A nurse notes that a client is confused, impulsive, and unstable with mobility. The nurse fears the client is in danger of harming themselves so they ask for a sitter to stay at the bedside to keep the client company and minimize the risk for falls. What ethical principle is the nurse demonstrating?

Nonmaleficence

Veracity

Fidelity

Beneficence

Answer and Explanation

The Correct Answer is A

The correct answer is choice A. By asking for a sitter to stay at the bedside to keep the client company and minimize the risk for falls, the nurse is demonstrating the ethical principle of nonmaleficence. Nonmaleficence refers to the duty to do no harm to the client, and in this case, the nurse is taking proactive steps to prevent harm to the client by ensuring their safety and well-being. Veracity (choice B) refers to the principle of truthfulness and honesty in communication, fidelity (choice C) refers to the principle of keeping promises and maintaining trust in the nurse-client relationship, and beneficence (choice D) refers to the principle of promoting good and doing what is in the best interest of the client. While all of these principles are important in nursing practice, the nurse in this scenario is primarily demonstrating nonmaleficence by taking action to prevent harm to the client.

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Correct Answer is C

Explanation

A.This option is incorrect because a PVR of 400 mL is significantly higher than normal. Documenting without further intervention could lead to complications if the high residual volume persists.

B.While an external catheter may be beneficial for managing incontinence or monitoring urine output, it does not address the underlying issue of urinary retention. An external catheter would not relieve the retained urine in the bladder.

C.A post-void residual (PVR) of 400 mL is abnormally high, indicating that the bladder is not emptying effectively, which can lead to discomfort, urinary tract infection (UTI), and potential kidney issues if left untreated. An in-and-out catheterization allows for temporary relief by emptying the bladder and can also help prevent bladder distention. Contacting the physician to report the findings and obtain an order is appropriate to manage this condition safely.

D. Encouraging the client to attempt voiding again without intervention may not be effective in reducing the high PVR. This delay could increase the risk of bladder distention and discomfort.

A. Tertiary B. Primary C. Quaternary D. Secondary

Correct Answer is A

Explanation

The correct answer is choice A, tertiary.

Tertiary prevention aims to improve quality of life and reduce the negative impact of a chronic illness or disability, such as helping the man regain lost function after a stroke. Occupational therapy is a common intervention in tertiary prevention, as it focuses on helping patients adapt to their limitations and develop compensatory strategies to perform daily activities.

Primary prevention aims to prevent a disease or injury before it occurs, such as immunizations or health education to prevent stroke risk factors. Secondary prevention aims to detect and treat a disease in its early stages to prevent complications, such as screening for high blood pressure or high cholesterol levels. Quaternary prevention aims to reduce the harm caused by unnecessary or excessive healthcare interventions, such as avoiding overprescribing medications.

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Naxlex Comprehensive Predictor Exams

A client had his Foley catheter removed six hours ago and has just voided for the first time. The nurse performs a bladder scan to check for any post-void residual. The results of the post-void residual (PVR) from the bladder scan are 400mL of urine. What should the nurse do next?

Correct Answer is C

Explanation

A 54-year-old man is participating in occupational therapy following a strokecausing right-sided weakness. What level of health promotion is being exhibited?

Correct Answer is A

Explanation

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