The nurse is explaining the rationale for seeking the family's permission to apply a physical re-straint to a combative client. This is an example of the nurse exhibiting the professional principle of:
1. Advocacy
2. Responsibility
3. Accountability
4. Confidentiality
ANS: 3
Accountability refers to the ability to answer for one's own actions. Nurses should ensure that their professional actions are explainable to their clients and to their employer. The remaining op-tions are reflective of other professional principles.
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1. pneumonia with sepsis. 2. drug overdose. 3. severe head trauma. 4. severe chest contusion.
The nurse assesses an adult client with the nursing diagnosis of "impaired gas exchange.". Which assessment data does the nurse use to determine if the client's plan of care is effective?
1. SaO2 of 88% 2. Pink nail beds 3. Asymmetrical excursion 4. Intercostal retractions present