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

Choice A rationale

Consulting with the client’s family would delay critical actions in an emergency. Additionally, family members cannot override the legal documentation of the client's wishes, such as a living will. Ethical guidelines prioritize the client's autonomy, but without a written DNR, the nurse should prioritize immediate life-saving efforts.

Choice B rationale

A living will outlines patient preferences, but it is not legally enforceable without a corresponding provider’s order. Complying with it without a written DNR could violate legal and professional standards. The nurse must initiate life-saving actions unless explicitly instructed otherwise by the provider.

Choice C rationale

Without a written DNR, the nurse must take measures to preserve life as per standard resuscitation guidelines. Legal protection applies to actions taken during a cardiac arrest to avoid negligence. This ensures that the client receives immediate care until proper clarification is made.

Choice D rationale

Contacting the provider during a cardiac arrest introduces a delay, increasing the risk of irreversible damage or death. While it is essential to clarify orders, emergency protocol dictates acting promptly to save the client’s life in the absence of clear documentation.

Choice A rationale

A weight gain of 1 kg (2.2 lb) in 48 hours can be an early indicator of fluid retention in clients with heart failure. However, this change is not immediately life-threatening and can be addressed by monitoring or adjusting medications, making it lower priority compared to acute allergic reactions.

Choice B rationale

Paranoia in dementia clients reflects cognitive decline or psychological distress, which requires management but does not pose an immediate threat to physical health. It is important but not the highest priority for immediate reporting.

Choice C rationale

Progression of a pressure ulcer to stage III indicates worsening tissue damage, requiring evaluation of wound care strategies. However, this concern does not constitute an urgent situation compared to an acute allergic reaction that can compromise airway and systemic stability.

Choice D rationale

Itching after receiving cefaclor PO is a possible sign of an allergic reaction. Allergic reactions can escalate to anaphylaxis, posing immediate life-threatening risks. Recognizing and reporting this symptom promptly is critical for client safety.