A nurse administers an incorrect medication to a client. Following an assessment of the client, the nurse determines that the client has not experienced any adverse effects as a result of the medication. The nurse does not complete an incident report because no harm came to the client. Which of the following ethical principles did the nurse violate?

Autonomy.

Veracity.

Confidentiality.

Beneficence.

Answer and Explanation

The Correct Answer is B

A. Autonomy: This principle refers to respecting a patient's right to make their own decisions about their healthcare. In this scenario, the nurse's actions did not directly impact the client's autonomy, as the client was not involved in the decision-making process regarding the incident report.

B. Veracity: This principle involves being truthful and transparent. By not completing an incident report, the nurse failed to uphold veracity, as this action concealed the truth about the medication error, potentially affecting future care and trust in the healthcare system.

C. Confidentiality: This principle is about protecting patient information. The nurse's failure to report the incident did not violate confidentiality, as it did not involve disclosing or mishandling the client's private information.

D. Beneficence: This principle focuses on doing good and acting in the best interest of the patient. While the nurse's intention might have been to avoid unnecessary alarm, failing to report the incident could prevent the healthcare team from learning from the mistake and improving patient safety, thus indirectly affecting beneficence.

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Correct Answer is C

Explanation

Choice A rationale:

Cleaning the wound by scrubbing the site with gauze is not an appropriate intervention for a stage 3 pressure ulcer. Scrubbing can damage the fragile tissue, increase the risk of infection, and delay wound healing. Gentle cleaning with a mild solution and avoiding trauma to the wound bed are recommended.

Choice B rationale:

Massaging reddened areas with dressing changes is contraindicated for pressure ulcers, especially stage 3 ulcers. Massaging can cause further damage to the tissues and disrupt the healing process. Dressing changes should focus on maintaining a clean and moist environment to promote healing.

Choice C rationale:

(Correct Choice) Repositioning the client at least every 2 hours is a crucial intervention to prevent further pressure ulcers and facilitate wound healing. Regular repositioning helps relieve pressure on specific areas and improves blood circulation, reducing the risk of tissue breakdown and the development of new ulcers.

Choice D rationale:

Applying a heat lamp twice a day is not recommended for stage 3 pressure ulcers. Heat can increase blood flow to the area, potentially exacerbating inflammation and delaying healing. Pressure ulcers require a clean and moist environment for optimal healing.

A. Sanguineous. B. Serous. C. Purulent. D. Serosanguineous.

Correct Answer is D

Explanation

Choice A rationale:

Sanguineous. Sanguineous drainage is typically bright red and consists of fresh blood. It indicates active bleeding from the wound. In this case, the drainage described is not bright red but rather light red-pink, suggesting that it is not purely sanguineous.

Choice B rationale:

Serous. Serous drainage is thin, watery, and typically clear or slightly yellowish in color. It is a normal part of the wound healing process and is not indicative of active bleeding. However, the drainage described in the question is light red-pink, which is not consistent with serous drainage.

Choice C rationale:

Purulent. Purulent drainage is thick, often opaque, and can range in color from yellow to green. It indicates the presence of infection in the wound. The description of watery light red-pink drainage does not align with the characteristics of purulent drainage.

Choice D rationale:

Serosanguineous. Serosanguineous drainage is a combination of serous and sanguineous fluids. It appears as a thin, watery drainage that is pink-tinged due to the presence of a small amount of blood. This description matches the observed drainage in the question. Serosanguineous drainage is common during the initial stages of wound healing and is considered a normal part of the process.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A Medical-Surgical nurse is developing a plan of care for a client who has a stage 3 pressure ulcer. Which of the following interventions should the nurse include in the plan?

Correct Answer is C

Explanation

A nurse on the Medical-Surgical unit is assessing a patient's wound dressing, and observes a watery light red-pink drainage. The nurse should document this drainage as which of the following?

Correct Answer is D

Explanation

A nurse is caring for an Islamic client who is recovering from a motor vehicle accident. The patient is observing Ramadan, the ninth lunar month. The nurse understands that a good diet is important for the client's wounds to heal. Which action should the nurse take regarding the client's diet?

A Medical-Surgical nurse is providing discharge teaching for a client who has a new prescription for home oxygen. Which of the following instructions should the nurse include in the teaching?

A nurse is assessing a client's cardiovascular system. To palpate for unexpected pulsations in the pulmonic area, at which anatomical location should the nurse place her fingers?

A nurse caring for a client who has an infected wound removes a dressing saturated with blood and purulent drainage. How should the nurse dispose of the dressing material?

A nurse is caring for a patient on a Medical-Surgical unit with a wound that has a drain and a dressing that needs changing. Which action should the nurse take first?

A nurse is teaching a client's spouse about how to obtain a blood pressure reading. Which of the following actions by the spouse indicates a need for further instruction?

A Medical-Surgical nurse is teaching a client about the uses of cranberry juice. Which of the following information should the nurse include in the teaching?