A client with leukemia is being considered for a bone marrow transplant. The healthcare team is
discussing the risks and benefits of this treatment and
... [Show More] other possible treatments with the goal of
inflicting the least possible harm on the client. Which principle of healthcare ethics is the team
practicing?
Justice
Fidelity
Autonomy
Nonmaleficence Correct
Rationale: Nonmaleficence is the avoidance of hurt or harm. Remember that in healthcare ethics, ethical
practice involves not only the will to do good but also the equal commitment to do no harm. Healthcare
professionals try to balance the risks and benefits of a plan of care while striving to do the least possible
harm. Justice refers to fairness and equity and ensuring fair allocation of resources, such as nursing care
for all clients. Fidelity is the keeping of promises made to clients, families, and other healthcare
professionals. Autonomy refers to a person’s independence and represents an agreement to respect
another’s right to determine his or her course of action.
Test-Taking Strategy: Use the process of elimination and think about the definition of each item in the
options. Note the relationship of the words “least possible harm” in the question and the definition of
nonmaleficence. Review the principles of healthcare ethics if you had difficulty with this question.
Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., p. 314). St. Louis: Mosby.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
SendIntegrated Process: Nursing Process/Implementation
Content Area: Ethical/Legal
Awarded 0.0 points out of 1.0 possible points.
2.ID: 383691785
Which action by the nurse represents the ethical principle of beneficence?
The nurse upholds a client’s decision to refuse chemotherapy for lung cancer.
The nurse follows a plan of care designed to relieve pain in a client with cancer.
The nurse administers an immunization to a child even though it may cause discomfort. Correct
The nurse provides equal amounts of care to all assigned clients on the basis of illness acuity.
Rationale: Beneficence is taking action to help others. Although administration of a child’s immunization
might cause discomfort, the benefits of protection from disease outweigh the temporary discomfort.
Fidelity is keeping promises made to clients, families, and other healthcare professionals. Autonomy is a
person’s independence. Respecting another’s autonomy means that you are agreeing to respect that
person’s right to determine his or her course of action. Justice refers to fairness and equity, including fair
allocation of resources, such as nursing care for all clients.
Test-Taking Strategy: Focus on the subject, beneficence. Recalling that beneficence refers to taking action
to help others will direct you to the correct option. Review the principles of healthcare ethics if you had
difficulty with this question.
Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., p. 314). St. Louis: Mosby.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/ImplementationContent Area: Ethical/Legal
Awarded 0.0 points out of 1.0 possible points.
3.ID: 383693578
The nursing instructor asks a student to name an example of false imprisonment. Which of the following
situations reflects a violation of this client right?
Performing a procedure without consent
Telling the client that he or she may not leave the hospital Correct
Threatening to give a client a medication against his or her will
Observing the provision of care to the client without the client’s permission
Rationale: Telling a client that he or she may not leave the hospital constitutes false imprisonment.
Performing a procedure without consent is an example of battery. Threatening to give a client a
medication against his or her will is assault. Invasion of privacy takes place with unreasonable intrusion
into an individual’s private affairs. Observing the provision of care to a client without the client’s
permission is an example of invasion of privacy.
Test-Taking Strategy: Focus on the subject, an example of false imprisonment. Note the relationship of
the subject and the words in the correct option. If you had difficulty with this question, review the
concept of false imprisonment.
References: Cherry, B., & Jacob, S. (2008). Contemporary nursing issues: Trends & management (4th ed.,
pp. 175, 176). St. Louis: Mosby.
Zerwekh, J., & Claborn, J. (2009). Nursing today: Transition and trends (6th ed., p. 424).
Cognitive Ability: Evaluating
Client Needs: Safe and Effective Care Environment
Integrated Process: Teaching and LearningContent Area: Ethical/Legal
Awarded 0.0 points out of 1.0 possible points.
4.ID: 383692438
A nurse and a nursing assistant enter a client’s room to provide care and find the client lying on the floor.
The nurse should first:
Ask the nursing assistant to complete an incident report
Check the client’s level of consciousness and vital signs Correct
Ask the nursing assistant to assist in getting the client back to bed
Contact the unit secretary on the intercom and ask that the client’s physician be called
Rationale: When a client sustains a fall, the nurse must first assess the client. The nurse should check the
client’s level of consciousness and vital signs and look for any bruises or injuries sustained in the fall. If
the nurse determines that the client has not sustained any injuries and that it is safe to move the client,
the nurse should ask the nursing assistant to assist in getting the client into bed. The nurse should then
contact the physician and file an incident report.
Test-Taking Strategy: Note the strategic word “first.” Use the steps of the nursing process to answer the
question. The correct option is the only one that addresses assessment. Remember to always assess the
client first if a client sustains a fall. Review client injuries and procedures for filing incident reports if you
had difficulty with this question.
References: Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: Patient–centered
collaborative care (6th ed., p. 180). St. Louis: Saunders.
Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., p. 403). St. Louis: Mosby.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/ImplementationContent Area: Delegating/Prioritizing
Awarded 0.0 points out of 1.0 possible points.
5.ID: 383691791
Which of the following actions exemplifies the use of evidence-based practice in the delivery of client
care?
Donning sterile gloves to change an abdominal wound dressing Correct
Encouraging a client to take an herbal substance to treat his insomnia
Advising a client to agree to the treatment recommended by her physician
Taking a rectal temperature from a client for whom bleeding precautions have been instituted
Rationale: Evidence-based practice is an approach to client care in which the nurse integrates the client’s
preferences, clinical expertise, and the best research evidence to deliver quality care. Donning sterile
gloves to change an abdominal wound dressing reflects evidence-based practice, because it prevents the
entrance of harmful bacteria into the wound. The remaining options do not reflect evidence-based
practice. Taking an herbal substance could be harmful to some clients. It is nontherapeutic for a nurse to
advise a client to agree to a treatment. Because of the risk of injury to the rectal mucosa, rectal
temperature-taking is avoided in the client for whom bleeding precautions have been instituted.
