A nurse is reviewing client charts to collect data on the number of urinary catheters that were removed within 48 hours of surgery. This collection of information demonstrates which of the following processes?

Structure audit

Benchmarking

Outcome audit

Process audit

Answer and Explanation

The Correct Answer is C

A. A structure audit examines the resources, facilities, and organizational structure in place rather than specific patient outcomes or interventions.

B. Benchmarking involves comparing performance metrics to industry standards or best practices but does not specifically apply to this situation.

C. An outcome audit focuses on the results of care, specifically looking at the effectiveness of care practices, such as the timely removal of urinary catheters, to prevent complications.

D. A process audit evaluates the methods and processes of care rather than the outcomes, which is not applicable in this context.

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Correct Answer is D

Explanation

A. A brief loss of consciousness suggests a less immediate need for life-saving intervention, which would not warrant a red tag; this client would likely be assigned a yellow tag for delayed care.

B. Fixed pupils indicate severe neurological damage or death, making this client unlikely to benefit from emergency interventions. In a mass casualty event, this client would likely be assigned a black tag.

C. A client with burns covering 70% of their body is likely in critical condition, but due to the extensive nature of the injuries, this client may not receive immediate life-saving interventions and might be assigned a yellow or black tag.

D. A compromised airway represents an immediate, life-threatening condition requiring urgent intervention, making this client a priority for treatment and thus assigned a red tag.

A. A nurse raises all four side rails on the bed of a client who is confused. B. A nurse administers prescribed opioids to a client who has a terminal illness and respiratory rate of 8/min. C. A nurse elects not to care for a client who had an abortion. D. A nurse withholds nutrition from a client who has a do-not-resuscitate (DNR) order.

Correct Answer is B

Explanation

A. Raising all four side rails on a confused client’s bed is considered a restraint and violates the principle of autonomy. Restraints should only be used as a last resort and require a provider’s order. Ethical practice involves finding less restrictive alternatives, such as using a sitter or bed alarms.

B. Administering opioids to a terminally ill client, even with a low respiratory rate, aligns with ethical nursing principles such as beneficence (relieving suffering) and nonmaleficence (preventing harm) when used for palliative care. In end-of-life care, the priority is comfort, and pain management is considered ethical even if it may impact respiration. This aligns with the principle of double effect, which justifies an action intended for good (pain relief) even if it has potential negative side effects (respiratory depression).

C. Electing not to care for a client due to personal beliefs is an example of bias and does not adhere to the ethical principle of fidelity, which requires nurses to provide care regardless of personal beliefs.

D. Withholding nutrition from a client with a DNR order is not ethical unless there is a clear directive regarding the client's wishes, and it may cause harm.

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A nurse is reviewing client charts to collect data on the number of urinary catheters that were removed within 48 hours of surgery. This collection of information demonstrates which of the following processes?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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