A charge nurse pulls a new nurse to the side to discuss documenting a patient’s blood pressure of 202/122 mmHg without reporting it. The patient is now in the ICU. How does the charge nurse best explain how this reflects negligence?
This action is consistent with libel, a felony criminal action.
There was poor interprofessional communication with the healthcare team.
You failed to act as a reasonably prudent nurse would under similar circumstances.
You did not re-assess your patient’s blood pressure.
The Correct Answer is C
Choice A reason: Labeling the action as libel, a felony, is incorrect, as libel involves defamatory statements, not clinical errors. Negligence relates to failing to meet care standards, not legal defamation. This mischaracterizes the issue, focusing on legal terms irrelevant to the failure to report critical hypertension, per nursing liability.
Choice B reason: While poor interprofessional communication may have contributed, it does not fully capture the negligence. The primary issue is not reporting a critical blood pressure (202/122), which a prudent nurse would address. Communication is secondary to the nurse’s failure to act on a life-threatening finding, per professional standards.
Choice C reason: Failing to act as a prudent nurse under similar circumstances defines negligence, as not reporting 202/122 mmHg endangered the patient, leading to ICU transfer. A reasonable nurse would have notified the provider, preventing harm, aligning with legal and ethical standards of care and accountability.
Choice D reason: Not reassessing blood pressure is relevant but not the core negligence. The primary issue is failing to report the critical reading, which required immediate action. Reassessment alone would not address the urgency of notifying the provider, making this less comprehensive than negligence, per standards.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Not touching the patient until assessment completion is unnecessary, as gentle touch may be required to feel pulse or position the patient. Avoiding touch does not ensure accurate respiratory assessment and may hinder observation of chest movement, per respiratory assessment guidelines.
Choice B reason: Informing the patient that respirations are being counted may alter their breathing pattern due to awareness, leading to inaccurate rates. Conscious breathing can increase or decrease the rate, compromising the assessment’s validity, per clinical observation techniques.
Choice C reason: Obtaining respirations without the patient knowing ensures an accurate rate, as awareness can cause altered breathing. Discreetly counting while appearing to check the pulse preserves natural respiration, aligning with standard assessment techniques for reliable respiratory rate data, per nursing practice.
Choice D reason: Estimating respirations is inappropriate, as it lacks precision, risking inaccurate data. Counting respirations for 30-60 seconds provides an objective rate, critical for identifying abnormalities like tachypnea or bradypnea, ensuring proper clinical decision-making, per respiratory assessment standards.
Correct Answer is A
Explanation
Choice A reason: Administering eye drops to the lower conjunctival sac ensures optimal drug absorption and minimizes corneal irritation. The conjunctival sac, a mucous membrane, allows medication to spread across the eye surface, treating conjunctivitis by targeting bacterial or inflammatory processes. This method avoids systemic absorption via the nasolacrimal duct, enhancing local efficacy and safety.
Choice B reason: Dropping medication onto the cornea risks irritation or injury, as the cornea is a sensitive, avascular tissue responsible for light refraction. Conjunctivitis treatment requires medication to contact the conjunctiva, not the cornea directly. This method could cause discomfort and reduce drug efficacy, as it does not target the inflamed conjunctival tissue.
Choice C reason: The sclera by the outer canthus is not ideal for eye drop administration. The sclera, a tough connective tissue, has poor drug absorption compared to the conjunctival sac. Drops placed here may run off, reducing contact with the inflamed conjunctiva in conjunctivitis, leading to ineffective treatment and potential waste of medication.
Choice D reason: The sclera by the inner canthus is near the nasolacrimal duct, increasing the risk of systemic drug absorption rather than local treatment of conjunctivitis. Drops should target the lower conjunctival sac to ensure contact with the inflamed tissue, maximizing therapeutic effect while minimizing systemic side effects like tachycardia from certain medications.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.