Nokea
A nurse is caring for a group of clients. The nurse demonstrates adherence to the ethical principle of fidelity by doing which of the following?
- A. Keeping an appointment with a client
- B. Allowing a new mother to hold her stillborn infant
- C. Confirming that a client going for surgery has signed a consent form
- D. Refusing to disclose information about a client to the media
Correct Answer: A
Rationale: The correct answer is A: Keeping an appointment with a client. Fidelity in nursing ethics refers to the nurse's obligation to be faithful and keep promises made to clients. By keeping an appointment with a client, the nurse is demonstrating reliability and honoring their commitment, which is essential for building trust and maintaining the therapeutic relationship. Choices B, C, and D do not directly relate to fidelity. Allowing a mother to hold her stillborn infant (B) is an example of compassion and emotional support, confirming a client's surgery consent form (C) is related to autonomy and informed consent, and refusing to disclose client information to the media (D) is about confidentiality and privacy, not fidelity.
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A nurse is planning care for a client who has anorexia nervosa. The nurse should make which of the following client goals the priority?
- A. Identify changes within the family unit that promote the client's autonomy.
- B. Gain 2 pounds of weight per week.
- C. Make positive statements about improvements in body image.
- D. Feel in control of her behavior.
Correct Answer: B
Rationale: The correct answer is B: Gain 2 pounds of weight per week. In anorexia nervosa, the primary goal is to restore the client's weight to a healthy level to prevent serious health complications. Weight restoration is crucial in addressing the physical consequences of severe malnutrition and improving overall health. Gaining weight at a steady pace of 2 pounds per week is a realistic and safe goal.
Other choices are incorrect because:
A: Identifying changes within the family unit is important but not the priority compared to addressing the physical health concerns.
C: Making positive statements about improvements in body image is important for psychological well-being but does not address the immediate health risks associated with anorexia.
D: Feeling in control of behavior is a valid goal, but weight restoration takes precedence due to the critical nature of the client's physical health in anorexia nervosa.
A nurse is assisting a newly licensed nurse with delegating tasks to an assistive personnel on the unit. Which of the following statements by the nurse explains the purpose of delegation?
- A. Delegation provides appropriate resources for the client.
- B. Delegation promotes discharge teaching activities for clients.
- C. Delegation permits a designated individual to meet a goal on your behalf.
- D. Delegation decreases health care costs.
Correct Answer: C
Rationale: Rationale: Answer C is correct because delegation allows a designated individual to accomplish a specific task or goal on behalf of the delegator. This ensures efficient and effective delivery of care while maximizing resources. Option A is incorrect as it refers to resource allocation, not delegation's purpose. Option B is incorrect as delegation is not solely for discharge teaching. Option D is incorrect as while delegation may contribute to cost-effectiveness, it is not its primary purpose.
A nurse is assessing four clients on a medical-surgical unit. Which of the following clients should the nurse care for first?
- A. A client who has pneumonia and has an axillary temperature of 38° C (101° F)
- B. A client who has diarrhea and requests clear liquids for breakfast
- C. A client who has a cast on the left leg and reports numbness and paresthesia
- D. A client who has type 1 diabetes mellitus and has a fasting blood glucose level of 150
Correct Answer: C
Rationale: The correct answer is C because numbness and paresthesia in a client with a cast can indicate compartment syndrome, a medical emergency requiring immediate attention to prevent tissue damage or loss of limb. This condition can lead to permanent disability if not addressed promptly. Clients with pneumonia (choice A) and elevated temperature can be managed with antipyretics and antibiotics, while a client with diarrhea (choice B) requesting clear liquids can be managed with dietary adjustments. A client with type 1 diabetes and a blood glucose level of 150 (choice D) may require insulin adjustment but is not as urgent as addressing potential compartment syndrome.
A nurse is teaching a class on torts. The nurse should instruct the class that administering an antibiotic medication to a competent client after the client has refused it is an example of which of the following torts?
- A. False imprisonment
- B. Assault
- C. Battery
- D. Negligence
Correct Answer: C
Rationale: The correct answer is C: Battery. Battery is the intentional harmful or offensive touching of another person without consent. In this scenario, administering the antibiotic medication to a competent client after they have refused it constitutes a deliberate act of touching the client without their consent, which aligns with the definition of battery.
False imprisonment (A) involves restricting a person's freedom of movement unlawfully, which does not apply in this case. Assault (B) involves the threat of harmful or offensive contact, not the actual act itself. Negligence (D) is the failure to exercise proper care in a situation, which is not applicable here as the action was intentional.
An RN from the maternal-newborn unit is being floated to a medical-surgical unit. Which of the following clients should the charge nurse on the medical-surgical unit plan to assign to the RN?
- A. A client who has acute pancreatitis
- B. A client who is one-day postoperative following a total abdominal hysterectomy
- C. A client who had a stroke and is to be admitted
- D. A client who has terminal end-stage renal disease
Correct Answer: B
Rationale: The correct answer is B: A client who is one-day postoperative following a total abdominal hysterectomy. This assignment is appropriate because a nurse from the maternal-newborn unit would likely have experience with postoperative care, wound care, pain management, and monitoring for complications such as hemorrhage or infection. The nurse would also be knowledgeable about assessing vital signs, managing surgical drains, and providing education on postoperative care.
Choice A (acute pancreatitis) would require specific knowledge and skills related to the gastrointestinal system, which may not be within the RN's expertise from the maternal-newborn unit. Choice C (stroke admission) would require expertise in neurology and rehabilitation, which may not be the RN's area of focus. Choice D (end-stage renal disease) would require expertise in nephrology and dialysis, which may not be the RN's specialty.
Assigning the RN to a client who is postoperative following a total abdominal hysterectomy aligns with the RN's background in maternal