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

Are you taking the medication as prescribed? This is because warfarin is a blood-thinning medication that affects the prothrombin time (PT) and the international normalized ratio (INR).

The PT measures how long it takes for blood to clot, and the INR is a calculation based on the PT that standardizes the results across different laboratories. A normal INR range is 0.8 to 1.1 for people who are not taking warfarin. People who take warfarin usually have a target INR range of 2 to 3, depending on their condition.

An INR of 0.8 means that the blood clots faster than normal, which increases the risk of blood clots and strokes.

This could indicate that the client is not taking enough warfarin or is taking other medications or foods that interfere with warfarin’s effect.

Choice A is wrong because bleeding gums are a sign of excessive bleeding, which could happen if the INR is too high, not too low.

Choice C is wrong because blood in stools is also a sign of excessive bleeding, which could happen if the INR is too high, not too low.

Choice D is wrong because unusual bruising is another sign of excessive bleeding, which could happen if the INR is too high, not too low.

A. A normal reaction to a position change. B. Gait belt applied. C. Orthostatic hypotension noted with dangling. D. Elevated blood sugar probable.

Correct Answer is C

Explanation

Orthostatic hypotension noted with dangling.

This means that the client’s blood pressure drops when changing position from lying down to sitting or standing. This can cause symptoms such as paleness, sweating, rapid pulse, weakness, and dizziness.

The nurse should document this finding and report it to the physician.

Choice A is wrong because a normal reaction to a position change would not cause such severe symptoms.

Choice B is wrong because the gait belt applied is not a finding but an intervention.

Choice D is wrong because elevated blood sugar probable is not a finding but a speculation.

Choice E is wrong because spot accucheck obtained is not a finding but an action.

Choice F is wrong because fear of falling expressed by a client is not a finding related to the client’s vital signs or physical condition.

Choice G is wrong because provided reassurance is not a finding but a nursing measure.

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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?”.

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Naxlex Comprehensive Predictor Exams

A client who is taking warfarin has an international normalized ratio (INR) of 0.8. Which question should a nurse ask to further evaluate the client?

Correct Answer is B

Explanation

A nurse is getting a client out of bed to ambulate for the first time. The client is pale, diaphoretic, has a pulse of 100/minute, and says, “I feel weak. Let me sit on the side of the bed for a minute.” What finding should the nurse document?

Correct Answer is C

Explanation

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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?”.