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","C","E"]

Explanation

A) Observe the client's skin integrity every 2 hr. - Regular skin assessments are essential to monitor for any signs of skin breakdown or injury related to the use of restraints.
B) Use a square knot to secure the client's restraint to the bed. - A quick-release knot, not a square knot, should be used to secure restraints for easy removal in case of an emergency.

C) Ensure that 2 fingers can be placed between the restraint and the client. - This ensures that the restraint is not too tight, allowing for circulation and preventing injury.
D) Tie the ends of the restraint to the client's bed rail. - Restraints should not be tied to the bed rail as it can increase the risk of injury and entrapment.
E) Pad bony prominences before applying a restraint. - Padding bony prominences helps prevent pressure injuries and discomfort for the client.

A. Hearing acuity intact B. Oriented to person only C. Full range of motion bilateral lower extremities D. Ability to use call light

Correct Answer is B

Explanation

A) Hearing acuity intact - Intact hearing acuity does not directly increase the risk for potential client injuries.
B) Oriented to person only - Being oriented to person only may indicate confusion or disorientation, which can increase the risk for potential client injuries due to impaired decision-making or awareness of surroundings.
C) Full range of motion bilateral lower extremities - Having a full range of motion in the lower extremities does not directly increase the risk for potential client injuries.
D) Ability to use call light - The ability to use a call light indicates the client's ability to seek assistance, which reduces the risk for potential client injuries.

View Question and Answer

Body System	Findings
Neurological	Alert and oriented to person, place, and time; deep tendon reflexes 4+
Musculoskeletal	Generalized weakness with equal bilateral muscle strength and mild leg cramping
Respiratory	: Lungs clear
Cardiovascular	: Heart rate irregular, Heart rate 95/min
Gastrointestinal	Bowel sounds hyperactive x 4 quadrants

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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?

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Naxlex Comprehensive Predictor Exams

A nurse at a long-term care facility is reinforcing teaching with a newly licensed nurse about the proper use of restraints. Which of the following instructions should the nurse include in the teaching? (Select all that apply.)

Correct Answer is ["A","C","E"]

Explanation

A nurse is collecting data from a client who has an acute condition. Which of the following findings should the nurse identify as increasing the risk for potential client injuries?

Correct Answer is B

Explanation

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