The nurse is eating lunch in the hospital cafeteria, which is crowded with visitors and other staff. A health care provider approaches the nurse and asks, "How is my client Ms. Jones in room 312 doing?" Which response by the nurse would be most appropriate?

"Let's step away from the area to discuss it."

"You will have to speak to the nurse caring for her while I am on break."

"I do not know because I am off duty right now."

"Ms. Jones was fine when I last checked on her during rounds."

Answer and Explanation

The Correct Answer is A

Choice A reason: This response is appropriate because it maintains client confidentiality by suggesting to move away from the crowded area before discussing private information. It shows respect for the client's privacy and adheres to HIPAA regulations.

Choice B reason: While this response directs the health care provider to the appropriate person, it does not address the immediate need for privacy. It is important to ensure that any discussion about the client is done in a confidential manner.

Choice C reason: This response is not ideal because it can come across as dismissive and does not offer to address the situation appropriately. Ensuring client confidentiality should remain a priority even if the nurse is off duty.

Choice D reason: This response violates client confidentiality by sharing information about the client's condition in a public setting. It is crucial to discuss such details in a private area to protect the client's privacy.

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Correct Answer is D

Explanation

Choice A reason: Violation of justice is not a specific legal term used in civil actions. It generally refers to an unfair act or omission but is not applicable to this scenario where specific legal actions are being considered.

Choice B reason: Assault involves creating a fear of imminent harmful or offensive contact. While restraining the client could involve assault, the primary legal issue here is the unlawful confinement of the client.

Choice C reason: Invasion of privacy involves intrusion into someone's personal life without consent. This situation does not relate to privacy invasion but rather to the client's right to freedom and autonomy.

Choice D reason: False imprisonment occurs when someone is confined or restrained against their will without legal justification. The nurse's refusal to restrain the client is appropriate as forcibly restraining a competent client who wishes to leave the hospital would constitute false imprisonment.

A. Heart rate of 104 bpm B. Tympanic temperature of 102.6°F (39.2°C) C. Blood pressure of 158/90 mmHg D. Respiratory rate of 24 breaths/min

Correct Answer is B

Explanation

Choice A reason: A heart rate of 104 bpm can be expected in a client with pneumonia and after suctioning. Tachycardia (elevated heart rate) can occur as a response to infection, stress, or the suctioning procedure itself. While it should be monitored, it is not the most critical finding.

Choice B reason: A tympanic temperature of 102.6°F (39.2°C) is unexpected and indicates a significant fever, which may suggest a worsening infection or sepsis. This finding requires immediate attention as it could indicate that the current treatment for pneumonia is not effective, and the client's condition may be deteriorating.

Choice C reason: A blood pressure of 158/90 mmHg, though elevated, may be less critical in the context of this client's condition. Hypertension can occur due to various factors, including stress and illness, and should be monitored but is not the most urgent priority compared to a high fever.

Choice D reason: A respiratory rate of 24 breaths/min is slightly elevated but can be expected in a client with pneumonia and after suctioning. This rate indicates mild tachypnea, which should be monitored but is not as immediately concerning as a high fever.

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The nurse is eating lunch in the hospital cafeteria, which is crowded with visitors and other staff. A health care provider approaches the nurse and asks, "How is my client Ms. Jones in room 312 doing?" Which response by the nurse would be most appropriate?

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Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

The nurse is assessing a mechanically ventilated client with pneumonia after providing deep oral suctioning to the client. Which assessment finding would be unexpected and be a priority for the nurse to address?

Correct Answer is B

Explanation

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