Which of the following actions by the new nurse requires immediate intervention by the experienced nurse?

Does not let patient know that nurse is assessing respirations.

Auscultating heart sounds using bell of stethoscope.

Assessing both carotid pulse sites at the same time.

Cleaning stethoscope between patient assessments.

Answer and Explanation

The Correct Answer is C

Choice A rationale
It is a common practice for nurses to assess a patient’s respirations without explicitly stating so. This is because patients may alter their breathing pattern if they know it’s being observed.
Choice B rationale
Auscultating heart sounds using the bell of the stethoscope is a standard practice in nursing. The bell of the stethoscope is used specifically to listen to low-frequency sounds such as heart murmurs.
Choice C rationale
Assessing both carotid pulse sites at the same time is dangerous and should be avoided. This action can lead to reduced blood flow to the brain, possibly causing the patient to faint or experience a decrease in cerebral blood flow.
Choice D rationale
Cleaning the stethoscope between patient assessments is a recommended practice to prevent the spread of infections.

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Correct Answer is B

Explanation

Choice A rationale
While auscultating the lung fields can provide valuable information about the patient’s respiratory status, it is not the most immediate action needed for a COPD patient with an oxygen saturation of 89%4.
Choice B rationale
Administering oxygen is the most appropriate action for a COPD patient with an oxygen saturation of 89%. This will help increase the patient’s oxygen saturation and alleviate their shortness of breath.
Choice C rationale
Elevating the head of the bed can help improve lung expansion and ease breathing, but it is not as immediately effective as administering oxygen.
Choice D rationale
Assisting the patient to get up to the chair is not the most immediate action needed for a COPD patient with an oxygen saturation of 89%4.

A. Justice. B. Accountability. C. Confidentiality. D. Fidelity.

Correct Answer is B

Explanation

Choice A rationale
Justice refers to fairness and equality in healthcare. While it is an important ethical principle in nursing, it does not specifically compel a nurse to report missing medication26.
Choice B rationale
Accountability is the ethical standard that compels a nurse to report missing medication. Nurses are accountable for their actions and are responsible for reporting any discrepancies or issues that could impact patient safety26.
Choice C rationale
Confidentiality refers to the protection of patient information. While it is an important ethical principle in nursing, it does not specifically compel a nurse to report missing medication26.
Choice D rationale
Fidelity refers to the commitment to fulfill promises and obligations. While it is an important ethical principle in nursing, it does not specifically compel a nurse to report missing medication26.

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Which of the following actions by the new nurse requires immediate intervention by the experienced nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient with chronic obstructive pulmonary disease (COPD) is experiencing shortness of breath while breathing room air. The patient’s pulse oximetry reading is 89% and their respiratory rate is 22. What should be the nurse’s priority action?

Correct Answer is B

Explanation

A nurse is conducting a medication count of narcotics in the cart. The nurse discovers an incorrect count and missing narcotic medication. Which ethical standard compels the nurse to report the missing medication?

Correct Answer is B

Explanation

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