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.”.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A 40-year-old client who has a blood pressure of 138/98 mm Hg should be referred for immediate treatment. This is because this client has grade 1 hypertension according to the International Society of Hypertension (ISH) guidelines, which define hypertension as a systolic blood pressure (SBP) of 140 mm Hg or higher and/or a diastolic blood pressure (DBP) of 90 mm Hg or higher in the office or clinic. This client also has a high risk of cardiovascular complications due to their age and elevated DBP.
Choice A is wrong because a 20-year-old client who has a blood pressure of 125/60 mm Hg does not have hypertension. This client has normal blood pressure according to the ISH guidelines, which define normal blood pressure as an SBP of less than 130 mm Hg and a DBP of less than 85 mm Hg in the office or clinic. This client also has a low risk of cardiovascular complications due to their age and low DBP.
Choice C is wrong because a 55-year-old client who has a blood pressure of 142/68 mm Hg does not need immediate treatment. This client has grade 1 hypertension according to the ISH guidelines, but their DBP is normal. The ISH guidelines recommend lifestyle interventions for three to six months before medication in patients with grade 1 hypertension and no comorbidities.
This client may have other risk factors that need to be assessed, such as obesity, diabetes, or smoking, but they do not require urgent referral.
Choice D is wrong because a 70-year-old client who has a blood pressure of 150/78 mm Hg does not need immediate treatment. This client has grade 1 hypertension according to the ISH guidelines, but their DBP is normal. The ISH guidelines recommend a target blood pressure of less than 140/90 mm Hg within three months for patients older than 65 years, and after three months reduce the target to less than 130/80 mm Hg.
This client may have other risk factors that need to be assessed, such as chronic kidney disease, heart failure, or atrial fibrillation, but they do not require urgent referral.
Correct Answer is D
Explanation
The needle gauge size for subcutaneous injections should be between 25 and 31, depending on the patient’s size and the viscosity of the medication.
A smaller gauge number means a larger diameter needle, which can cause more pain and tissue damage.
Choice A is wrong because 8 is too large for subcutaneous injections and can cause bleeding and bruising.
Choice B is wrong because 20 is also too large for subcutaneous injections and can cause similar complications as choice A.
Choice C is wrong because 21 is still too large for subcutaneous injections and can cause discomfort and injury to the patient.
The needle length for subcutaneous injections should be between ½ inch and ⅝ inch, depending on the amount of subcutaneous tissue present. The nurse should pinch the skin and insert the needle at a 45-degree angle to ensure proper delivery of the medication.
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