A charge nurse observes a client fall while ambulating with an assistive personnel and notes that the client's gait belt was not in place. When reviewing the incident report, the charge nurse finds that the report does not mention the gait belt. Which of the following ethical principles should the charge nurse follow?

Beneficence

Fidelity

Nonmaleficence

Veracity

Answer and Explanation

The Correct Answer is D

A. Beneficence refers to the ethical principle of doing good and promoting the well-being of clients, but it is not directly related to the integrity of incident reporting.

B. Fidelity involves being faithful to commitments and promises, but in this context, it does not address the importance of accurate reporting.

C. Nonmaleficence means "do no harm," which is essential in nursing practice, but it is not the principle that emphasizes honesty in documentation.

D. Veracity is the ethical principle that emphasizes truthfulness and accuracy, making it crucial for the charge nurse to ensure that the incident report accurately reflects the circumstances of the fall, including the absence of the gait belt.

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Correct Answer is B

Explanation

A. Changing total parenteral nutrition (TPN) tubing every 48 hours is incorrect. According to most guidelines, TPN tubing should be changed every 24 hours to reduce the risk of infection.

B. Changing peripheral IV primary tubing every 96 hours is a recommended practice in many healthcare settings. It balances infection prevention with cost-effectiveness and is widely accepted for maintaining IV line sterility.

C. Replacing peripheral IV solution bags every 96 hours would not be appropriate, as IV fluid bags should typically be replaced every 24 hours to prevent bacterial contamination.

D. Replacing TPN solution bags every 48 hours is not advisable, as TPN solutions should be replaced every 24 hours to minimize infection risks associated with high-sugar content solutions.

A. Meet with nursing staff to review the policy regarding advance directives. B. Reinforce the potential consequences of not having this information on record to the nursing staff. C. Ask nurses who are caring for clients without this information in the medical record to obtain it. D. Remind nurses to obtain this information during the admission process.

Correct Answer is A

Explanation

A. Meeting with the nursing staff to review the policy regarding advance directives addresses the systemic issue of documentation. This action helps to ensure that all staff are aware of the importance of advance directives and the necessity for proper documentation moving forward.

B. Reinforcing potential consequences is important but may not directly resolve the immediate lack of documentation in the records. Education without action does not change current practice.

C. Asking nurses to obtain the information is a necessary step, but it is essential first to address the overall understanding and policy compliance with the entire nursing staff.

D. Reminding nurses to obtain this information during the admission process is a good practice, but it does not address the current records that are lacking documentation.

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Naxlex Comprehensive Predictor Exams

A nurse is serving on a committee whose task is to plan cost-effective care at the facility. Which of the following client care tasks should the nurse recommend?

Correct Answer is B

Explanation

While auditing the medical records of clients currently on an oncology unit, the nurse manager finds that six of the 15 records lack documentation regarding advance directives. Which of the following is the priority action for the nurse to take?

Correct Answer is A

Explanation

A charge nurse provides an annual in-service for the nursing staff regarding ethical practice. Which of the following actions should the nurse include as an example of ethical practice?

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A charge nurse is assessing the room of a newly admitted client who has dysphagia. Which of the following pieces of equipment should the nurse ensure is available in the client's room?

A charge nurse is supervising the actions taken by a staff nurse following a client fall. The charge nurse should identify that which of the following actions by the staff nurse indicates an understanding of the procedure?

A nurse is attending an interprofessional team conference for a client who experienced a stroke. For which of the following findings should the team request a prescription for a referral to the occupational therapist?

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A nurse on an acute mental health unit is assessing four clients. Which of the following clients is the highest priority?

A nurse is teaching a client about advance directives. Which of the following statements by the client indicates an understanding of the teaching?