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 B

Explanation

A) Placing a sterile instrument within 1.3 cm (0.5 in) of the edge of the sterile field - Sterile items should be kept within the confines of the sterile field to maintain sterility.
B) Opening the top flap of the sterile tray package away from their body - Opening the sterile package away from the body helps prevent contamination from airborne particles or droplets.
C) Dropping sterile objects onto the field from a height of 5 cm (2 in) - Dropping sterile objects can create air currents that may introduce contamination to the sterile field, for instance, through splashing.
D) Placing the cap of a sterile solution on a clean surface with the inside facing down

- Sterile items should be handled with care to maintain sterility, and placing the cap with the inside facing down may introduce contamination. The inside of the cap should face up.

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

Correct Answer is B

Explanation

A) Apply cornstarch powder to the perineal area. - Cornstarch powder may increase the risk of infection and should be avoided in the perineal area, especially for clients with fecal incontinence.
B) Place a moisture barrier ointment over the perineal area. - Moisture barrier ointment helps protect the skin from irritation and breakdown caused by fecal incontinence.
C) Turn the client every 4 hr. - Turning the client every 2 hours is recommended for preventing pressure ulcers, but it does not specifically address fecal incontinence.
D) Cleanse the perineal area with povidone-iodine solution. - Povidone-iodine solution is not typically used for routine perineal care and may irritate the skin.

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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 setting up a sterile field in a client's room. Which of the following actions should the nurse take?

Correct Answer is B

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 B

Explanation

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