A nurse is caring for a client who experienced a lacerated spleen and has been on bedrest for several days. The nurse auscultates decreased breath sounds in the lower lobes of both lungs. The nurse should realize that this finding is most likely an indication of which of the following conditions?

Delayed gastric emptying

Pulmonary edema

An upper respiratory infection

Atelectasis

Answer and Explanation

The Correct Answer is D

A. Delayed gastric emptying is not associated with decreased breath sounds in the lower lobes of the lungs. It is more commonly associated with gastrointestinal symptoms such as bloating and nausea.
B. While pulmonary edema can cause respiratory symptoms, such as crackles and wheezes, decreased breath sounds in the lower lobes are not typically indicative of pulmonary edema. Pulmonary edema is more commonly associated with fluid accumulation in the lungs, leading to crackles and other signs of fluid overload.
C. An upper respiratory infection primarily affects the upper airways, such as the nose and throat, and typically presents with symptoms such as nasal congestion, sore throat, and cough. It is not typically associated with decreased breath sounds in the lower lobes of the lungs.
D. Atelectasis refers to the collapse or closure of a part of the lung, leading to decreased air entry and breath sounds in the affected area. In a client who has been on bedrest for several days, atelectasis can occur due to reduced lung expansion and ventilation. Decreased breath sounds in the lower lobes are a common finding in atelectasis, especially when the condition affects the bases of the lungs, as gravitational forces can exacerbate the collapse of lung tissue in dependent areas. Therefore, this finding is most consistent with atelectasis.

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Correct Answer is B

Explanation

Answer: B. Non-maleficence

Rationale:

A. Utility:
The principle of utility refers to actions that maximize the overall good or benefit for the greatest number of people. In this scenario, the nurse’s refusal to share the surgeon's medical diagnosis does not directly relate to maximizing benefits, so this principle is not applicable.

B. Non-maleficence:
Non-maleficence is the ethical principle that involves the obligation to avoid causing harm to others. By not disclosing the surgeon's medical diagnosis, the nurse is protecting the surgeon's privacy and confidentiality, thereby preventing potential harm that could arise from sharing sensitive health information without consent.

C. Paternalism:
Paternalism refers to making decisions for others with the belief that it is in their best interest, often overriding their autonomy. The nurse's action of withholding information is not based on deciding what is best for the other nurse but rather on adhering to confidentiality principles.

D. Justice:
Justice in healthcare refers to fairness in the distribution of resources and treatment. The situation does not pertain to equitable treatment or allocation of resources, so this principle is not relevant in this context.

A. Clear the respiratory tract B. Cut the umbilical cord C. Stimulate the infant to cry D. Dry the infant off and cover the head

Correct Answer is A

Explanation

A. Clear the respiratory tract: This is the correct action. Clearing the newborn's respiratory tract is the priority immediately after delivery to ensure adequate breathing. The nurse should suction the mouth and nose with a bulb syringe to remove any mucus or amniotic fluid and facilitate effective respiration.
B. Cut the umbilical cord: Cutting the umbilical cord is an important step in newborn care, but it is typically done after ensuring the newborn's immediate respiratory needs are met. The priority immediately after delivery is to establish effective breathing.
C. Stimulate the infant to cry: While stimulating the infant to cry can help clear the airways and establish effective breathing, it should be done concurrently with clearing the respiratory tract. Therefore, clearing the respiratory tract takes precedence over stimulating the infant to cry.
D. Dry the infant off and cover the head: Drying the infant and covering the head are important steps in newborn care to prevent heat loss and maintain thermal regulation. However, these actions can be done after ensuring the newborn's respiratory tract is clear and breathing is established.

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A nurse is caring for a client who experienced a lacerated spleen and has been on bedrest for several days. The nurse auscultates decreased breath sounds in the lower lobes of both lungs. The nurse should realize that this finding is most likely an indication of which of the following conditions?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing care for a surgeon on a medical-surgical unit. A nurse from another unit asks the nurse about the surgeon's medical diagnosis. The nurse responds that he is unable to provide the information requested. The nurse is displaying which of the following ethical principles?

Correct Answer is B

Explanation

Rationale:

A nurse is caring for a client who just delivered a newborn. Following the delivery, which nursing action should be done first to care for the newborn?

Correct Answer is A

Explanation

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