The nurse cares for a client diagnosed with Type 1 diabetes and Raynaud’s disease. The orders include continuous pulse oximetry monitoring. Which situation requires an intervention by the nurse?

The nurse discusses the pulse oximetry findings with the client.

The client has the pulse oximeter and automatic blood pressure cuff on the same arm.

The pulse oximeter is placed on the ring finger of the client’s right hand.

The nurse instructs nursing assistive personnel to obtain a pulse oximetry reading.

Answer and Explanation

The Correct Answer is B

Choice A reason: Discussing pulse oximetry findings with the client is appropriate and promotes understanding, not requiring intervention. A blood pressure cuff on the same arm affects readings, making this incorrect, as it’s a correct nursing action for the client with Raynaud’s and diabetes.

Choice B reason: A blood pressure cuff on the same arm as the pulse oximeter disrupts blood flow, causing inaccurate readings, especially in Raynaud’s disease. This requires intervention, aligning with monitoring accuracy standards, making it the correct situation for the nurse to address immediately.

Choice C reason: Placing the pulse oximeter on the ring finger is appropriate, avoiding Raynaud’s-affected areas. A cuff on the same arm is problematic, making this incorrect, as it’s a standard placement not requiring intervention in the client’s monitoring setup.

Choice D reason: Instructing assistive personnel to obtain readings is acceptable if within their scope. A cuff on the same arm affects accuracy, making this incorrect, as it’s not an issue compared to the intervention needed for the pulse oximeter placement error.

Choice E reason: An LPN recording the pulse from the oximeter is within their role and not problematic. A cuff on the same arm requires intervention, making this incorrect, as it’s a correct action unlike the inaccurate monitoring setup needing nurse correction.

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Correct Answer is A

Explanation

Choice A reason: Increasing fiber during Crohn’s exacerbation worsens diarrhea and inflammation, indicating a misunderstanding. A low-fiber diet is recommended, making this the correct statement needing further instruction, as it contradicts the nurse’s teaching on managing dietary needs during Crohn’s disease flare-ups.

Choice B reason: Avoiding caffeinated beverages is correct, as they stimulate the gut and worsen Crohn’s symptoms. This aligns with dietary teaching, making it incorrect, as it shows understanding, unlike the incorrect fiber statement requiring further instruction from the nurse.

Choice C reason: Learning stress-reduction techniques is appropriate, as stress can trigger Crohn’s exacerbations. This reflects understanding of self-management, making it incorrect, as it aligns with the nurse’s teaching, unlike the fiber statement indicating a need for further dietary instruction.

Choice D reason: Recognizing exacerbations and remissions is accurate for Crohn’s disease, showing disease knowledge. This aligns with the nurse’s education, making it incorrect, as it demonstrates understanding, unlike the fiber statement that requires further instruction to correct the client’s misconception.

A. Nonmaleficence. B. Fidelity. C. Beneficence. D. Veracity.

Correct Answer is D

Explanation

Choice A reason: Nonmaleficence ensures no harm but is secondary to veracity, which provides truthful information for consent. Truthfulness is critical, making this incorrect, as it’s not the primary ethical principle the nurse prioritizes when soliciting informed consent from a patient.

Choice B reason: Fidelity involves keeping promises but doesn’t directly ensure the patient receives accurate information for consent. Veracity is key, making this incorrect, as it’s less relevant than the nurse’s focus on truthfulness during the informed consent process.

Choice C reason: Beneficence promotes well-being but is less critical than veracity, which ensures informed decision-making. Truthful disclosure is primary, making this incorrect, as it’s secondary to the nurse’s ethical priority when obtaining informed consent from the patient.

Choice D reason: Veracity, or truthfulness, is the most important principle, ensuring the patient receives accurate information for informed consent. This aligns with ethical standards, making it the correct principle the nurse prioritizes to support autonomous decision-making during the consent process.

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The nurse cares for a client diagnosed with Type 1 diabetes and Raynaud’s disease. The orders include continuous pulse oximetry monitoring. Which situation requires an intervention by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is providing discharge teaching for a client with newly diagnosed Crohn's disease about dietary measures to implement during exacerbation episodes. Which statement made by the client indicates a need for further instruction?

Correct Answer is A

Explanation

Which ethical principle is most important when soliciting informed consent from a patient?

Correct Answer is D

Explanation

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