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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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

Correct Answer is ["A","B","C","D"]

Explanation

An irregular heart rhythm could indicate potential cardiovascular issues. Additionally, deep tendon reflexes graded at 4+ suggest hyperreflexia, which may be associated with neurological disorders and should be investigated further.

Hyperactive bowel sounds in all four quadrants could indicate gastrointestinal hypermotility, which might require prompt assessment to determine the underlying cause.

Generalized weakness and mild leg cramping also require follow-up to determine the cause.

A. "I will rinse the contaminants from a bedpan with hot water." B. "I will wear sterile gloves when bathing a client who is incontinent." C. "I will use disinfectant to clean the blood pressure cuff after use on a client." D. "I will double-bag a client's linens each day."

Correct Answer is C

Explanation

A) "I will rinse the contaminants from a bedpan with hot water." - While rinsing with hot water can help clean a bedpan, it does not effectively disinfect it.

B) "I will wear sterile gloves when bathing a client who is incontinent." - Sterile gloves are not necessary for routine bathing tasks; clean, non-sterile gloves are appropriate.
C) "I will use disinfectant to clean the blood pressure cuff after use on a client." - This statement indicates an understanding of the importance of disinfection to prevent the spread of infection.
D) "I will double-bag a client's linens each day." - Double-bagging linens may be unnecessary and does not directly address infection control principles.

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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

Correct Answer is ["A","B","C","D"]

Explanation

A charge nurse is observing a newly licensed nurse caring for a client group. Which of the following statements by the newly licensed nurse indicates an understanding of infection control principles?

Correct Answer is C

Explanation

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