A nurse receives a telephone call from a client's family member, who asks the nurse for an update on the client's condition. Which of the following actions should the nurse take to maintain the client's confidentiality?
Request additional information about the caller's relationship to the client.
Provide a general update about the client's condition over the telephone.
Refer the family member to the client's provider for the update.
Encourage the family member to contact the client directly for information.
The Correct Answer is C
Choice A rationale:
Request additional information about the caller's relationship to the client. Rationale: While understanding the caller's relationship to the client is important for confirming the legitimacy of the request, it doesn't address the core concern of maintaining client confidentiality. Sharing information with individuals solely based on their relationship can still lead to breaches in privacy.
Choice B rationale:
Provide a general update about the client's condition over the telephone. Rationale: Providing a general update over the telephone is not a secure method of maintaining client confidentiality. General updates can inadvertently disclose sensitive information and should only be communicated through secure and private channels.
Choice C rationale:
Refer the family member to the client's provider for the update. Rationale: This choice is the correct answer as it ensures that the family member receives accurate and appropriate information from the authorized source, which is the client's healthcare provider. This approach maintains the confidentiality of the client's medical information and adheres to privacy regulations.
Choice D rationale:
Encourage the family member to contact the client directly for information. Rationale: Encouraging direct contact between the family member and the client for information sharing can potentially compromise the client's privacy. The client might not want their condition disclosed to certain individuals, and it's the responsibility of the healthcare provider to ensure that sensitive information is shared appropriately and securely.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale: Selecting a site at least 5 cm (2 in) away from the umbilicus is essential because the tissue around the navel is often tougher and has altered vascularity, which can lead to inconsistent medication absorption.
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Choice B rationale: Air bubbles in prefilled syringes, such as those used for enoxaparin, should not be expelled. The air bubble is designed to be injected last to seal the medication within the subcutaneous tissue and prevent leakage.
Choice C rationale: Aspiration is no longer recommended for subcutaneous injections. There are no large blood vessels in the subcutaneous layer, and aspiration increases the risk of tissue trauma, hematoma formation, and client discomfort.
Choice D rationale: Subcutaneous injections should be administered at a 45° to 90° angle, depending on the amount of subcutaneous fat available. A 15° angle is used specifically for intradermal injections, such as TB skin tests.
Correct Answer is A
Explanation
Choosing the best intervention for a client with fever due to infection:
The most appropriate intervention for a client with fever due to infection depends on various factors, including the severity of the fever, the client's age and overall health, and their individual preferences. Let's analyze each option and explain its rationale:
a. Encourage fluid intake of 2,500 mL/day.
Rationale:
- Pros:Fever often leads to increased sweating and fluid loss through respiration. Maintaining adequate hydration is crucial to prevent dehydration, which can worsen discomfort and potentially lead to complications like organ dysfunction. Encouraging a fluid intake of 2,500 mL/day is generally recommended for adults with fever, although individual needs may vary based on factors like body size and activity level.
- Cons:While hydration is essential, forcing fluids on a client who experiences nausea or vomiting can be counterproductive. Additionally, some clients with certain medical conditions, like heart failure, may require fluid restriction, making this option inappropriate.
b. Maintain the environmental temperature at 16°C to 18°C (60°F to 65°F).
Rationale:
- Cons:Excessively cool environments can trigger shivering, which actually increases body heat production and can worsen the fever. Additionally, maintaining such a low room temperature can be uncomfortable for the client and may increase their risk of chills.
c. Immerse the client in cold water.
Rationale:
- Cons:Immersing a client in cold water, like a bath, can be a dangerous and counterproductive intervention. The sudden chill can trigger violent shivering, significantly increasing body heat production and potentially causing shock. Moreover, rapid cooling can be uncomfortable and even risky for people with certain health conditions like heart disease.
d. Assist the client to ambulate.
Rationale:
- Cons:While ambulation is generally encouraged for healthy clients, it may not be suitable for everyone with a fever. Depending on the severity of the fever and the client's overall condition, ambulation could be tiring and even unsafe. In some cases, rest may be more appropriate to promote comfort and recovery.
Therefore, the most appropriate intervention for a client with fever due to infection is:
a. Encourage fluid intake of 2,500 mL/day.
Remember:
- Individualize care based on the client's specific needs and preferences.
- Monitor the client's response to interventions and adjust as needed.
- Consult with the healthcare provider for guidance on managing the fever and addressing any underlying infection.
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