Question

A charge nurse observes a client fall while ambulating with an assistive personnel and notes that the client's gait belt was not in place. When reviewing the incident report, the charge nurse finds that the report does not mention the gait belt. Which of the following ethical principles should the charge nurse follow?

Answer 1

Correct Answers:

Veracity

Rationale :

☀Veracity refers to the ethical obligation to tell the truth.

☀ In this situation, the charge nurse must ensure that the incident report includes accurate information regarding the absence of the gait belt, which is a critical safety device.

☀Omitting this detail compromises the integrity of documentation and may prevent appropriate corrective action.

☀Upholding veracity ensures transparency and supports quality improvement in client care.

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Answer 2

Correct Answers:

"Please ask your relative about this, because I cannot share information about her"

Rationale :

🔸This response protects the client’s confidentiality and privacy, which are essential aspects of ethical and legal nursing practice.

🔸Under HIPAA, a nurse cannot disclose any information about a client without explicit consent, even to family or visitors.

🔸The nurse must maintain professional boundaries and redirect the visitor appropriately.

🔸Sharing or accessing the medical record without permission would be a breach of confidentiality.

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Answer 3

Correct Answers:

Pharmacist

Rationale :

🌟A social worker can assist with identifying resources to obtain necessary medical equipment, such as a nebulizer, for a family in financial distress.

🌟This promotes access to care and supports adherence to the treatment plan.

🌟Pharmacists and respiratory therapists provide education but do not coordinate financial resources.

🌟Child protective services would not be appropriate unless neglect or abuse is suspected.

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Answer 4

Correct Answers:

A client who has Type 1 diabetes and uses an insulin pump

Rationale :

🦠A client with Type 1 diabetes using an insulin pump requires coordinated care involving nursing, endocrinology, dietetics, and possibly diabetes education to ensure safe and effective management.

🦠This situation benefits from an interdisciplinary conference to evaluate the client’s needs and prevent complications.

🦠The other options involve standard care that does not require team collaboration at this time.

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Answer 5

Correct Answers:

Deep red color on the center of a client's wound

Rationale :

📌A deep red color in the wound bed is a sign of granulation tissue, indicating healthy wound healing.

📌 This tissue is rich in new blood vessels and denotes proper tissue perfusion.

📌In contrast, serosanguineous drainage, inflammation, or surrounding erythema may indicate complications such as infection or delayed healing.

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Answer 6

Correct Answers:

An evidence-based nursing journal

Rationale :

🧨When looking for reliable health information, an evidence-based nursing journal is the most credible and professional source.

🧨It provides peer-reviewed, current data on medical conditions like Tay-Sachs disease.

🧨 While providers are knowledgeable, journals support independent nursing research.

🧨Collaborative websites can be inaccurate, and case managers may not be familiar with rare genetic conditions.

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Answer 7

Correct Answers:

A client who is postoperative following a laminectomy 12 hr ago and is unable to void

Rationale :

🧠Postoperative urinary retention following spinal surgery may indicate neurologic impairment and must be addressed immediately.

🧠This client has the highest priority due to the potential for permanent damage.

🧠 Clients with MRSA and fever or absent pedal pulses are important but not as emergent.

🧠Starting chemotherapy is planned care, not an urgent issue.

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Answer 8

Correct Answers:

Determine factors that interfere with the documentation of client education

Rationale :

💡Before implementing any interventions, the nurse manager should first identify the barriers preventing staff from meeting benchmarks.

💡This aligns with the problem-solving and quality improvement process, which begins with assessment.

💡 Training, performance reviews, and incentives are helpful, but only after identifying the root cause.

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Answer 9

Correct Answers:

A client who is receiving IV chemotherapy and is ambulatory

Rationale :

🌞During a fire evacuation, priority is given to clients who are most mobile and least dependent, as they can be safely moved with minimal assistance.

🌞 This ambulatory client receiving IV chemotherapy can evacuate quickly.

🌞Clients with restraints, chest tubes, or traction require more resources and may be moved after ambulatory clients.

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Answer 10

Correct Answers:

Request orientation to the medical-surgical unit

Rationale :

🧩When floating to an unfamiliar unit, the first step is to request orientation to ensure safe, effective care.

🧩This orientation allows the nurse to understand protocols, equipment, and workflows.

🧩 Floating without orientation increases the risk of errors and unsafe practice.

🧩Other options may be useful later but are not the first action.

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QLexNursing

2 : A nurse is speaking with a visitor who asks a question about the status of a relative who is a client on the unit. Which of the following responses by the nurse is appropriate?

3 : A nurse is providing discharge teaching to the parent of a toddler who has a new diagnosis of asthma. The parent states she is unable to afford the nebulizer prescribed for the child. Which of the following referrals should the nurse recommend?

4 : A nurse working on a medical-surgical unit is managing the care of four clients. The nurse should schedule an interdisciplinary conference for which of the following clients?

5 : A nurse is assessing pressure ulcers on four clients to evaluate the effectiveness of a change in wound care procedure. Which of the following findings indicates wound healing?

6 : A nurse is caring for a client who requests information about the prevalence of Tay-Sachs disease. Which of the following resources should the nurse use to obtain this information?

7 : A nurse on a medical-surgical unit is caring for four clients. The nurse should recognize that which of the following clients is the highest priority?

8 : During a staff meeting, a unit manager reviews the results for documenting client education and finds that they are below the benchmark. Which of the following strategies should the nurse manager implement first?

9 : A charge nurse is planning to evacuate clients on the unit because there is a fire on another floor. Which of the following clients should the nurse evacuate first?

10 : A nurse from the labor and delivery unit is assigned to float to a medical-surgical unit. Which of the following actions should the nurse take first?