A nurse on a medical-surgical unit receives a telephone call from an individual who identifies himself as the client's employer.
The employer asks the nurse about the client's condition.
Which of the following is an appropriate response by the nurse?

"The client's condition is stable right now.”.

"I will tell him you called.”.

"I cannot confirm or deny that we have a client by that name.”.

"He is here in the hospital, but I cannot tell you anything else.”. . .

Answer and Explanation

The Correct Answer is C

Choice A rationale

Stating that the client's condition is stable right now is a breach of patient confidentiality and does not comply with privacy regulations.

Choice B rationale

Telling the employer that the nurse will inform the client about the call is also a breach of confidentiality, as it implies that the client is indeed there.

Choice C rationale

Responding with "I cannot confirm or deny that we have a client by that name" is an appropriate and professional way to protect patient confidentiality and comply with privacy laws.

Choice D rationale

Stating that the client is in the hospital but not providing further details still reveals the client's location, which breaches patient confidentiality and privacy regulations. .

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Correct Answer is A

Explanation

Choice A rationale

Restricting the number of visitors for clients can help reduce environmental stressors by minimizing noise and activity, creating a more calm and controlled environment conducive to healing.

Choice B rationale

Turning on loud music in client care areas is incorrect as loud noises can increase stress and anxiety in clients, hindering their recovery and comfort.

Choice C rationale

Offering the clients many choices regarding care is incorrect. Too many choices can overwhelm clients, increasing stress and making decision-making difficult, especially in an acute care setting.

Choice D rationale

Assigning different nurses to provide care for clients each day is incorrect. Consistency in caregivers helps build trust and rapport, reducing stress for the clients by providing a familiar and predictable routine. .

A. Apply cornstarch powder to the perineal area. B. Turn the client every 4 hours. C. Cleanse the perineal area with povidone-iodine solution. D. Place a moisture barrier ointment over the perineal area.

Correct Answer is D

Explanation

Choice A rationale

Applying cornstarch powder to the perineal area can lead to clumping and skin irritation, especially in a moist environment. It is not recommended for managing fecal incontinence.

Choice B rationale

Turning the client every 4 hours is important for preventing pressure ulcers but does not directly address fecal incontinence. Frequent turning should be combined with other measures for skin protection.

Choice C rationale

Cleansing the perineal area with povidone-iodine solution can be harsh and drying to the skin. It is not typically recommended for routine care of fecal incontinence.

Choice D rationale

Placing a moisture barrier ointment over the perineal area protects the skin from irritation and breakdown caused by fecal matter. It creates a protective layer, which is essential in managing fecal incontinence.

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A nurse on a medical-surgical unit receives a telephone call from an individual who identifies himself as the client's employer.The employer asks the nurse about the client's condition.Which of the following is an appropriate response by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting in creating a plan to reduce environmental stressors for clients in an acute care unit.Which of the following actions should the nurse include in the plan?

Correct Answer is A

Explanation

A nurse is caring for an older adult client who has fecal incontinence.Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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A nurse on a medical-surgical unit receives a telephone call from an individual who identifies himself as the client's employer.
The employer asks the nurse about the client's condition.
Which of the following is an appropriate response by the nurse?