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?

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

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

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

"I will tell him you called."

Answer and Explanation

The Correct Answer is A

A.   "He is here in the hospital, but I cannot tell you anything else."- This response respects the client's confidentiality and does not disclose protected health information to unauthorized individuals.

B.   "I cannot confirm or deny that we have a client by that name."- This response is evasive and does not provide any useful information.
C.   "The client's condition is stable right now."- Disclosing the client's condition without their consent is a violation of confidentiality.
D.   "I will tell him you called."- This response breaches the client's confidentiality by confirming their presence in the hospital.

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Correct Answer is A

Explanation

A. History of dementia- Dementia can impair cognitive function and increase the risk of accidents or injuries, such as falls or wandering.
B. Steady gait- A steady gait indicates good balance and is not typically considered a risk factor for accidents or injuries.
C. History of gastric reflux- Gastric reflux may cause discomfort but is not directly related to an increased risk of accidents or injuries.
D. Age of 45- While age can be a risk factor for certain conditions, such as falls in older adults, being 45 years old alone does not necessarily indicate an increased risk of accidents or injuries.

A. Obtain urine from the drainage bag if a urinary specimen is required. B. Use a catheter securing device to hold the catheter in place. C. Change the catheter bag every 3 days and as needed. D. Position the drainage bag higher than the client's bladder.

Correct Answer is B

Explanation

A. Obtain urine from the drainage bag if a urinary specimen is required- Urine specimens should be collected from the catheter port using a sterile technique, not from the drainage bag.
B. Use a catheter securing device to hold the catheter in place- A catheter securing device helps prevent movement or accidental removal of the catheter, reducing the risk of trauma or dislodgment.
C. Change the catheter bag every 3 days and as needed- Catheter bags should be changed according to facility policy or if they become soiled, not necessarily every 3 days.
D. Position the drainage bag higher than the client's bladder- The drainage bag should be positioned lower than the client's bladder to facilitate urine drainage by gravity and prevent reflux into the bladder.

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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 reviewing a client's electronic medical record (EMR). Which of the findings should the nurse identify as a risk factor for a potential accident or injury?

Correct Answer is A

Explanation

A nurse is caring for a client who had an indwelling urinary catheter inserted 3 days ago. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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