A nurse on a medical-surgical unit is caring for four clients. Which of the following actions by the nurse demonstrates fidelity?

Administering a pain medication to a client before ambulation

Stopping feeding for a client who becomes short of breath

Telling a client she will return with a medication and she does

Dividing time and care evenly between clients

Answer and Explanation

The Correct Answer is C

A. Administering pain medication before ambulation is an example of patient-centered care and pain management but does not specifically demonstrate fidelity, which relates to keeping promises and being trustworthy.
B. Stopping feeding when a client becomes short of breath is an appropriate response to prevent aspiration, but it is not an example of fidelity.
C. Telling a client she will return with a medication and following through with that commitment demonstrates fidelity by fulfilling a promise and showing reliability.
D. Dividing time and care between clients is part of effective time management, but it does not specifically represent fidelity, which emphasizes keeping promises to clients.

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Correct Answer is C

Explanation

A. While the nurse's notes may include observations about the client's condition, recording that an incident report was filed does not provide pertinent details regarding the client's care and is not appropriate.
B. Incident reports are confidential documents and should not be shared with the client's family, so providing a copy of the report is inappropriate.
C. Documenting the facts about the incident in the medical record is essential to provide a complete account of the client's care and any resulting changes or observations. This documentation is important for continuity of care and legal purposes.
D. Incident reports should not be placed in the medical record, as they are separate documents intended for internal review and quality assurance purposes.

A. A client who has dementia and is experiencing paranoia B. A client who has a UTI and reports itching after receiving a dose of cefaclor PO C. A client who has heart failure and has gained 1 kg (2.2 lb) in the last 48 hr D. A client who has a pressure ulcer on the left heel that has progressed from stage II to stage III

Correct Answer is D

Explanation

A. While paranoia in a client with dementia can be concerning, it is not immediately life-threatening and may require additional support or medication adjustments.
B. Itching after receiving a dose of cefaclor may indicate an allergic reaction, but further assessment would be needed to determine the severity.
C. A weight gain of 1 kg (2.2 lb) in a client with heart failure should be monitored, but it is not an immediate concern unless accompanied by other symptoms of fluid overload.
D. The progression of a pressure ulcer from stage II to stage III indicates a worsening condition that requires urgent intervention to prevent further complications and potential infection, making it the highest priority to report.

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A nurse on a medical-surgical unit is caring for four clients. Which of the following actions by the nurse demonstrates fidelity?

Nursing Test Bank

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