At the end of the shift, a nurse enters a crowded elevator and is standing near a client’s health care provider.
Which response of the nurse is most appropriate when the health care provider asks, “How is my client in room 913 doing?”.

“I don’t know because I am off duty now and I think you need to ask the nurse coming on this shift.”.

“That is privileged, confidential information and I can’t discuss it with you now.”.

“Why don’t we step off the elevator to discuss this in a more private area?”.

“The client was stable before I left 30 minutes ago, but had to be restrained for agitation.”.

Answer and Explanation

The Correct Answer is C

The nurse should respect the client’s privacy and confidentiality by not discussing the client’s condition in a crowded elevator, even with the health care provider. The nurse should suggest a more private area to have the conversation.

Choice A is wrong because it shows a lack of professionalism and accountability. The nurse should be able to provide a brief update on the client’s status to the health care provider, even if the nurse is off duty.

Choice B is wrong because it implies that the healthcare provider does not have the right to access the client’s information, which is not true. The health care provider is part of the health care team and has a legitimate need to know the client’s condition.

Choice D is wrong because it violates the client’s privacy and confidentiality by disclosing sensitive information in front of other people. The nurse should not share any details about the client’s condition or treatment without the client’s consent or unless it is necessary for the client’s care.

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Correct Answer is B

Explanation

Ask the client to describe the discomfort. This is the best action to establish a nursing diagnosis of pain related to an abdominal incision because it allows the nurse to assess the location, intensity, quality, and duration of the pain, as well as any factors that aggravate or relieve it.

This information can help the nurse to plan appropriate interventions and evaluate their effectiveness.

Choice A. Continue to observe the client is wrong because it does not address the client’s pain or communicate empathy. The nurse should not ignore or minimize the client’s pain, but rather acknowledge it and offer assistance.

Choice C. Encourage the client to progressively relax all muscle groups is wrong because it is a nonpharmacological intervention that may help to reduce pain, but it does not establish a nursing diagnosis of pain. The nurse should first assess the client’s pain before implementing any interventions.

Choice D. Administer the prescribed analgesic and document the client’s response is wrong because it is a pharmacological intervention that may help to relieve pain, but it does not establish a nursing diagnosis of pain. The nurse should first assess the client’s pain before administering any medications.

A. A client with a fasting blood sugar of 187. B. A client with expiratory wheezing after an albuterol treatment. C. A client who has been called to surgery 2 hours early. D. A client with a blood pressure of 178/90 and needs a dose of atenolol.

Correct Answer is B

Explanation

A client with expiratory wheezing after an albuterol treatment.

This indicates that the client has a severe bronchospasm that is not responding to the medication and may lead to respiratory failure.

The client needs immediate intervention to improve airway patency and oxygenation.

Choice A is wrong because a fasting blood sugar of 187 mg/dL is high but not life- threatening. The normal range for fasting blood sugar is less than 99 mg/dL.

The client may have diabetes or prediabetes and needs further evaluation and treatment, but this is not a priority over choice B.

Choice C is wrong because a client who has been called to surgery 2 hours early may need some preparation and education, but this is not an urgent situation.

The client can wait until the nurse has assessed the other clients.

Choice D is wrong because a blood pressure of 178/90 mmHg is elevated but not critical. The normal range for blood pressure is less than 120/80 mmHg.

The client needs a dose of atenolol, which is a beta

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At the end of the shift, a nurse enters a crowded elevator and is standing near a client’s health care provider. Which response of the nurse is most appropriate when the health care provider asks, “How is my client in room 913 doing?”.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

For a client who is crying and seems agitated after major abdominal surgery, which action should a nurse take to establish a nursing diagnosis of pain related to an abdominal incision?

Correct Answer is B

Explanation

A nurse has received report on four clients. What client should the nurse see first?

Correct Answer is B

Explanation

The nurse knows that documentation should record the interventions and the care given to the client. What is the rationale?

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At the end of the shift, a nurse enters a crowded elevator and is standing near a client’s health care provider.
Which response of the nurse is most appropriate when the health care provider asks, “How is my client in room 913 doing?”.