Nokea
The nurse offers to stay late to assist the next shift because they are short-staffed. Which ethical principle is the nurse demonstrating?
- A. Non-maleficence
- B. Paternalism
- C. C. Beneficence
- D. D. Veracity
Correct Answer: C
Rationale: Staying late to assist (C) demonstrates beneficence by acting to benefit staff and clients through additional support. Non-maleficence (A), paternalism (B), and veracity (D) do not apply to this act of goodwill.
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The nurse recognizes that the most effective way to resolve a conflict is through
- A. compromising.
- B. accommodating.
- C. avoiding.
- D. a win-win solution.
Correct Answer: D
Rationale: A win-win solution (D) resolves conflict by addressing all parties’ needs, fostering collaboration and long-term resolution. Compromising (A) and accommodating (B) may leave issues unresolved, and avoiding (C) delays resolution.
The nurse is educating staff on adult basic life support. It would be appropriate to include which of the following? Select all that apply.
- A. Carotid pulse check should not take more than 20 seconds.
- B. The rate of chest compressions should be 100-120 per minute.
- C. Chest compression depth should be 2 inches on the center breastbone.
- D. Chest tube insertion should be prepared after five minutes of CPR.
- E. Early defibrillation is essential in the survival of ventricular fibrillation.
Correct Answer: B, E
Rationale: Chest compression rate of 100-120/minute (B) and early defibrillation for ventricular fibrillation (E) are correct per AHA guidelines. Pulse check is ≤10 seconds (A), depth is ~2.4 inches (C), and chest tube insertion (D) is not part of BLS.
The nurse is caring for a client admitted for an exacerbation of Meniere’s disease. Which of the following nursing interventions is of the highest priority when caring for this client?
- A. Determining if the client has experienced hearing loss.
- B. Initiating fall risk measures.
- C. Ensuring adherence to a low-sodium diet.
- D. Administering prescribed anticholinergic medications.
Correct Answer: B
Rationale: Initiating fall risk measures (B) is the highest priority in Meniere’s exacerbation due to vertigo, which poses an immediate safety risk. Hearing loss assessment (A), low-sodium diet (C), and medications (D) are important but secondary to preventing falls.
The nurse is caring for four clients on a medical-surgical unit. Which of the following tasks would be a priority for the nurse to complete?
- A. teaching a client scheduled for discharge how to ambulate with crutches
- B. witnessing informed consent for a client needing an emergency laparotomy
- C. irrigating a client's ostomy who reports abdominal cramping
- D. calculating the intake and output of a client with diabetes insipidus (DI)
Correct Answer: B
Rationale: Witnessing informed consent for an emergency laparotomy (B) is a priority, as it ensures legal and ethical requirements are met for urgent surgery. Crutch training (A), ostomy irrigation (C), and intake/output calculation (D) are important but less time-sensitive.
The nurse is teaching a group of students about incident reports. Which of the following situations would require an incident report? A visitor. Select all that apply.
- A. refusing to wear personal protective equipment (PPE).
- B. adjusting a client's infusion pump.
- C. requesting that their family member get pain medication.
- D. assisting their family member with brushing their teeth.
- E. stating that they fell while using the bathroom.
Correct Answer: A, B, E
Rationale: Refusing PPE (A), adjusting an infusion pump (B), and falling in the bathroom (E) are safety incidents requiring reports, as they pose risks or indicate harm. Requesting pain medication (C) and assisting with tooth brushing (D) are not reportable unless escalated.