Which statement made by the nurse to a client reflects the ethical principle of nonmaleficence?

"Your family is encouraged to visit you at any time."

"I am going to put your side rails up on your bed when we transfer you to another unit."

"I am going to hold your next dose of medication and contact your prescriber because you have developed hives."

"I understand you are very upset. Do you mind if I sit with you?"

Answer and Explanation

The Correct Answer is C

Nonmaleficence is an ethical nursing principle requiring avoidance of harm, prioritizing harm prevention, patient safety, and risk avoidance through interventions that reduce injury, complications, and iatrogenic outcomes overall.

Rationale:

A. This statement reflects family support and visitation policy rather than nonmaleficence. It promotes emotional comfort but does not address prevention of harm or patient safety concerns. Nonmaleficence focuses on avoiding patient harm primarily. Thus it is incorrect choice here.

B. This statement represents routine fall prevention during patient transfer rather than a direct ethical response to harm. It reduces injury reduction risk but is procedural safety practice. Nonmaleficence involves preventing patient harm actively. This is general safety care.

C. This statement directly demonstrates medication safety by preventing further exposure to a drug causing harm. Holding the dose addresses adverse reaction signs such as hives indicating hypersensitivity. This prevents worsening allergic response progression. It aligns with nonmaleficence principle.

D. This statement reflects therapeutic communication aimed at providing emotional support rather than preventing physical harm. It demonstrates empathy and presence in patient interaction. However it does not address nonmaleficence principle directly. It is supportive but not safety focused.

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Correct Answer is B

Explanation

Respiratory acidosis occurs when alveolar hypoventilation impairs the clearance of carbon dioxide, leading to hypercapnia. The kidneys eventually compensate through bicarbonate retention, but acute shifts cause rapid pH drops below 7.35. Obstruction or impaired gas exchange are the primary physiological triggers for this acid-base imbalance.

Rationale:

A. Oxygen administration treats hypoxemia, but the client’s PaO2 of 87 mmHg is currently within the normal 80-100 mmHg range. This intervention does not address the underlying hypercapnia or the elevated PaCO2 level. Oxygen won't improve ventilation mechanics in this specific scenario.

B. This is the priority intervention to facilitate carbon dioxide removal. Promoting lung expansion and clearance of secretions through coughing and deep breathing improves alveolar ventilation and restores acid-base balance. It addresses the root cause of respiratory acidosis directly.

C. While the provider should be informed of abnormal results, the nurse must first implement independent nursing interventions. Stabilizing the client through improved ventilation is the immediate priority before performing clerical notification. Immediate clinical action takes precedence over reporting.

D. The pulse oximetry provides a non-invasive estimate of oxygen saturation, but the ABG already confirms a normal PaO2 level. Obtaining more data on oxygenation is redundant and delays the necessary treatment for respiratory distress. Focus must remain on correcting the pH.

A. A PICOT question B. Hierarchy of evidence. C. Qualitative research D. Critical pathway

Correct Answer is D

Explanation

A critical pathway is a multi-professional standardized map that outlines the sequence and timing of clinical interventions for specific diagnoses. By integrating evidence-based protocols, these tools streamline the delivery of care and minimize variations in treatment. They serve as a primary mechanism for managing utilization review and ensuring cost-effective, high-quality outcomes within a predetermined timeframe.

Rationale:

A. The PICOT framework is a specialized tool used to formulate clinical questions during the initial stages of research or evidence discovery. While it helps nurses identify knowledge gaps, it is not a direct guide for the daily delivery of interdisciplinary bedside care. PICOT focus is on inquiry structure rather than the operational coordination of a client’s treatment plan.

B. The hierarchy of evidence is a grading system used to evaluate the methodological quality and reliability of research findings. It assists clinicians in determining which studies provide the most robust data for clinical decision-making. However, it functions as a theoretical framework for research appraisal, not a practical clinical tool for coordinating team-based care activities.

C. Qualitative research is a scientific method used to explore subjective experiences, perceptions, and social phenomena through non-numerical data. While it provides deep insights into the human response to illness, it does not provide a structured timeline for medical and nursing interventions. It lacks the prescriptive nature required to guide a synchronized interdisciplinary care plan.

D. A critical pathway is the priority tool for guiding interdisciplinary care as it defines milestone achievements for a specific client population. It facilitates communication across departments by identifying the optimal sequence of nursing, medical, and rehabilitative actions. This tool is essential for identifying variances and ensuring the team meets established clinical benchmarks efficiently.

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Which statement made by the nurse to a client reflects the ethical principle of nonmaleficence?

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