A nurse is prioritizing care for four clients.
Which of the following tasks should the nurse perform first?

Administer an antibiotic for a client who has methicillin-resistant Staphylococcus aureus.

Change the dressing for a client who has a decubitus ulcer.

Initiate oxygen therapy via nasal cannula for a client who has COPD.

Initiate a 24-hour urine collection for a client who has end-stage kidney disease.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Administering an antibiotic for a client with methicillin-resistant Staphylococcus aureus is essential to manage the infection. However, it does not require immediate attention compared to conditions threatening airway or oxygenation.

Choice B rationale

Changing the dressing for a decubitus ulcer is important for infection prevention and wound healing. However, it does not represent a life-threatening priority requiring urgent action compared to oxygenation needs.

Choice C rationale

Initiating oxygen therapy for a client with COPD addresses compromised oxygenation, a critical and life-threatening issue. Ensuring adequate oxygen levels is the highest priority in the ABCs of nursing (Airway, Breathing, Circulation).

Choice D rationale

Initiating a 24-hour urine collection for end-stage kidney disease is essential for diagnostic purposes but is not an immediate life-threatening need. Other tasks take precedence due to the urgency of stabilizing respiratory function. .

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Correct Answer is A

Explanation

Choice A rationale

Autonomy refers to the client’s right to make informed decisions about their care and treatment without external coercion. Acknowledging the client’s decision to discontinue treatment supports this principle, promoting respect for individual rights and preferences.

Choice B rationale

Fidelity involves maintaining trust and honoring commitments, such as upholding professional promises to deliver care. While important, it does not directly address the client’s right to refuse treatment in this scenario.

Choice C rationale

Justice pertains to fairness and equitable distribution of resources and care. This principle focuses on broader societal and ethical considerations rather than the individual’s decision-making rights.

Choice D rationale

Beneficence is the principle of acting in the best interest of the client, promoting their well-being. While relevant, it does not specifically address respecting the client’s right to refuse treatment.

A. A staff member places a midstream urine sample in a specimen refrigerator after collecting it. B. A staff member wipes a countertop with chlorhexidine solution to clean the area following a blood spill. C. A nurse uses alcohol-based antiseptic to clean his hands after talking with a client who has varicella zoster. D. A nurse pours sterile 0.9% sodium chloride irrigation solution on an open pressure wound prior to collecting a specimen for culture.

Correct Answer is C

Explanation

Choice A rationale

Refrigerating a midstream urine sample aligns with proper storage protocols, as it prevents degradation and ensures accurate results. This action adheres to infection control standards, minimizing contamination risks during specimen processing.

Choice B rationale

Cleaning with chlorhexidine following a blood spill adheres to effective infection control practices. Chlorhexidine is a potent antiseptic that eliminates pathogens and reduces infection risks, particularly after exposure to bloodborne microorganisms.

Choice C rationale

Alcohol-based antiseptic is ineffective against varicella zoster, which requires soap and water or antimicrobial agents to ensure decontamination. Misuse of antiseptics in this scenario poses an infection hazard as the nurse may inadvertently facilitate pathogen transmission.

Choice D rationale

Using sterile 0.9% sodium chloride irrigation solution is a standard wound-cleaning procedure, promoting sterility and minimizing infection risks. This practice aligns with aseptic techniques critical in specimen collection and wound care management. .

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A nurse is prioritizing care for four clients.Which of the following tasks should the nurse perform first?

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Naxlex Comprehensive Predictor Exams

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?

Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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A nurse is prioritizing care for four clients.
Which of the following tasks should the nurse perform first?