A nurse begins to bathe a newly admitted client who reports that they have not had anything to eat that day.
The nurse interrupts the bath and obtains a healthy meal for the client.
This action by the nurse is an example of which of the following?

Choice A rationale: Countertransference is not the appropriate concept in this scenario. Countertransference refers to the nurse's emotional response to the client, which may be based on the nurse's unresolved issues and can negatively affect the therapeutic relationship. In this case, the nurse's actions are not driven by unresolved issues but by a desire to meet the client's basic needs.

Choice B rationale: Promoting trust is the most suitable explanation for the nurse's actions. By interrupting the bath and providing a healthy meal to a newly admitted client who hasn't eaten all day, the nurse is demonstrating empathy, compassion, and a commitment to meeting the client's physiological needs. This action helps build trust between the nurse and the client, as the client can see that their well-being is a priority.

Choice C rationale: Boundary crossing refers to actions that may blur or violate professional boundaries between a nurse and a client. While the nurse is going beyond the routine bath to provide a meal, this action is justified by the client's immediate need and doesn't constitute an inappropriate boundary crossing. The nurse is still maintaining professionalism in caring for the client.

Choice D rationale: Veracity is the principle of truth-telling and honesty in healthcare. It doesn't directly apply to this situation since the nurse's actions are not about providing information or disclosing something to the client. Instead, the nurse's primary concern is the client's nutritional well-being.

Choice A rationale:

A client who has a new diagnosis of diabetes mellitus and is awaiting teaching about meal planning requires education and counseling about managing their condition, including meal planning and blood glucose monitoring. This client should be assigned to a registered nurse or an advanced practice nurse with expertise in diabetes care.

Choice B rationale:

A client who has a urinary output of 30 mL in the past hour may have an issue with urinary retention or inadequate fluid intake. This client needs immediate assessment and intervention, including monitoring urinary output and assessing for urinary retention. Assigning this client to a licensed practical nurse (LPN) may delay timely intervention.

Choice C rationale:

A client who is postoperative following a hip arthroplasty and has a respiratory rate of 10/min requires monitoring of vital signs and assessment for potential respiratory complications. While the respiratory rate is within the normal adult range, postoperative clients are at risk for respiratory issues, such as atelectasis or pneumonia. LPNs are qualified to monitor vital signs and assess for early signs of respiratory distress in stable postoperative clients.

Choice D rationale:

A client who is newly admitted and requires an admission assessment should be assigned to a registered nurse (RN) or an advanced practice nurse. The admission assessment typically involves a comprehensive evaluation of the client's physical and psychosocial health, including a detailed history and physical examination, which falls within the scope of practice of an RN.