Adult Health Nursing Answer Key

Correct Answer: A

Rationale: Confidentiality is the ethical principle that requires healthcare providers to keep client information private and not disclose it without the client's consent. When client information is shared beyond the interdisciplinary team without the client's consent, it breaches the trust and privacy expected in the nurse-client relationship. This breach not only violates the ethical principle of confidentiality but also undermines the client's autonomy and right to control their own personal information. Maintaining confidentiality is crucial for building trust and ensuring the well-being of the client.

Correct Answer: A

Rationale: The inappropriate use of restraints or seclusion is considered a form of false imprisonment, which is an intentional tort. False imprisonment occurs when someone intentionally restricts another person's freedom of movement without their consent or legal justification. In healthcare settings, using restraints or seclusion inappropriately on a patient can constitute false imprisonment if it is not done for the safety of the patient or others and without proper authorization. This act can lead to legal consequences and liabilities for healthcare providers.

Correct Answer: B

Rationale: The correct action for the nurse to ensure patient safety during a bedside bronchoscopy procedure is to obtain informed consent from the patient or their legal representative. Informed consent is a vital ethical and legal requirement before any medical procedure. It ensures that the patient understands the risks, benefits, and alternatives of the procedure, as well as gives the patient the authority to make decisions about their healthcare. By obtaining informed consent, the nurse ensures that the patient has been properly informed and agrees to undergo the bronchoscopy, which promotes patient autonomy and safety. Administering sedation, using topical anesthesia, and restricting food intake are also important aspects of bronchoscopy preparation, but obtaining informed consent is the primary action to prioritize patient safety.

Correct Answer: C

Rationale: When documenting pitting edema in a patient's notes, it is important to include details such as the degree of edema (A), duration of indentation (B), and depth of edema (D) as these parameters are relevant in assessing the severity of the condition and monitoring changes over time. However, mentioning the degree of temperature (C) is not directly related to assessing pitting edema. Temperature is typically assessed as part of a general physical assessment for signs of infection or inflammation and is not specifically needed when documenting pitting edema.

Correct Answer: C

Rationale: The nurse's priority action when noticing a malfunctioning anesthesia machine in the operating room should be to inform the anesthesia provider immediately. Anesthesia providers are responsible for administering anesthesia safely during surgical procedures, and they need to be made aware of any equipment issues promptly to ensure patient safety. Continuing with the surgical procedure using a malfunctioning anesthesia machine can pose serious risks to the patient's well-being. Using an alternative anesthesia machine may be an option, but informing the anesthesia provider first ensures that the appropriate action is taken to address the issue effectively. Documenting the malfunction in the equipment log is important for record-keeping purposes, but it should not take precedence over informing the anesthesia provider and taking immediate action to address the problem.