PASSPORT QUIZ 1 QUESTION AND RATIONALE

A client tells the visiting community health nurse that another client's name and phone number were seen on the call display after the previous day's nurse used the client's home phone. What should the nurse do in response to this conversation?

Leaving personal information in view of other people is a breach of confidentiality. The nurse should inform the other nurse of the incident. The other options are incorrect because they do not protect the client's privacy and do not address the behavior of the other nurse.

A client is scheduled for surgery at 8 a.m.(0800). While completing the preoperative checklist, the nurse sees that the surgical consent form isn't signed. It's time to administer the preoperative analgesic. Which nursing action takes the highest priority in this situation?

Notifying the surgeon takes priority because the physician must obtain informed consent before the client receives drugs that can alter cognition. Giving the preoperative analgesic at the scheduled time would alter the client's ability to give informed consent. Obtaining consent to surgery isn't within the scope of nursing practice, although the nurse may confirm or witness consent. Canceling surgery isn't within the scope of nursing practice.

A nurse working in the triage area of an emergency department sees several pediatric clients arrive simultaneously. Which client should be treated first?

The child with the airway emergency should be treated first because of the risk of epiglottitis. The 3-year-old with the barking cough and fever should be suspected of having croup and should be seen promptly, as should the child with the laceration. The nurse would need to gather information about the child with Down syndrome to determine the priority of care.

A client has refused all medications for 3 days. The client states, "I don't want to take those pills anymore." What is the nurse's best response?

The nurse should attempt to find out the reason behind the client's refusal. There could be a misunderstanding the nurse can correct. The nurse should not assume the client wants the route changed. The nurse should not try to coerce the client or refer the client to someone else without finding out the reason for the refusal.

A client who tested positive for human immunodeficiency virus (HIV) and has pancreatitis is admitted to the medical unit. The nurse director from another unit comes into the medical unit nurses' station and begins reading the client's chart. The staff nurse questions the director about reading the client's chart. The director states that the client is a neighbor's son. What action should the nurse take?

Personal health information may not be used for purposes not related to health care. The nurse director found reading the chart is not providing health care to the client and therefore does not require access to the chart. The nurse should confront the nurse director and request the return of the client's chart. The director should not have access to this client's health care information regardless of the client's HIV status. If the nurse director does not comply with the nurse's request, the nurse should report the incident to the nurse manager, so the infraction can be reported through the proper channels. The staff nurse should not report the incident to the medical director. Asking the nurse director about permission from a medical director to read the chart does not protect client confidentiality.

A charge nurse tells a new nurse, "You really need to get your skills up to speed." The statement hurts and embarrasses the new nurse. How can the new nurse best handle the situation?

The charge nurse's statement is vague; the priority issue is to gather information about what was meant. Meeting privately with the charge nurse is one way to diffuse tension in a nonthreatening manner and gather information that might have professional value for the nurse. Stating that the nurse felt hurt immediately focuses on subjective issues rather than objective concerns. Professional respect dictates inquiring about what the charge nurse meant, rather than telling the charge nurse to be more specific. Discussing the situation with a coworker may make the nurse feel better but doesn't address the issue at hand.

The nurse is caring for a client scheduled for surgery who, on the morning of the scheduled operation, states a desire to cancel it. What would be the best response by the nurse?

The client has a right to have a change of mind even after the consent has been signed. It is important to explore the reasons why the client wants to cancel and allay concerns. Wishes need to be respected even if the surgery is cancelled. Telling the client that the consent has been signed and surgery can't be cancelled indicates that there is no choice. Discussing fears is helpful, but does not solve the immediate problem of wanting to cancel the surgery.

The nurse manager has assigned a nurse as the circulating nurse for a surgical abortion. The nurse has a religious objection and wishes to refuse to participate in an abortion. What should the nurse manager of the operating room do?

The nurse should not be required to participate in an abortion if it contradicts the nurse's religious beliefs. The behavior should not be reflected negatively on the nurse's evaluation. Preparing equipment and supplies for the case may be viewed as the same as circulating for the case. The nurse has a right not to participate in an abortion unless it is an absolute emergency and no one else is available to care for the client.

A nurse manager overhears a nurse caring for a client with an I.V. make this statement: "If you don't stop playing with your I.V., I will tie your hand to the side rail." What is the most appropriate response by the nurse manager to address this situation?

The nurse's response is threatening and could legally be interpreted as assault. The manager must intervene in the best interest of the client and take the opportunity to educate the nurse regarding the comments and potential actions. The other options do not represent appropriate interventions for the scenario described.

A nurse finds that a colleague is intoxicated while on duty. What appropriate action would the nurse take?

When a colleague is intoxicated while on duty, the nurse should immediately inform the nursing supervisor, who may take necessary action. It would be an irresponsible action if the nurse tells the colleague to go home. Confronting the colleague by asking if he or she is intoxicated may result in denials and an attempt to avoid any repercussions. The nurse should not involve other staff members to protect the privacy of the colleague. Only the nursing supervisor needs to be made aware of the situation.