A nurse administers an incorrect medication to a client. Following an assessment of the client, the nurse determines that the client has not experienced any adverse effects as a result of the medication. The nurse does not complete an incident report because no harm came to the client. Which of the following ethical principles did the nurse violate?

Autonomy.

Veracity.

Confidentiality.

Beneficence.

Answer and Explanation

The Correct Answer is B

A. Autonomy: This principle refers to respecting a patient's right to make their own decisions about their healthcare. In this scenario, the nurse's actions did not directly impact the client's autonomy, as the client was not involved in the decision-making process regarding the incident report.

B. Veracity: This principle involves being truthful and transparent. By not completing an incident report, the nurse failed to uphold veracity, as this action concealed the truth about the medication error, potentially affecting future care and trust in the healthcare system.

C. Confidentiality: This principle is about protecting patient information. The nurse's failure to report the incident did not violate confidentiality, as it did not involve disclosing or mishandling the client's private information.

D. Beneficence: This principle focuses on doing good and acting in the best interest of the patient. While the nurse's intention might have been to avoid unnecessary alarm, failing to report the incident could prevent the healthcare team from learning from the mistake and improving patient safety, thus indirectly affecting beneficence.

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Correct Answer is A

Explanation

Choice A rationale:

This choice is correct. Hepatitis B is primarily transmitted through contact with infected blood and bodily fluids. Contact precautions are designed to prevent the spread of infections that are transmitted through direct or indirect contact. These precautions include wearing gloves and gowns when in contact with the client or their environment.

Choice B rationale:

Droplet precautions are not appropriate for hepatitis B. Droplet precautions are used for infections that are spread through respiratory droplets, like coughing or sneezing. Hepatitis B is not primarily transmitted through respiratory droplets.

Choice C rationale:

Standard precautions involve the use of protective barriers such as gloves, gowns, masks, and eye protection to prevent the transmission of infections. While these precautions should always be practiced, they are not specifically tailored to hepatitis B, which has its own set of precautions.

Choice D rationale:

Airborne precautions are used for infections that are spread through small respiratory particles that remain suspended in the air for longer periods. Hepatitis B is not transmitted through airborne routes, so airborne precautions are not necessary.

A. Patient ate half of his breakfast tray. B. Patient has a raised erythematous rash below the knee. C. Patient has a capillary refill of less than 2 seconds. D. Patient is incontinent of stool.

Correct Answer is D

Explanation

Choice A rationale:

The choice "Patient ate half of his breakfast tray" is not the correct answer. While poor appetite or decreased intake can impact a patient's nutritional status, it is not a direct indicator of pressure ulcer risk.

Choice B rationale:

The choice "Patient has a raised erythematous rash below the knee" is not the correct answer. This might indicate a localized skin issue, such as an allergic reaction or dermatitis, but it is not a clear sign of pressure ulcer risk.

Choice C rationale:

The choice "Patient has a capillary refill of less than 2 seconds" is not the correct answer. Capillary refill time assesses peripheral circulation and is useful in evaluating perfusion, but it is not specifically indicative of pressure ulcer risk.

Choice D rationale:

The correct answer is "Patient is incontinent of stool." Choice D is the correct answer. Incontinence, especially fecal incontinence, increases the risk of pressure ulcer development. Prolonged exposure to moisture from urine or stool weakens the skin's integrity, making it more susceptible to breakdown when pressure is applied over bony prominences.

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Naxlex Comprehensive Predictor Exams

A nurse is admitting a client who has hepatitis

Correct Answer is A

Explanation

A nurse on a Medical-Surgical unit is caring for an elderly patient. Which of the following nursing observations would indicate that the patient is at risk for developing a pressure ulcer?

Correct Answer is D

Explanation

A nurse is teaching a client's spouse about how to obtain a blood pressure reading. Which of the following actions by the spouse indicates a need for further instruction?

A nurse is educating a newly licensed nurse about ethical principles. Which of the following situations is an example of beneficence?

A nurse in an emergency department is caring for a client who has a deep laceration on her left lower forearm and is bleeding heavily from the wound. Which of the following interventions should the nurse perform first?

A nurse is admitting a client who has a wound infected with methicillin-resistant Staphylococcus aureus (MRSA). Which of the following types of precautions should the nurse plan to initiate?

A nurse is assessing a client who has a pressure ulcer. The nurse should recognize which of the following findings is a manifestation of a stage 3 pressure ulcer?

A nurse notices an assistive personnel (AP) preparing to deliver a food tray to his client who practices the Orthodox Jewish faith. On the tray is a roast beef dinner with nonfat milk. Which of the following actions should the nurse take?

A school nurse identifies that a child has pediculosis capitis (head lice) and educates the child's parents about the condition. Which of the following statements by the parents indicates an understanding of the teaching?

A nurse is caring for a client who is participating in a research study for an experimental chemotherapy medication. After three treatments, the experimental medication is discontinued due to evidence of rapidly advancing kidney failure. Which of the following ethical principles was demonstrated?