ETHICS & PRIORITY SETTING
This ethical principle means “do no harm,” such as double-checking all medications before giving them.
What is nonmaleficence?
Nonmaleficence requires nurses to actively prevent harm—e.g., preventing medication errors or refusing unsafe orders.
This team member can perform ADLs, take vital signs on stable patients, and assist with ambulation.
Answer: Who is the UAP/CNA?
Rationale: CNAs perform tasks that are routine, non-clinical, repetitive, and involve no assessment or uncontrolled outcomes.
Pursed-lip breathing and barrel chest are hallmark assessments of this chronic lung disease.
Answer: What is COPD?
Rationale: Air trapping causes hyperinflation → barrel chest; pursed-lip breathing helps keep airways open during exhalation.
This type of angina is predictable and relieved by rest or nitroglycerin.
Answer: What is stable angina?
Rationale: Stable angina occurs with exertion and resolves with rest because myocardial oxygen supply meets demand once workload decreases.
__________ is the most accurate indicator of fluid status.
Answer: What is daily weight?
Rationale: Weight changes reflect fluid shifts more accurately than urine output or vital signs; 1 kg = 1 liter fluid.
A client refuses chemotherapy. The nurse first performs this action before notifying the provider.
What is assessing the client’s understanding of the treatment?
Rationale: Autonomy requires the nurse to ensure the refusal is informed. The NCLEX rule: always assess first, then notify the provider.
LPNs may reinforce teaching but cannot perform this part of the nursing process.
Answer: What is initial teaching or evaluation?
Rationale: Only RNs can perform initial teaching or evaluate patient learning because these require clinical judgment. LPNs may reinforce only.
A client suddenly has absent breath sounds and tracheal deviation. This life-threatening condition is suspected.
Answer: What is a tension pneumothorax?
Rationale: Air accumulates and shifts mediastinum → tracheal deviation. This rapidly compromises ventilation and circulation.
An irregularly irregular rhythm with no P waves describes this dysrhythmia.
Answer: What is atrial fibrillation?
Rationale: Disorganized atrial firing eliminates P waves; irregular ventricular response leads to “irregularly irregular” rhythm—stroke risk ↑.
Severe flank pain radiating to the groin and hematuria are classic signs of this condition.
Answer: What are renal calculi (kidney stones)?
Rationale: Stones irritate the ureter → hematuria and intense spasmodic flank → groin pain (renal colic).
Two “right” values conflict—such as autonomy vs beneficence—describes this type of ethical challenge.
What is an ethical dilemma?
Rationale: Ethical dilemmas occur when both possible actions have ethical justification, creating tension between values.
These three nursing tasks can never be delegated.
Answer: What are assessment, teaching, and evaluation?
Rationale: These require RN-level critical thinking and cannot be performed by LPNs or UAPs under any circumstance.
If a chest tube disconnects from the drainage system, the nurse immediately places the tube end into this.
Answer: What is sterile water?
Rationale: Sterile water immediately reestablishes a water seal, preventing air from entering the pleural space.
BNP elevation and an ejection fraction below 40% are diagnostic clues for this disorder.
Answer: What is heart failure?
Rationale: BNP increases as ventricles stretch; EF <40% indicates systolic dysfunction and poor pumping ability.
Pain 30–60 minutes after eating and worsened by food is typical of this type of ulcer.
Answer: What is a gastric ulcer?
Rationale: Gastric ulcers worsen with food because acid increases while the stomach is already irritated.
When a newly admitted client becomes suddenly confused, this priority framework suggests they should be assessed before a chronic COPD patient with stable symptoms.
Answer: What is acute vs chronic prioritization?
Rationale: Sudden changes (acute) take priority over predictable chronic issues because they may signal life-threatening deterioration.
A patient is expressing fear about surgery, and the nurse says, “You’ll be fine.” This non-therapeutic technique is called this.
Answer: What is false reassurance?
Rationale: False reassurance shuts down communication and minimizes the patient’s concerns; it prevents emotional processing
pink, frothy sputum and severe dyspnea in a heart failure patient indicate this emergency condition.
Answer: What is pulmonary edema?
Rationale: Left-sided HF → fluid into alveoli → impaired gas exchange → frothy sputum and hypoxia. Requires rapid oxygen and diuretics.
A congenital defect that causes a loud harsh murmur, failure to thrive, and left-to-right shunting.
Answer: What is a ventricular septal defect (VSD)?
Rationale: Left ventricle pressure > right → blood flows into RV → pulmonary overcirculation → poor feeding and weight gain.
A child with thick sticky secretions, steatorrhea, and pancreatic insufficiency likely has this genetic disorder.
Answer: What is cystic fibrosis?
Rationale: CF causes impaired chloride transport → thick mucus affecting lungs and pancreas → malabsorption and fatty stools.
A patient with terminal cancer tells the nurse, “I know the team wants me to continue treatment, but I don’t want to anymore.” The provider insists the treatment must continue. What is the nurse’s best action?
Answer:
What is advocate for the patient’s stated wishes and request an ethics consult?
Rationale:
Autonomy protects the patient’s right to refuse treatment, even if the team disagrees. When conflict persists between patient and provider, the appropriate escalation is to involve the ethics committee. The nurse must also document and advocate for the patient’s choice
Which task is appropriate to delegate to an LPN?
A. Teaching a patient how to use a metered-dose inhaler
B. Completing an initial admission assessment
C. Monitoring a stable patient’s breath sounds
D. Evaluating a new medication’s effectiveness
Correct Answer: C
Rationale:
LPNs may monitor stable clients and collect data. Assessment, teaching, and evaluation must be performed by the RN.
A patient with asthma uses their rescue inhaler but continues wheezing and has a respiratory rate of 32/min. What is the nurse’s priority?
A. Encourage fluids to loosen secretions
B. Administer oxygen and notify the provider
C. Have the patient rest and recheck in 10 minutes
D. Offer a warm beverage to relax airway muscles
Correct Answer: B
Rationale:
Worsening respiratory symptoms after SABA use indicate poor response → risk of respiratory failure. Oxygen and provider notification are priority.
A patient with heart failure reports gaining 3 lbs in 24 hours. What should the nurse do first?
A. Restrict all oral fluids immediately
B. Assess lung sounds
C. Ask the patient to weigh again for accuracy
D. Notify dietary services to change sodium intake
Correct Answer: B
Rationale:
A sudden weight gain suggests fluid retention. Lung assessment determines if pulmonary edema is developing, which is the priority safety concern.
A patient with suspected kidney stones reports severe flank pain and nausea. What is the nurse’s priority intervention?
A) Administer pain medication
B) Encourage ambulation
C) Encourage oral fluid intake
D) Strain all urine for stones
Answer:
Strain all urine for stone collection.
Rationale:
Straining urine helps identify the type of stone, which guides treatment and prevention. Pain control and fluids are important, but stone retrieval is the critical diagnostic step.