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 B
Explanation
Choice A reason: This is not the correct choice because the Good Samaritan Act is a law that protects health care providers and other individuals from legal liability when they provide emergency care to someone who is injured or ill outside of a health care facility. The act does not apply to the staff in the emergency department, who are expected to follow the standards of care and obtain consent for treatment.
Choice B reason: This is the correct choice because implied consent is a type of consent that is assumed when a client is unable to give verbal or written consent due to their condition, and the treatment is necessary to save their life or prevent further harm. The staff can proceed with emergency surgery based on implied consent, as the client is unconscious and has extensive internal injuries that require immediate intervention.
Choice C reason: This is not the correct choice because a living will is a document that expresses a client's wishes regarding their end-of-life care, such as whether they want to receive life-sustaining treatments or not. A living will does not apply to the client in this scenario, who is not terminally ill or in a persistent vegetative state, and who may recover from their injuries with surgery.
Choice D reason: This is not the correct choice because nonmaleficence is an ethical principle that means to do no harm or prevent harm to the client. Nonmaleficence does not permit the staff to proceed with emergency surgery, as it does not override the need for consent. The staff should also consider the principle of beneficence, which means to do good or promote the well-being of the client.
Correct Answer is B
Explanation
Choice A reason: Closing the fire doors and the doors to the clients' rooms is an action that the nurse should take after activating the fire alarm, as it helps to contain the fire and prevent smoke inhalation.
Choice B reason: Activating the fire alarm is the first action that the nurse should take after removing the client from the room, as it alerts the fire department and the rest of the staff and clients about the fire.
Choice C reason: Extinguishing the fire is an action that the nurse should take only if the fire is small and confined, and after activating the fire alarm and ensuring the safety of the client and self. The nurse should use the appropriate fire extinguisher and follow the PASS technique (pull, aim, squeeze, sweep).
Choice D reason: Removing all clients from the unit is an action that the nurse should take only if the fire is large and spreading, and after activating the fire alarm and ensuring the safety of the client and self. The nurse should follow the RACE protocol (rescue, alarm, confine, extinguish/evacuate) and the facility's emergency plan.
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