A nurse in a long-term care facility is caring for a group of clients. The nurse should recognize that which of the following information is the highest priority to report to the nursing supervisor?

A client who has dementia and is experiencing paranoia

A client who has a UTI and reports itching after receiving a dose of cefaclor PO

A client who has heart failure and has gained 1 kg (2.2 lb) in the last 48 hr

A client who has a pressure ulcer on the left heel that has progressed from stage II to stage III

Answer and Explanation

The Correct Answer is B

A. Paranoia in a client with dementia requires monitoring and interventions for safety but is not immediately life-threatening.
B. Itching after receiving cefaclor (a cephalosporin antibiotic) indicates a possible allergic reaction. This can progress rapidly to anaphylaxis, making it the highest priority to report immediately.
C. A 1 kg weight gain in 48 hours in a client with heart failure is significant and should be reported, but it is not as urgent as a potential allergic reaction.
D. A pressure ulcer progressing from stage II to stage III requires timely intervention but does not present the immediate risk to life that an allergic reaction does.

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Correct Answer is A

Explanation

A. Not providing an interpreter for a client who speaks a different language may violate the client's right to understand their care, leading to potential legal issues regarding informed consent and patient safety.
B. A provider speaking to a client alone about suspected partner violence is appropriate as it ensures the client's privacy and safety during a sensitive discussion.
C. Prescribing a kosher meal tray for a client who practices the Orthodox Jewish faith is respectful and meets the dietary needs of the client, which is not a legal issue.
D. A client requesting that a nurse provide information to their partner is not inherently a legal issue, but the nurse must ensure that the client has consented to share their information to protect confidentiality.

A. Autonomy B. Fidelity C. Beneficence D. Justice

Correct Answer is A

Explanation

A. Autonomy refers to the right of individuals to make their own decisions regarding their healthcare, including the right to refuse treatment, which the nurse has supported in their response.
B. Fidelity involves being faithful to commitments made to patients, such as providing care and support, but does not directly pertain to the client's right to refuse treatment.
C. Beneficence focuses on promoting the well-being of the client, which may not align with the client’s decision to refuse treatment in this context.
D. Justice refers to fairness in healthcare and ensuring equitable treatment, but it does not address the specific right of the client to refuse treatment.

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A nurse in a long-term care facility is caring for a group of clients. The nurse should recognize that which of the following information is the highest priority to report to the nursing supervisor?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A charge nurse is observing the actions of the facility staff on the unit. Which of the following actions should the charge nurse identify as a possible legal issue?

Correct Answer is A

Explanation

A nurse is caring for a client who has a terminal illness and states that they wish to discontinue their enteral feedings. The nurse responds by saying, "You have a right to refuse treatment." This response by the nurse demonstrates which of the following ethical principles?

Correct Answer is A

Explanation

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