A charge nurse observes a client fall while ambulating with an assistive personnel and notes that the client's gait belt was not in place. When reviewing the incident report, the charge nurse finds that the report does not mention the gait belt. Which of the following ethical principles should the charge nurse follow?

Nonmaleficence

Fidelity

Veracity

Beneficence

Answer and Explanation

The Correct Answer is C

A.   Nonmaleficence: This principle emphasizes the obligation to avoid causing harm. While the absence of a gait belt could have contributed to the client's fall, the primary ethical concern in this scenario is related to truthfulness and honesty in documentation rather than solely avoiding harm.
B.   Fidelity: Fidelity refers to the obligation to fulfill commitments and obligations. While accurate documentation is part of professional integrity, the primary ethical issue in this scenario is related to honesty and accuracy in reporting rather than fidelity to commitments.
C.   Veracity: This is the correct answer. Veracity refers to truthfulness and honesty. The charge nurse should ensure that incident reports accurately reflect the circumstances surrounding a client's fall, including the absence of a gait belt, to maintain ethical standards and promote patient safety.
D.   Beneficence: Beneficence involves acting in the best interest of the patient and promoting their well-being. While the absence of a gait belt may have compromised the client's safety, the primary ethical issue in this scenario is related to truthfulness in reporting rather than directly promoting the client's well-being.

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Correct Answer is B

Explanation

A. Reinforce the potential consequences of not having this information on record to the nursing staff: While reinforcing the importance of advance directives is necessary, the immediate priority is to ensure that missing information is obtained.
B. Ask nurses who are caring for clients without this information in the medical record to obtain it: This is the correct answer. The priority action is to address the missing documentation by
instructing nurses to obtain advance directive information from clients who lack it in their medical records.
C. Meet with nursing staff to review the policy regarding advance directives: While policy review may be necessary, it is not the immediate action needed to address the missing documentation.
D. Remind nurses to obtain this information during the admission process: While obtaining advance directive information during the admission process is important, the priority is to address the missing documentation for current clients.

A. "I will place a client who requires protective isolation in a negative airflow room." B. "I will wear a cover gown when caring for a client who has herpes simplex." C. "I will use an alcohol-based hand cleanser when caring for a client who has Clostridium difficile." D. "I will wear an N95 respirator mask when caring for a client who is on contact precautions."

Correct Answer is B

Explanation

A. "I will place a client who requires protective isolation in a negative airflow room.": Protective isolation is typically used for clients who are immunocompromised, not necessarily in negative airflow rooms. Negative airflow rooms are often used for clients with airborne infections, such as tuberculosis.

B. "I will wear a cover gown when caring for a client who has herpes simplex.": This is the correct answer. Herpes simplex is a virus that can be transmitted through direct contact or contact with contaminated surfaces, so wearing a gown can help prevent the spread of the infection.
C. "I will use an alcohol-based hand cleanser when caring for a client who has Clostridium difficile.": Alcohol-based hand sanitizers are not effective against Clostridium difficile spores. Handwashing with soap and water is recommended for C. difficile infection control.
D. "I will wear an N95 respirator mask when caring for a client who is on contact precautions.": N95 respirator masks are typically used for airborne precautions, not contact precautions.

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Naxlex Comprehensive Predictor Exams

While auditing the medical records of clients currently on an oncology unit, the nurse manager finds that six of the 15 records lack documentation regarding advance directives. Which of the following is the priority action for the nurse to take?

Correct Answer is B

Explanation

A nurse manager is reviewing isolation guidelines with a newly licensed nurse. Which of the following statements indicates an understanding of the teaching?

Correct Answer is B

Explanation

A nurse is caring for a client who requests a copy of their medical records immediately. Which of the following responses should the nurse make?

A nurse is conducting a disaster preparedness drill with a group of nurses who are orienting to the facility. Which of the following triage tag colors should the nurse instruct the group to apply to a client who has full-thickness burns on 72% of his body?

A charge nurse is evaluating a newly licensed nurse and presents a performance improvement plan to the nurse for remediation. Which of the following outcomes should indicate to the charge nurse that the plan has been effective?

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A nurse manager is reviewing the rate of medication errors on a surgical floor and finds that it is 20% above the national average. Which of the following actions should the nurse manager take?

A nurse is assessing a client's comprehension of a pulmonary function test prior to the procedure. Which of the following client statements indicates to the nurse an understanding of the procedure?