A nurse notes that a client is confused, impulsive, and unstable with mobility. The nurse fears the client is in danger of harming themselves so they ask for a sitter to stay at the bedside to keep the client company and minimize the risk for falls. What ethical principle is the nurse demonstrating?

Nonmaleficence

Veracity

Fidelity

Beneficence

Answer and Explanation

The Correct Answer is A

The correct answer is choice A. By asking for a sitter to stay at the bedside to keep the client company and minimize the risk for falls, the nurse is demonstrating the ethical principle of nonmaleficence. Nonmaleficence refers to the duty to do no harm to the client, and in this case, the nurse is taking proactive steps to prevent harm to the client by ensuring their safety and well-being. Veracity (choice B) refers to the principle of truthfulness and honesty in communication, fidelity (choice C) refers to the principle of keeping promises and maintaining trust in the nurse-client relationship, and beneficence (choice D) refers to the principle of promoting good and doing what is in the best interest of the client. While all of these principles are important in nursing practice, the nurse in this scenario is primarily demonstrating nonmaleficence by taking action to prevent harm to the client.

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Correct Answer is B

Explanation

A. Skin was pink, warm, dry, and intact. Capillary refill was less than 5 seconds in all fingers. Radial pulses were +4 and equal bilaterally. Grips were strong 10 out of 10 and equal bilaterally:
Incorrect. Capillary refill should be less than 2-3 seconds for normal findings; less than 5 seconds would be too long and could indicate poor perfusion. Radial pulses graded +4 are not typical and suggest a bounding pulse, which could indicate an abnormal condition. Grips graded 10/10 is not the standard grading system; typically, grips are graded out of 5.

B. Skin was pink, warm, dry, and intact. Capillary refill was less than 3 seconds in all fingers. Radial pulses were +2 and equal bilaterally. Grips were strong 5/5 and equal bilaterally:
Correct. This option uses proper terminology. Capillary refill of less than 3 seconds is normal, radial pulses graded +2 are normal, and grips are appropriately graded on a 5-point scale, with 5/5 being the normal strength.

C. Skin was pink, warm, dry, and intact. Capillary refill was more than 3 seconds in all fingers. Radial pulses were 1 and equal. Grips were strong 4/4 and symmetrical:
Incorrect. Capillary refill of more than 3 seconds indicates delayed perfusion, which is abnormal. Radial pulses graded 1 indicate a weak pulse, which is not within normal limits. Additionally, grips are usually graded out of 5, not 4.

D. Skin was warm and dry and intact. Capillary refill was less than 3 seconds in all fingers. Radial pulses were 3. Grips were strong and equal:
Incorrect. While some aspects are correct (capillary refill), the pulse grading system is incomplete here. Radial pulses should be recorded as +1 to +4, and +3 would indicate a stronger-than-normal pulse, which is not typical for normal findings. Grip strength is not fully documented here either, as it should include a scale (e.g., 5/5).

A. Document and describe interventions performed by the previous shift nurse. B. Use standard terminology and commonly used medical abbreviations. C. Factually record the date and time the healthcare provider was notified of a concern and exact healthcare provider response. D. Do not document nursing interventions ahead of time before performing them. E. Document nursing interventions performed by the nurse who is documenting.

Correct Answer is ["B","C","D","E"]

Explanation

correct answers are:

B Use standard terminology and commonly used medical abbreviations.

C Factually record the date and time the healthcare provider was notified of a concern and exact healthcare provider response.

D o not document nursing interventions ahead of time before performing them.

E Document nursing interventions performed by the nurse who is documenting.

Nurses play a crucial role in patient care and documentation guidelines are important to ensure accuracy, completeness, and continuity of care. Using standard terminology and commonly used medical abbreviations is important to ensure that documentation is clear, concise, and easily understood by all members of the healthcare team. This practice helps avoid confusion, facilitates communication, and ensures that all healthcare professionals can accurately interpret and act upon the documented information.

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Naxlex Comprehensive Predictor Exams

The nurse performed an assessment on a patient's upper extremities. All findings were within normal limits. Which reflects the most accurate and complete terminology used when documenting these normal results?

Correct Answer is B

Explanation

A new nurse understands that documentation guidelines are important to ensure accuracy. The nurse would perform which of the following documentation guidelines? Select all that apply.

Correct Answer is ["B","C","D","E"]

Explanation

The physician orders penicillin G 1,000,000 units IM. The label on the vial of powdered penicillin G reads to reconstitute with 1.6 mL of sterile water to achieve a concentration of 5,000,000 units/mL. How many mL will the nurse give to the client for the ordered dose?

A new perioperative nurse is being educated regarding surgical asepsis. What observations by the preceptor would indicate that there is a need for further education and reinforcement of the principles of asepsis?

The physician orders penicillin G 1,000,000 units IM. The label on the vial of powdered penicillin G reads to reconstitute with 1.6 mL of sterile water to achieve a concentration of 5,000,000 units/mL. How many mL will the nurse give to the client for the ordered dose?

Which of the following scenarios would represent proper delegation as applies to delegating care to the right professional?

A student nurse is performing a urinary catheterization for the first time and inadvertently contaminates the catheter by touching the bed linens. What should the nurse do to maintain surgical asepsis for this procedure?

A client had his Foley catheter removed six hours ago and has just voided for the first time. The nurse performs a bladder scan to check for any post-void residual. The results of the post-void residual (PVR) from the bladder scan are 400mL of urine. What should the nurse do next?

Kübler-Ross defines five stages of psychosocial responses to dying and death. Which of the following statements is characteristic of the denial stage?

A nurse is using the SOAP documentation format to chart on their patient in a systematic and organized way. When using SOAP, what sections would be present in the charting? Select all that apply.