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A nurse is caring for a client who is dying. The nurse should incorporate the principle of nonmaleficence into practice by taking which of the following actions?
- A. Withholding a dose of narcotic pain medication when the client has respiratory depression
- B. Discussing advance directives with the client and the client's family
- C. Providing comfort care measures to the client
- D. Allowing the client's family unlimited visitation at the time of death
Correct Answer: A
Rationale: Correct Answer: A
Rationale: Nonmaleficence is the ethical principle of doing no harm. In this scenario, withholding a dose of narcotic pain medication when the client has respiratory depression aligns with this principle as administering the medication could further compromise the client's respiratory status and potentially harm them. By withholding the medication, the nurse is prioritizing the client's safety and well-being.
Summary of Incorrect Choices:
B: Discussing advance directives is important but does not directly relate to nonmaleficence in this context.
C: Providing comfort care measures is essential but does not specifically demonstrate the principle of nonmaleficence.
D: Allowing unlimited visitation may support emotional well-being but does not directly address the principle of nonmaleficence.
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A nurse manager is providing an inservice program about delegation to assistive personnel (AP) with staff nurses on the unit. Which of the following statements by a staff nurse indicates an understanding of the teaching?
- A. The nurse relinquishes accountability for client outcomes when care is delegated to an AP.
- B. The nurse should consider the AP's level of experience when making delegation decisions.
- C. The AP can provide client education about how to perform basic self-care to the client.
- D. The AP can re-delegate a task to another AP who has similar work experience.
Correct Answer: B
Rationale: The correct answer is B: The nurse should consider the AP's level of experience when making delegation decisions. This answer demonstrates an understanding of the key principle of delegation, which is to assign tasks based on the competency and skill level of the individual. Considering the AP's experience ensures safe and effective delegation.
Incorrect choices:
A: Incorrect because the nurse remains accountable for client outcomes even when delegating tasks.
C: Incorrect because client education should typically be done by licensed healthcare providers.
D: Incorrect because delegation should not involve re-delegating tasks to another uninvolved AP.
In summary, choice B reflects the importance of assessing the AP's competency when delegating tasks, ensuring safe and quality care.
An RN is delegating care activities to a licensed practical nurse (LPN). Which of the following is the priority criterion the RN should consider when delegating?
- A. Agency policies for the LPN
- B. The documented experience level of the LPN
- C. The documented skill level of the LPN
- D. State Nurse Practice Act for the LPN
Correct Answer: D
Rationale: The correct answer is D: State Nurse Practice Act for the LPN. This is the priority criterion because the Nurse Practice Act outlines the scope of practice for LPNs in a specific state, ensuring that the tasks delegated are within their legal scope. This helps to protect patient safety and ensures legal compliance.
A: Agency policies for the LPN - Agency policies are important but do not take precedence over legal requirements outlined in the Nurse Practice Act.
B: The documented experience level of the LPN - Experience level is important but does not guarantee legal authority to perform certain tasks.
C: The documented skill level of the LPN - Skill level is important but does not override legal limitations set by the Nurse Practice Act.
A nurse is providing discharge teaching for a client who has a new prescription for home oxygen. Which of the following instructions should the nurse include in the teaching?
- A. Use wool blankets on your bed.
- B. Store unused oxygen tanks horizontally.
- C. Check your oxygen equipment once each week.
- D. Do not adjust the oxygen flow rate.
Correct Answer: D
Rationale: The correct answer is D: Do not adjust the oxygen flow rate. This is crucial to prevent complications such as hypoxia or oxygen toxicity. Adjusting the flow rate without medical guidance can be dangerous. A: Using wool blankets can increase the risk of fire hazard. B: Storing unused oxygen tanks horizontally can cause leaks due to the pressure change. C: Checking equipment weekly is important, but not adjusting the flow rate is more critical for safety.
A nurse checks with assistive personnel on the unit throughout the shift to determine if they are completing tasks. The nurse is demonstrating which of the following rights of delegation?
- A. Right circumstances
- B. Right supervision
- C. Right communication
- D. Right person
Correct Answer: B
Rationale: The correct answer is B: Right supervision. By checking with assistive personnel on the unit throughout the shift, the nurse is ensuring that tasks are being completed under their supervision. This demonstrates the nurse's responsibility to oversee and monitor the work of the assistive personnel, ensuring that tasks are being carried out correctly and safely. The other choices are incorrect because: A) Right circumstances pertains to ensuring the task is appropriate for delegation; C) Right communication involves clear instructions and feedback; D) Right person involves selecting the appropriate individual for the task.
A nurse is caring for a client who is scheduled for surgery but is hesitant to sign the consent form. Which of the following actions should the nurse take first?
- A. Notify the surgeon of the client's hesitation.
- B. Document the client's refusal to sign the consent form.
- C. Ask the client about their concerns regarding the surgery.
- D. Contact the client's family to discuss the procedure.
Correct Answer: C
Rationale: Asking the client about their concerns allows the nurse to address specific fears or misunderstandings, promoting informed consent and respecting the client's autonomy.