A nurse on a medical-surgical unit is caring for a patient who is also a hospital employee. Several nurses have called seeking information about the patient.
What should the nurse do in response to these inquiries?

Refer Questions to the nursing supervisor

Transfer calls directly to the patient’s room

Acknowledge that the person is a patient on the unit, but give no specific details about the patient’s condition

Contact the patient’s provider

Answer and Explanation

The Correct Answer is C

Rationale for Choice A:

Refer Questions to the Nursing Supervisor:

While it's essential to involve the nursing supervisor in situations that require their expertise or authority, it's not always necessary for basic inquiries about a patient's presence on the unit.

Disadvantages of referring calls to the nursing supervisor in this scenario:

It could delay the dissemination of essential information to concerned colleagues.

It could increase the workload of the nursing supervisor, potentially diverting their attention from more critical tasks. It could create a perception of a lack of transparency or openness among staff members.

Rationale for Choice B:

Transfer calls directly to the patient’s room:

Transferring calls directly to a patient's room without their consent breaches their privacy and confidentiality. It could also place undue stress on the patient, especially if they are not prepared to receive calls or discuss their health status.

Disadvantages of transferring calls directly to the patient’s room:

It violates the patient's right to privacy and confidentiality. It could disrupt the patient's rest and recovery.

It could place the patient in an uncomfortable position of having to answer questions about their health when they may not feel ready to do so.

Rationale for Choice C:

Acknowledge that the person is a patient on the unit, but give no specific details about the patient’s condition:

This approach strikes a balance between protecting the patient's privacy and providing necessary information to concerned colleagues. It verifies the patient's presence on the unit without disclosing any sensitive details about their health, thus adhering to ethical and legal guidelines.

Advantages of acknowledging the patient’s presence without providing details:

Respects the patient's right to privacy and confidentiality. Aligns with ethical and legal principles of healthcare.

Provides basic information to concerned colleagues without compromising patient information. Helps to establish trust and transparency among staff members.

Rationale for Choice D:

Contact the patient’s provider:

Contacting the patient's provider for every inquiry about the patient's presence is not practical or efficient. It could overburden the provider and delay the relay of information to concerned colleagues.

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Correct Answer is C

Explanation

Choice A rationale:

A colostomy is a surgical opening in the abdomen that allows stool to pass through the colon and out of the body. While a colostomy may increase the risk of certain complications, such as dehydration and skin irritation, it does not directly increase the risk of aspiration. This is because the colostomy bypasses the upper digestive tract, where aspiration typically occurs.

Choice B rationale:

An ileostomy is a similar surgical opening in the abdomen, but it diverts the small intestine rather than the colon. Like a colostomy, an ileostomy does not directly increase the risk of aspiration. However, it may lead to dehydration and electrolyte imbalances, which could indirectly contribute to aspiration risk.

Choice C rationale:

Enteral feedings through an NG tube are a common way to provide nutrition to patients who cannot eat by mouth. However, these feedings can also increase the risk of aspiration. This is because the NG tube bypasses the normal swallowing mechanisms, which help to protect the airway. If the feeding tube is not properly positioned or if the patient has impaired gastric motility, formula could enter the lungs and cause aspiration pneumonia.

Choice D rationale:

A chest tube is a drainage tube that is inserted into the chest cavity to remove air or fluid. While a chest tube may cause some discomfort and respiratory issues, it does not directly increase the risk of aspiration.

A. A patient who has heart failure and is receiving diuretic therapy. B. A patient who has gastroenteritis and is receiving oral fluids. C. A patient who has end-stage kidney disease who will undergo dialysis. D. A patient who has NPO status since midnight for an endoscopy.

Correct Answer is D

Explanation

Rationale for Choice A:

Diuretics promote fluid loss, increasing the risk of fluid volume deficit.

Heart failure can lead to fluid retention, but diuretic therapy is often used to manage this excess fluid.

However, in this case, the patient is receiving diuretic therapy, which suggests that their fluid status is being actively managed.

Therefore, while this patient is at risk for fluid volume deficit, they are not the most likely candidate among the options presented.

Rationale for Choice B:

Gastroenteritis can lead to fluid loss through vomiting and diarrhea.

However, this patient is receiving oral fluids, which helps to replenish lost fluids and electrolytes.

As long as the patient is able to tolerate oral fluids and is not experiencing excessive fluid losses, they are not at significant risk for fluid volume deficit.

Rationale for Choice C:

End-stage kidney disease can impair the kidneys' ability to regulate fluid balance.

However, dialysis is a treatment that helps to remove excess fluid and waste products from the body.

Therefore, while this patient is at risk for fluid volume imbalances, they are receiving treatment to manage this risk.

Rationale for Choice D:

NPO status means that the patient has been instructed to have nothing by mouth. This means that the patient has not been able to consume any fluids since midnight.

Even in the absence of excessive fluid losses, this prolonged period of fluid restriction can lead to dehydration and fluid volume deficit.

Therefore, this patient is the most likely to be experiencing fluid volume deficit among the options presented.

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A nurse on a medical-surgical unit is caring for a patient who is also a hospital employee. Several nurses have called seeking information about the patient.What should the nurse do in response to these inquiries?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a group of patients on an adult medical-surgical unit.Which patient should the nurse identify as having the highest risk for aspiration?

Correct Answer is C

Explanation

A nurse is collecting data about the fluid status of four patients.Which patient should the nurse identify as being at risk for fluid volume deficit?

Correct Answer is D

Explanation

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A nurse on a medical-surgical unit is caring for a patient who is a hospital employee. Several nurses have called seeking information about the patient. What action should the nurse take in response to inquiries from the nurses?

A nurse on a medical-surgical unit is caring for a patient who is also a hospital employee. Several nurses have called seeking information about the patient.
What should the nurse do in response to these inquiries?