Which action will the nurse perform first to prevent harm for a client suspected to have fluid overload?

Assessing blood pressure.

Measuring intake and output.

Elevating the head of the bed.

Checking for presence of dependent edema.

Answer and Explanation

The Correct Answer is C

Choice A reason: Assessing blood pressure monitors fluid overload but doesn’t immediately reduce respiratory strain. Elevating the head of the bed improves breathing, making this incorrect, as it’s less urgent than the nurse’s first action to prevent harm from fluid overload.

Choice B reason: Measuring intake and output tracks fluid balance but is less immediate than elevating the bed to ease breathing. This is incorrect, as it delays the nurse’s priority action to alleviate respiratory distress in a client with suspected fluid overload.

Choice C reason: Elevating the head of the bed is the first action to reduce respiratory distress in fluid overload by decreasing venous return. This aligns with acute care priorities, making it the correct action to prevent harm in the client with suspected hypervolemia.

Choice D reason: Checking for dependent edema confirms fluid overload but doesn’t address immediate respiratory risks. Elevating the bed is urgent, making this incorrect, as it’s secondary to the nurse’s first action to improve breathing in the fluid-overloaded client.

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Correct Answer is D

Explanation

Choice A reason: Nonmaleficence ensures no harm but is less central than veracity, which ensures truthful disclosure for informed consent. Truthfulness enables autonomous decisions, making this incorrect, as it’s secondary to the ethical priority of honesty in the consent process for femur surgery.

Choice B reason: Fidelity involves keeping promises but doesn’t directly address the truthful disclosure required for informed consent. Veracity ensures the patient understands risks, making this incorrect, as it’s less relevant than honesty in the nurse’s role during the consent process for surgery.

Choice C reason: Beneficence promotes well-being but is secondary to veracity, which provides accurate information for the patient’s decision. Truthfulness is critical for consent, making this incorrect, as it’s not the primary ethical principle when soliciting informed consent for the femur procedure.

Choice D reason: Veracity, or truthfulness, is the most important ethical principle, ensuring the patient receives accurate information about risks and benefits for informed consent. This aligns with surgical ethical standards, making it the correct principle for the nurse to prioritize during the consent process.

A. “I need to increase the fiber in my diet.” B. “I will need to avoid caffeinated beverages.” C. “I’m going to learn some stress-reduction techniques.” D. “I can have exacerbations and remissions with Crohn’s disease.”

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.

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Which action will the nurse perform first to prevent harm for a client suspected to have fluid overload?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is taking care of a 60-year-old client who is scheduled for open reduction internal fixation of the left femur. Which ethical principle is most important when soliciting informed consent from the patient?

Correct Answer is D

Explanation

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?

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The nurse caring for a client with chronic obstructive pulmonary disease (COPD) anticipates which arterial blood gas (ABG) findings?

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A nurse in an emergency department is caring for a client who has a blood pressure of 254/139 mm Hg. The nurse recognizes that the client is in a hypertensive crisis. Which of the following actions should the nurse take first?

A nurse is providing teaching to a client who has venous insufficiency of the lower extremities. Which of the following statements by the client indicates an understanding of the teaching?

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