A nurse is caring for a client when they erroneously administer a medication dosage that is greater than the amount prescribed. Which of the following ethical principles is the nurse demonstrating when they notify the provider of the medication error?

Rationale:

A. This option is correct because all significant changes in the client’s condition, including the sudden deterioration and intubation, must be documented accurately in the EMR. Thorough documentation ensures continuity of care, legal protection, and communication among the interprofessional team.

B. This option is correct because the client’s sudden deterioration and need for mechanical ventilation require immediate revision of the care plan. Updates should include new interventions, monitoring requirements, and goals relevant to the client’s current status, ensuring safe and appropriate care.

C. This option is correct because a negative variance occurs when the client’s actual progress deviates from the expected outcomes outlined in the critical pathway. The client’s sudden respiratory failure represents a deviation that should be recorded to guide future care planning and quality improvement.

D. This option is incorrect because the critical pathway should not be discontinued; it remains a guide for expected outcomes. Instead, variances should be documented, and the pathway adjusted as appropriate.

E. This option is incorrect because the client is acutely unstable and requires ongoing intensive care. Discharge summary documentation is premature and not relevant at this point.

Rationale:

A. This option is incorrect because allowing a client with cognitive impairment to sit at the nurses’ station during the day without supervision can increase risks for wandering, agitation, or injury. Clients with cognitive deficits often have difficulty understanding their environment and may inadvertently interfere with clinical operations or put themselves at risk. Safe, structured, and familiar environments are preferable.

B. This option is correct because placing the client’s room near the nurses’ station allows for closer monitoring and timely intervention if the client becomes confused, attempts to wander, or exhibits behavioral changes. This proximity supports patient safety while still promoting a sense of autonomy and privacy. Nurses can quickly respond to needs or emergencies, which is especially important for clients with cognitive impairment who may not recognize hazards or communicate effectively.

C. This option is incorrect because using full-length bed rails for clients with cognitive impairment is associated with increased risk of entrapment, injury, or falls if the client attempts to climb over them. Safer alternatives include half rails, low beds, or motion-sensor alarms, which protect the client while reducing risk.

D. This option is incorrect because a red wristband indicating fall risk is only a visual cue for staff and does not actively prevent falls. Comprehensive fall prevention requires environmental modifications, frequent monitoring, use of assistive devices, and individualized care plans rather than relying solely on identification bands.