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.

Answer and Explanation

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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Correct Answer is C

Explanation

Choice A rationale:

The neighbor is not authorized to provide consent for the client's procedure. The durable power of attorney for health care typically designates someone to make medical decisions when the client is unable to do so, but the neighbor's role may not extend to medical procedure consent.

Choice B rationale:

The client's spouse might have a legal standing to make decisions for the client, but the durable power of attorney for health care typically takes precedence over the spouse's decision-making authority in situations where it has been established.

Choice C rationale:

The provider, in this case, the medical doctor or healthcare professional performing the endoscopy, has the authority to obtain consent for the procedure. Informed consent is a crucial ethical and legal requirement, and the provider must ensure that the client or their designated decision-maker understands the procedure, its risks, and benefits before proceeding.

Choice D rationale:

A member of the facility's ethics committee does not typically have the authority to provide consent for a specific medical procedure on behalf of an incapacitated client. The ethics committee's role is to provide guidance on ethical dilemmas and issues but not to provide individual procedural consent.

A. Use a 5-mL syringe to flush the catheter. B. Change the site dressing and stabilization device every 24 hr. C. Expect blood to appear in the catheter lumen after flushing. D. Use chlorhexidine solution to clean the catheter.

Correct Answer is D

Explanation

Choice A rationale:

Using a 5-mL syringe to flush the catheter is not the best choice. Central venous access devices typically require a larger syringe for flushing to prevent excessive pressure and potential damage to the catheter. A smaller syringe like the 5-mL syringe can create higher pressure, which could cause complications.

Choice B rationale:

Changing the site dressing and stabilization device every 24 hours is not the recommended practice. The dressing and stabilization device should be changed according to facility policy and as needed, but a rigid 24-hour schedule is not necessary and might increase the risk of infection due to unnecessary exposure.

Choice C rationale:

Expecting blood to appear in the catheter lumen after flushing is incorrect. Blood in the catheter lumen after flushing could indicate complications such as a dislodged catheter or other issues requiring immediate attention. The catheter should ideally remain patent without the presence of blood.

Choice D rationale:

This is the correct choice. Using chlorhexidine solution to clean the catheter is an evidence-based practice to prevent infection at the insertion site. Chlorhexidine has broad-spectrum antimicrobial properties and helps reduce the risk of catheter-related infections.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has chosen a neighbor as their designee in their durable power of attorney for health care. The client is incapacitated and is scheduled for an endoscopy. The nurse should request that which of the following individuals provide consent for the procedure?

Correct Answer is C

Explanation

A nurse is caring for a client who has a central venous access device. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is caring for a client who is at risk for pressure injury formation due to immobility. The nurse should place the client in which of the following positions to reduce pressure on the client's bony prominences?

A nurse is teaching a client about self-administering a subcutaneous injection to the abdomen. Which of the following instructions should the nurse include?

A home health nurse is teaching a client who has a latex allergy about items typically found in the home that can trigger an allergic reaction. Which of the following items should the nurse instruct the client to avoid? (Select all that apply.).

A nurse is planning a community education session about the basic principles of first aid. Which of the following teaching strategies should the nurse implement for a group of adult learners in a community setting?

A nurse is inserting an NG tube for a client who has a new prescription for enteral feedings. Which of the following actions should the nurse take to verify the placement of the client's tube? (Select all that apply.).

A nurse is preparing to notify the provider about a change in a client's status. Which of the following information should the nurse plan to include in the "background" portion of the Situation, Background, Assessment, Recommendation (SBAR) Communication tool?

A nurse is reviewing the ABG results for a client. The client's results are pH 7.47, PaCO2 30 mm Hg, HCO3 25 mEq/L, and SaO2 90%. The nurse should identify that the client is experiencing which of the following acid-base imbalances?

A nurse is caring for a group of clients. Which of the following client-care situations requires the nurse to complete an incident report?