Rationale:
A. Nonmaleficence refers to the ethical principle of avoiding harm or preventing injury. By removing a fall hazard, the nurse is actively working to prevent harm to the client.
B. Veracity means telling the truth and being honest with clients, which is not demonstrated in this scenario.
C. Utility focuses on the greatest good for the greatest number, not on preventing individual harm in a direct care setting.
D. Autonomy is respecting the client’s right to make their own decisions about care, but it does not apply to removing environmental hazards.

Rationale:
A. A client refusing therapy is not an unusual occurrence and does not require an incident report—this should be documented in the nursing notes instead.
B. An injury to a visitor, staff, or client is considered an unusual event and requires an incident report for risk management and safety follow-up.
C. A client throwing tissues may be disruptive, but since no injury or safety issue occurred, an incident report is not required. Documentation of behavior is sufficient.
D. Administering medication 30 minutes late is generally within the accepted time frame for most scheduled medications and does not require an incident report.

Rationale:
A. Administering an initial NG tube feeding requires assessment of tube placement and tolerance, which are nursing responsibilities—not within the AP’s scope.
B. Collecting a urine specimen is a routine, noninvasive task appropriate for delegation to an AP.
C. Checking a client’s pain level involves assessment, which cannot be delegated to an AP—it requires a licensed nurse.
D. Instructing a client about splinting an incision involves teaching, which is the nurse’s role, not the AP’s.

Rationale:
A. Shortness of breath with left neck and shoulder pain may indicate cardiac ischemia and is urgent, but it is not as immediately life-threatening as uncontrolled external bleeding.
B. A raised red skin rash is uncomfortable and may indicate allergy or infection, but it is not life-threatening at this moment.
C. Flank pain with diaphoresis suggests possible renal calculi or another serious condition, but it does not take priority over airway, breathing, or circulation compromise.
D. Active bleeding from the groin poses an immediate threat to circulation and survival, making this client the highest priority based on the ABC (Airway, Breathing, Circulation) framework.

Rationale:
A. It is not appropriate for the client to independently mark the operative site; this could lead to errors. Site marking must be done by the surgical team per protocol.
B. Contacting the surgery department does not directly resolve the client’s confusion or ensure proper informed consent.
C. The surgeon is responsible for confirming and clarifying the surgical site with the client. The nurse should advocate for the client’s safety by notifying the surgeon of the discrepancy.
D. Proceeding with surgery despite the client’s expressed concern would be unsafe and violates the principles of informed consent and patient safety.

Rationale:
A. A client with emphysema and an oxygen saturation of 92% is stable and within an expected range for this condition. This client’s care can be appropriately managed by an LPN.
B. Admission assessments must be completed by an RN, not an LPN.
C. Administration of blood products (RBCs) requires an RN due to the need for close monitoring and rapid intervention for transfusion reactions.
D. Initiating oral nutrition after a stroke involves swallowing assessment and risk for aspiration, which must be performed by an RN.

Rationale:
A. A post-cesarean client with a PCA pump requires routine postoperative monitoring and pain management, which are familiar tasks for a medical-surgical RN. This makes the assignment appropriate.
B. A client with premature rupture of membranes at 32 weeks requires specialized obstetrical knowledge and monitoring for complications such as infection and preterm labor.
C. A client with preeclampsia on misoprostol induction requires close fetal and maternal monitoring, which demands specialized obstetric expertise.
D. A client with gestational diabetes undergoing nonstress tests needs interpretation of fetal monitoring results, which is outside the scope of practice for a floated med-surg RN.

Rationale:
A. Client concerns about meals should be addressed but do not require an incident report—these can be managed through dietary services or routine documentation.
B. Difficulty obtaining medication from the pharmacy is a systems issue, but it does not directly involve a client safety event and therefore does not require an incident report.
C. A client’s refusal of medication is their right and should be documented in the medical record, not reported as an incident.
D. Withholding a client’s scheduled medication constitutes a medication error/variance, which directly affects client safety and must be documented using an incident report.

A. The client’s aPTT is within the therapeutic range for heparin, so immediate interdisciplinary discussion is not required.

B. Clients using insulin pumps require coordination between the nurse, endocrinologist, and diabetes educator to ensure safe insulin administration and blood glucose management, making an interdisciplinary conference appropriate.

C. Orthostatic hypotension being managed with IV fluids can typically be addressed within routine nursing care without needing an interdisciplinary meeting.

D. The client’s albumin level is within normal limits, and risk for pressure injuries can be managed with standard nursing interventions without requiring a conference.

Rationale:
A. Counseling the staff nurse directly is not the charge nurse’s role in this situation. Formal evaluation and intervention are handled through appropriate channels, not peer-to-peer counseling.
B. The charge nurse should first gather objective data (such as documentation of behavior, medication handling, or performance concerns) to support further action. This ensures any report is factual and unbiased.
C. The facility’s ethics committee does not handle suspected staff impairment. Reporting goes through management and possibly employee health or human resources.
D. Assigning “safe” clients to the nurse does not address the potential risk to all clients and enables impaired practice, which is unsafe and unethical.