The nurse is completing a comprehensive history on a client admitted with weight loss and anorexia. What serum lab would the nurse expect to be ordered to evaluate the client’s nutritional status?

Choice A reason: HIPAA is a federal law that protects patient privacy and confidentiality of health information. While HIPAA is critical in nursing practice, it is a legal requirement rather than an ethical principle. Ethical principles are broader moral guidelines such as autonomy, beneficence, nonmaleficence, and justice. Therefore, HIPAA does not qualify as an ethical principle in this context.

Choice B reason: Duty to Warn is a legal and ethical obligation in specific circumstances, such as when a patient poses a danger to themselves or others. While it is related to ethical practice, it is considered more of a legal duty tied to safety rather than a foundational ethical principle guiding everyday nursing practice. Thus, it is not the best answer here.

Choice C reason: Beneficence is indeed an ethical principle that requires nurses to act in ways that benefit patients, promoting their well-being and preventing harm. However, the Question asks for the principle most directly emphasized in teaching new nurses, and autonomy is often prioritized because it underpins patient-centered care and informed consent. Beneficence is correct in general but not the best choice in this specific Question .

Choice D reason: Autonomy is a core ethical principle in nursing practice. It emphasizes respecting the patient’s right to make their own decisions about their care, even if those decisions differ from the nurse’s recommendations. Teaching new nurses about autonomy ensures they understand the importance of informed consent, patient rights, and shared decision-making. This principle is foundational to ethical nursing practice, making it the correct answer.

Choice A reason: Repeating the blood pressure in 30 minutes is unsafe because the client’s blood pressure has dropped significantly in a short period. Waiting could delay life-saving interventions. Immediate action is required to address potential shock or cardiovascular collapse.

Choice B reason: Documenting and continuing to monitor is inappropriate because the client is showing signs of acute hypotension. Passive monitoring without intervention places the client at risk for deterioration. Documentation is important but must accompany urgent action.

Choice C reason: Reassuring the client that they are doing well is misleading and unsafe. The client’s blood pressure indicates a critical condition that requires immediate intervention. False reassurance could delay recognition of the seriousness of the situation.

Choice D reason: Calling the Rapid Response team is the most appropriate action. A sudden drop in blood pressure from 120/82 to 88/50 suggests possible shock, internal bleeding, or sepsis. Rapid Response teams are trained to provide immediate advanced interventions, stabilize the client, and prevent cardiac arrest. This action prioritizes patient safety and aligns with emergency protocols.