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." is correct. Respecting patient confidentiality is crucial in healthcare. Revealing any information about a patient's condition without proper authorization or consent could breach confidentiality laws, such as HIPAA (Health Insurance Portability and Accountability Act) in the United States. Therefore, providing minimal to no information over the phone to an unidentified caller is the appropriate approach to safeguard the patient's privacy.
Choice B Reason:
"I will tell him you called." Is incorrect. This response implies that the nurse will pass along the information or the fact that the employer called, potentially breaching the patient's confidentiality by confirming the client's presence in the hospital to an unauthorized person.
Choice C Reason:
"The client's condition is stable right now." Is incorrect. Revealing any information about the patient's condition to someone who hasn't been authorized to receive such information can breach patient confidentiality. Even stating that the condition is stable discloses some level of the patient's health status without proper consent.
Choice D Reason:
"He is here in the hospital, but I cannot tell you anything else." Is incorrect. While this response acknowledges the patient's presence in the hospital, it also hints that the nurse has information about the patient. It doesn't adhere to the standard of patient confidentiality, potentially breaching the patient's privacy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason:
Checking the medical record for the client's signature on a previous consent form is incorrect. While a previous consent form might exist in the medical records, for certain procedures or situations, specific, current consent for each instance is often necessary. Verifying a previous consent form may not ensure the client's informed consent for the current procedure.
Choice B Reason:
Having another nurse co-sign the client's consent is incorrect. Co-signing a client's consent by another nurse doesn't substitute for the client's own signature and may not adequately verify the client's informed decision and understanding of the procedure.
Choice C Reason:
Obtaining verbal consent from the client is incorrect. While obtaining verbal consent is important, for invasive procedures like catheter insertion, it's essential to have written, witnessed consent to ensure proper documentation and confirmation that the client is fully informed and agrees to the procedure.
Choice D Reason:
Witnessing the client's signature on a consent form is correct. Express consent for medical procedures typically involves the client signing a consent form after being adequately informed about the procedure, its potential risks, benefits, and alternatives. Witnessing the client's signature on a consent form ensures that the client has provided informed consent for the specific procedure.
Correct Answer is C
Explanation
Choice A Reason:
Stomach contents are yellowish-green in color is incorrect. While the color of stomach contents might indicate various aspects of digestion or bile presence, a yellowish-green color alone might not necessarily be an immediate cause for concern unless accompanied by other symptoms or indications of a problem.
Choice B Reason:
Aspirated stomach contents' pH measures 6.5 is incorrect. A pH of 6.5 in aspirated stomach contents might indicate a less acidic environment, but it's not usually considered significantly abnormal. However, it's still essential to consider the context and the individual client's situation when interpreting pH values.
Choice C Reason:
Residual volume of stomach contents measures 90 mL is correct. A residual volume of 90 mL is considered high and could indicate delayed gastric emptying or potential issues with the client's ability to tolerate or absorb feedings. Reporting this finding to the provider is essential for further assessment and potential adjustments in the client's care plan.
Choice D Reason:
Hyperactive bowel sounds are present is incorrect. Hyperactive bowel sounds might suggest increased peristalsis or bowel activity. While this finding may be noted and monitored, it might not require immediate reporting unless it's associated with other concerning symptoms or complications.
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