The nurse is caring for a patient who refuses to bathe in the morning. When asked why, the patient says, "I always bathe in the evening." Which action by the nurse is best?
Explain the importance of maintaining morning hygiene practices.
Tell the patient that daily morning baths are the "normal" routine.
Cancel hygiene for the day and attempt again in the morning.
Defer the bath until evening and pass on the information to the next shift.
The Correct Answer is D
A. Explaining the importance of morning hygiene may overlook the patient's established routine and could create resistance.
B. Stating that morning baths are the "normal" routine does not acknowledge the patient's preferences, potentially causing the patient to feel invalidated.
C. Canceling hygiene for the day disregards the patient's needs and preferred routine.
D. Deferring the bath until evening respects the patient’s routine and preference, promoting patient-centered care and improving comfort and compliance with hygiene practices.
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Correct Answer is D
Explanation
A. The Good Samaritan Law typically protects individuals who provide care in emergency situations but may not apply if the actions taken are beyond the standard of care or are not in the nurse's training.
B. While the nurse's intention was to save the patient's life, the method employed was not a recognized standard procedure for airway management and may have caused harm.
C. Waiting for help may not have been an appropriate option if the patient's airway was compromised, but the method employed by the nurse was not advisable.
D. Cutting into the trachea and using a straw as a makeshift airway are actions that exceed the typical scope of nursing practice and could be deemed inappropriate, regardless of the outcome for the patient.
Correct Answer is C
Explanation
A. Certification relates to additional qualifications and does not directly involve independent nursing actions in patient care.
B. Licensure is the legal permission to practice nursing but does not describe decision-making and action in patient care.
C. Autonomy is demonstrated when the nurse independently assesses the patient’s fluid status and takes action to promote health by encouraging fluid intake. This reflects the nurse’s ability to make decisions and act based on professional judgment.
D. Accountability refers to being responsible for one's actions but does not specifically cover the independent decision-making shown here.