Test-Taking Strategy: Read each option carefully, focusing on the subject, evidence-based practice. Recall
the definition of evidence-based practice and note the words “sterile gloves” in the correct option.
Review the situations that reflect evidence-based practice if you had difficulty with this question.
Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., pp. 54-60). St. Louis: Mosby.
Cognitive Ability: Understanding
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/ImplementationContent Area: Leadership/Management
Awarded 0.0 points out of 1.0 possible points.
6.ID: 383693538
The registered nurse has accepted a new position as case manager in a hospital. Which of the following
responsibilities are part of the nurse’s new role? Select all that apply.
Evaluating and updating the plan of care as needed Correct
Prescribing treatments specific to the client’s needs
Assessing the client’s needs for home supplies and equipment Correct
Coordinating consultations and referrals to facilitate discharge Correct
Establishing a safe and cost-effective plan of care with the client Correct
Rationale: A case manager is a nurse who assumes responsibility for coordinating the client's care from
the point of admission through, and after, discharge. Specific responsibilities of the case manager include
establishing a safe and cost-effective plan of care with the client, coordinating consultations and
referrals, and facilitating discharge; initiating a plan of nursing care, care map, or clinical pathway as
appropriate to guide care and evaluating and updating the plan of care as needed; ensuring that the plan
of care is tailored to the client’s needs, taking into account the client’s diagnosis, self-care ability, and
prescribed treatments; assessing the client’s need for equipment such as oxygen or wound care supplies
and exploring available resources to provide the client with these supplies; providing resources that will
assist the client in maintaining independence as much as possible; and providing the client with
information on discharge procedures and the plan of care. The nurse does not prescribe treatments.
Test-Taking Strategy: Focus on the subject, the responsibilities of the case manager. Note the word
“prescribing” in the incorrect option. It is not within the role of the nurse to prescribe. Review the
responsibilities of the case manager if you have difficulty with this question.
Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., p. 21). St. Louis: Mosby.Cognitive Ability: Understanding
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Leadership/Management
Awarded 0.0 points out of 1.0 possible points.
7.ID: 383692428
The nurse manager of a quality improvement program asks a nurse in the neurological unit to conduct a
retrospective audit. Which of the following actions should the auditing nurse plan to perform in this type
of audit?
Checking the documentation written by a new nursing graduate on her assigned clients at the end of
the shift
Checking the crash cart to ensure that all needed supplies are readily available should an emergency
arise
Reviewing neurological assessment checklists for all clients on the unit to ensure that these
assessments are being conducted as prescribed
Obtaining the assigned medical record from the hospital’s medical record room to review
documentation made during a client’s hospital stay Correct
Rationale: Quality improvement, also known as performance improvement, is focused on processes or
systems that significantly contribute to client safety and effective client care outcomes. Criteria are used
to assess outcomes of care and determine the need for changes improve the quality of care. In a
retrospective, or “looking back,” audit, the medical record is inspected after the client’s discharge for
documentation of compliance with standards. In a concurrent, or “at the same time,” audit, the nursing
staff’s compliance with predetermined standards and criteria is assessed as the nurses are providing care
during the client’s stay. In this type of audit, a peer review approach in which members of the nursing
staff are involved in data collection may be implemented. Obtaining the a client’s medical record from
the medical record room for the purpose of reviewing documentation made during the client’s hospital
stay is an example of a retrospective audit. The incorrect options are examples of concurrent audits.Test-Taking Strategy: Focus on the subject, a retrospective audit. Note the relationship of the word
“retrospective” in the question and the description in the correct option. Review the procedures for
quality improvement and retrospective and concurrent audits if you have difficulty with this question.
Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., pp. 64, 65). St. Louis: Mosby.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Planning
Content Area: Leadership/Management
Awarded 0.0 points out of 1.0 possible points.
8.ID: 383692448
A nurse preparing a client for a bronchoscopy notes that the client is wearing a gold necklace. What
should the nurse do to safeguard the client’s necklace?
Ask the client whether the necklace is gold
Ask the client for permission to lock the necklace in the hospital safe Correct
Ask the client to remove the necklace and place it in the top drawer of the bedside table
Ask the client to sign a release to free the hospital of responsibility if the necklace is damaged or lost
during the procedure
Rationale: When a client has valuables, the nurse should give them to a family member or secure them
for safekeeping. Most healthcare institutions require that a client sign a release form that frees the
institution of responsibility if a valuable item (e.g., jewelry, money) is lost, but this does not safeguard
the client’s necklace. Valuables may be locked in a designated location such as the hospital’s safe.
Removing the necklace and putting it in a drawer does not safeguard it. Asking the client whether the
necklace is gold is inappropriate and unrelated to the subject.Test-Taking Strategy: Use the process of elimination and focus on the subject, safeguarding the client’s
necklace. Focusing on the subject and noting the word “lock” in the correct option will help you answer
correctly. Review the procedures for safeguarding a client’s valuables if you had difficulty with this
question.
Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., p. 1387). St. Louis: Mosby.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Ethical/Legal
Awarded 0.0 points out of 1.0 possible points.
9.ID: 383692487
A nurse providing preoperative care to a client who is scheduled for a left mastectomy and axillary lymph
node dissection notes that the client is wearing a wedding band on her left ring finger. The nurse should:
Tape the wedding band in place
Explain to the client why the wedding band must be removed Correct
Ask the client whether she would like to remove the wedding band or wear it to surgery
Ask the client to sign a release to free the hospital of responsibility if the wedding band is lost during
surgery [Show Less]