, but they are not as life-threatening as the client's increased intracranial pressure.
Choice D reason: The Glasgow Coma Scale score is the most important information for the nurse to report at shift change. The Glasgow Coma Scale is a tool that measures the client's level of consciousness based on eye opening, verbal response, and motor response. A decrease in the score indicates a deterioration in the client's neurological condition, which requires immediate intervention.
Correct Answer is A
Explanation
Choice A reason: This is an incorrect action by the unit nurse. Alcohol-based hand sanitizer is not effective against Clostridium difficile spores, which can cause severe diarrhea and colitis. The nurse should wash their hands with soap and water after removing gloves to prevent the spread of the infection.
Choice B reason: This is a correct action by the unit nurse. Wearing goggles when emptying the bedpan of liquid stool is a standard precaution that protects the nurse's eyes from exposure to body fluids. The nurse should also wear gloves and a gown when handling the bedpan.
Choice C reason: This is a correct action by the unit nurse. Placing the client in contact precautions is an appropriate measure for clients who have Clostridium difficile. Contact precautions prevent direct or indirect transmission of the infection through contact with the client or the client's environment. The nurse should use a single room or cohort the client with another client who has the same infection.
Choice D reason: This is a correct action by the unit nurse. Cleaning contaminated equipment with bleach-based solution is an effective way to kill Clostridium difficile spores, which can survive on surfaces for a long time. The nurse should follow the manufacturer's instructions for the dilution and contact time of the bleach solution.
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