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?
"I cannot confirm or deny that we have a client by that name."
"I will tell him you called."
"The client's condition is stable right now."
"He is here in the hospital, but I cannot tell you anything else."
The Correct Answer is A
Choice A Reason:
"I cannot confirm or deny that we have a client by that name." This response respects the patient's right to confidentiality under HIPAA (Health Insurance Portability and Accountability Act) regulations. It neither confirms nor denies the patient's presence in the hospital, preserving the patient's privacy and confidentiality.
Choice B Reason:
"I will tell him you called." This response doesn't uphold patient confidentiality. Revealing that the employer called could indirectly confirm the patient's presence in the hospital, potentially breaching confidentiality.
Choice C Reason:
"The client's condition is stable right now." Sharing any information about the patient's condition with someone who hasn't been authorized to receive it breaches patient confidentiality. Even sharing a seemingly benign statement about stability can indirectly disclose the patient's presence in the hospital.
Choice D Reason:
"He is here in the hospital, but I cannot tell you anything else. “While it refrains from divulging more information, it still confirms the patient's presence in the hospital, breaching confidentiality.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason:
Inserting an IV is not typically required for this specific test. The test involves applying a substance (pilocarpine) to the skin to stimulate sweat production in a localized area for sweat collection.
Choice B Reason:
Measuring protein in the urine over a 24-hour period is unrelated to the pilocarpine iontophoresis test for cystic fibrosis. Protein measurement in urine over a 24-hour period is a different diagnostic test used for various conditions, but not for cystic fibrosis diagnosis.
Choice C Reason:
Fasting for 8 hours prior to the test is not necessary for the pilocarpine iontophoresis test. There's no requirement for fasting before this particular test.
Choice D Reason:
"The test will measure the amount of chloride in your baby's sweat." Is correct. Pilocarpine iontophoresis testing is a diagnostic test used to measure the concentration of chloride in a person's sweat. Elevated chloride levels in sweat are a hallmark of cystic fibrosis, so this test helps in the diagnosis of the condition.

Correct Answer is C
Explanation
A. "Postpone burping the infant until after completing each feeding."Burping should not be postponed. Infants with a cleft palate may have more difficulty with feeding and may need to be burped more frequently to reduce the risk of aspiration and discomfort.
B. "Feed the infant 177.4 ml. (6 oz) of formula three times each day."The amount and frequency of feeding should be individualized based on the infant's needs and growth patterns. Typically, an infant with a cleft palate requires more frequent, smaller feedings, and the total volume needs to be adjusted according to their specific nutritional needs.
C. "Discontinue a feeding if the infant's eyes become watery."Watery eyes during feeding can be a sign of aspiration or feeding difficulties. If this occurs, it is important to stop the feeding and assess the situation, as it may indicate that the infant is not handling the feeding well and could be at risk for aspiration or other complications.
D. "Elevate the infant's head to a 10° angle during feedings."A 10° angle may be too shallow to effectively prevent aspiration. Typically, the head should be elevated to a greater degree, often 30-45°, to help facilitate safer feeding and reduce the risk of aspiration in infants with a cleft palate.
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