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?

Fidelity

Nonmaleficence

Beneficence

Veracity

Answer and Explanation

The Correct Answer is D

Choice A Reason:
Fidelity is inappropriate. Fidelity refers to the obligation to fulfill commitments and responsibilities. While important in maintaining trust and professional relationships, fidelity may not directly apply to the situation described.
Choice B Reason:
Nonmaleficence is inappropriate. Nonmaleficence is the principle of doing no harm. In this situation, ensuring the safety and well-being of the client is paramount, and failing to use a gait belt could potentially lead to harm. However, the primary issue in this scenario is the accuracy and completeness of the incident report rather than the act of causing harm.
Choice C Reason:
Beneficence is inappropriate. Beneficence is the principle of doing good and acting in the best interest of the client. While ensuring the use of a gait belt aligns with promoting the client's safety and well-being, the primary concern in this scenario is the integrity and honesty in reporting the incident accurately.
Choice D Reason:
Veracity is appropriate. Veracity refers to truthfulness and honesty. In this situation, the charge nurse should ensure that the incident report accurately reflects the circumstances of the fall, including the absence of the gait belt. Being truthful and transparent in reporting incidents is essential for maintaining trust, promoting accountability, and improving patient safety.

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Correct Answer is D

Explanation

Choice A Reason:
A client who has Guillain-Barré syndrome and a tracheostomy is incorrect. Guillain-Barré syndrome can be a complex condition, especially when accompanied by a tracheostomy. Caring for a client with this condition requires knowledge and experience in managing respiratory and neurological complications. It may not be suitable for a newly licensed nurse who may require more experience to manage such complex care needs.
Choice B Reason:
A client who has a brain tumor and is admitted for chemotherapy is incorrect. Caring for a client with a brain tumor undergoing chemotherapy involves understanding the effects of both the tumor and the treatment on the client's neurological status and overall well-being. It may require advanced assessment skills and knowledge of potential complications. Assigning this client to a newly licensed nurse may not be appropriate without additional support and supervision.
Choice C Reason:
A client who has multiple sclerosis and ataxia is incorrect. Multiple sclerosis (MS) can present with various neurological symptoms, including ataxia, which affects coordination and balance. Managing the care of a client with MS and ataxia may require familiarity with the disease process, symptom management strategies, and potential complications. It may be more suitable for a nurse with some experience in neurological nursing.
Choice D Reason:
A client who sustained a concussion and is being monitored for complications is correct. Caring for a client with a concussion being monitored for complications is typically within the scope of practice for a newly licensed nurse. Monitoring for changes in neurological status, assessing for signs of increased intracranial pressure, and providing supportive care are tasks that can be managed by a newly licensed nurse under appropriate supervision.

A. "I will have a client who is on airborne precautions wear a mask when out of her room." B. "I will place a client who has compromised immunity in a negative-pressure airflow room." C. "I will instruct visitors to wear a mask when visiting a client who is on contact precautions." D. "I will wear an N95 respirator mask when caring for a client who is on droplet precautions."

Correct Answer is A

Explanation

Choice A Reason:
Clients on airborne precautions (e.g., for tuberculosis, varicella, or measles) should wear a mask if they need to leave their room to prevent the spread of airborne pathogens to others. This helps to contain infectious particles and protect others from exposure.

Choice B Reason:
A client with compromised immunity should be placed in a positive-pressure airflow room, not a negative-pressure room. Positive-pressure rooms help prevent outside contaminants from entering the room, thereby protecting the immunocompromised client. Negative-pressure rooms are used for clients with airborne infectious diseases to prevent the spread of pathogens to other areas.

Choice C Reason:
Contact precautions typically involve wearing gloves and a gown to prevent the spread of infectious agents through direct contact. Masks are not generally required for visitors unless the client is also on droplet or airborne precautions. Therefore, this statement reflects a misunderstanding of the specific requirements for contact precautions.

Choice D Reason:
An N95 respirator mask is required for airborne precautions, not droplet precautions. For droplet precautions (e.g., for influenza, pertussis), a standard surgical mask is sufficient to protect against respiratory droplets.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is orienting a newly licensed nurse on the neurological unit. Which of the following clients should the nurse assign to the newly licensed nurse?

Correct Answer is D

Explanation

A nurse manager is reviewing isolation guidelines with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates understanding of isolation guidelines?

Correct Answer is A

Explanation

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 nurse is preparing a client for surgery. The client expresses concern that someone might steal her purse during the procedure. Which of the following actions should the nurse take?

A nurse on a surgical unit is preparing to transfer a client to a rehabilitation facility. Which of the following information should the nurse include in the change-of-shift report?

A nurse is planning discharge for a client who had a lung resection. The nurse initiates a referral for a social worker. Which of the following assessment data supports this referral?

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

A nurse is preparing to fax information to a rehabilitative facility prior to transferring a client. Which of the following actions should the nurse plan to take?

A nurse is observing a newly licensed nurse prepare a medication from an ampule for a client's injection. For which of the following actions by the newly licensed nurse should the nurse intervene?

A charge nurse is observing the staff on the unit. Which of the following situations should the charge nurse identify as a breach of confidentiality? (Select all that apply.)