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 C

Explanation

Choice A rationale

Injecting air into the ampule prior to drawing the medication into a syringe can cause the medication to spill and is not a safe practice.

Choice B rationale

Adding 0.5 mL of diluent to the medication is not a standard procedure for medication administration from an ampule and can lead to incorrect dosing.

Choice C rationale

Using a filter needle to aspirate the medication is important to prevent glass particles from the broken ampule from entering the syringe and being administered to the patient.

Choice D rationale

Cleansing the tip of the ampule with an alcohol swab after opening is unnecessary, as the medication is already inside the sealed ampule, and it can increase the risk of contamination.

A. Hyperactive bowel sounds are present. B. Stomach contents are yellowish green in color. C. Aspirated stomach contents' pH measures 6.5. D. Residual volume of stomach contents measures 90 mL.

Correct Answer is C

Explanation

Choice A rationale

Hyperactive bowel sounds indicate increased gastrointestinal activity, often associated with conditions like gastroenteritis or diarrhea. While it requires monitoring, it is not immediately concerning in the context of administering medications via a gastrostomy tube.

Choice B rationale

Yellowish-green stomach contents suggest the presence of bile, a normal finding in gastric aspirates. It indicates that the tube is correctly placed in the stomach, which is crucial before administering medications.

Choice C rationale

A pH of 6.5 for aspirated stomach contents suggests that the tube might be dislocated into the respiratory tract or intestines, as normal gastric pH ranges from 1.5 to 3.5. Reporting this finding is critical to avoid complications.

Choice D rationale

A residual volume of 90 mL is within the acceptable range for most clients with gastrostomy tubes. High residual volumes (usually over 200 mL) are more concerning and may require intervention.

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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

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Correct Answer is C

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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?