A nurse verbally contracts with a client to reassess their pain level after repositioning and an analgesic is given. The nurse returns within 60 minutes to evaluate effectiveness of the interventions. What ethical principle does this represent?

paternalism

confidentiality

responsibility

fidelity

Answer and Explanation

The Correct Answer is D

A. Paternalism: Paternalism refers to the healthcare provider making decisions on behalf of the client without their input or consent, typically for the client's perceived benefit. In this scenario, the nurse is not making decisions for the client but rather honoring an agreement to reassess pain after interventions.

B. Confidentiality: Confidentiality refers to maintaining the privacy and security of client information. It does not directly relate to the nurse's commitment to follow through on a verbal contract with the client regarding pain reassessment.

C. Responsibility: Responsibility involves being accountable for one's actions and obligations in providing care to clients. While responsibility is important in nursing practice, it does not specifically address the nurse's commitment to fulfill a verbal contract with the client regarding pain reassessment.

D. Fidelity: Fidelity, also known as loyalty or faithfulness, pertains to the nurse's obligation to uphold commitments made to clients. In this scenario, the nurse is demonstrating fidelity by returning within the agreed-upon time frame to evaluate the effectiveness of pain interventions as promised to the client. This principle emphasizes the importance of keeping promises and honoring agreements made with clients, thereby building trust and promoting ethical practice in nursing.

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Free Nursing Study Resources

Correct Answer is ["A","E"]

Explanation

When administering an enema to an adult patient with constipation, the nurse must insert the tubing into the patient's rectum to deliver the enema solution effectively. However, it's crucial to avoid inserting the tubing too far to prevent injury or discomfort to the patient. The recommended insertion distance varies depending on the individual patient's anatomy and the type of enema being administered.

A. 4 in. (10.2 cm):

Inserting the enema tubing approximately 4 inches (10.2 cm) into the patient's rectum is considered a safe and effective distance for most adult patients. This depth allows the enema solution to reach the sigmoid colon, facilitating the evacuation of stool and relieving constipation without risking insertion too deeply into the rectum.

B. 5 in (12.7 cm): Inserting the tubing 5 inches into the rectum is generally deeper than necessary and may increase the risk of injury or discomfort. This distance is not typically recommended for safe and effective administration of an enema.

C. 6 in. (15.25 cm): Inserting the tubing 6 inches into the rectum is deeper than necessary and may increase the risk of injury or discomfort. This distance is generally not recommended for safe and effective administration of an enema.

D. 2 in. (5.1 cm): Inserting the tubing 2 inches into the rectum is not considered a safe and effective distance for many adult patients. This distance does not allow for the effective delivery of the enema solution into the lower rectum and sigmoid colon without inserting the tubing too far.

E. 3 in. (7.6 cm): Inserting the tubing 3 inches into the rectum is also considered a safe and effective distance for many adult patients. This distance allows for the delivery of the enema solution into the lower rectum and sigmoid colon without inserting the tubing too far.

A. Jugular vein distention B. Skin turgor, tenting at clavicular area C. Elevated hematocrit D. Oral mucous membranes dry and sticky

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

Explanation

A. Jugular vein distention: Jugular vein distention is not typically associated with deficient fluid volume (dehydration). Instead, it is often seen in conditions of fluid overload, such as heart failure or volume overload. Therefore, this finding is not accurate for deficient fluid volume.

B. Skin turgor, tenting at clavicular area: Skin turgor refers to the skin's ability to return to its normal position after being pinched or pulled. In cases of deficient fluid volume (dehydration), skin turgor is decreased, leading to delayed return of the skin to its normal state. Tenting at the clavicular area is a specific sign of decreased skin turgor and is indicative of dehydration.

C. Elevated hematocrit: Deficient fluid volume (dehydration) leads to hemoconcentration, where there is a relative increase in the proportion of red blood cells to plasma volume. As a result, the hematocrit level, which represents the percentage of red blood cells in the total blood volume, increases. An elevated hematocrit is a laboratory finding commonly associated with deficient fluid volume.

D. Oral mucous membranes dry and sticky: Dehydration can lead to decreased saliva production and dryness of the oral mucous membranes. Dry and sticky oral mucous membranes are common clinical signs of deficient fluid volume (dehydration) and indicate inadequate fluid intake or loss.

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A nurse verbally contracts with a client to reassess their pain level after repositioning and an analgesic is given. The nurse returns within 60 minutes to evaluate effectiveness of the interventions. What ethical principle does this represent?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse must administer an enema to an adult patient with constipation. Which is a safe and effective distance for the nurse to insert the tubing into the patient's rectum? (SELECT ALL THAT APPLY)

Correct Answer is ["A","E"]

Explanation

The nurse assesses a client with a history of deficient fluid volume. What are the most accurate findings for this fluid volume status? (SELECT ALL THAT APPLY)

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

Explanation

What meal option should a nurse choose for a client with fluid volume excess who has been placed on a low-sodium diet?

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The nurse is performing an admission assessment on a client who has chronic pain. Which statement made by the client causes the most concern?