A nurse educator is providing an educational session on negligence. Which of the following situations is an example of nurse negligence?

A nurse omits a blood pressure assessment prior to administering Metoprolol.

A nurse finds a client who is on a diabetic diet eating a sugar-coated doughnut and immediately shouts, Stop eating that right now, and takes the doughnut out of the client's hand.

A client who is alert and oriented x 4 refuses their cardiac medications, but the nurse dissolves the medication in the client's cranberry juice.

A client alert and oriented x 2 wants to leave the hospital, and the nurse places the client in soft wrist restraints with the unlicensed assistive personnel until the provider comes to assess the situation.

Answer and Explanation

The Correct Answer is A

Choice A rationale

Negligence is defined as a failure to provide the standard of care that a reasonably prudent nurse would provide in a similar situation, leading to potential harm. Metoprolol is a beta-blocker that requires monitoring of vital signs because it decreases heart rate and blood pressure. By omitting the assessment, the nurse breaches the duty of care. Normal systolic blood pressure is typically 90 to 120 mmHg, and heart rate is 60 to 100 beats per minute.

Choice B rationale

Shouting and physically snatching an object from a client represents battery or assault rather than negligence. Battery involves intentional, non-consensual physical contact, while assault involves creating an apprehension of harmful contact. While the nurse's behavior is unprofessional and violates client rights to autonomy and dignity, it is classified as an intentional tort. Negligence is usually an unintentional failure to perform a required nursing action, such as an assessment or safety check, rather than an aggressive outburst.

Choice C rationale

This action constitutes battery and a violation of the right to informed consent. Administering medications secretly after a competent client has refused is an intentional act of deception and physical violation. Ethical principles of autonomy dictate that an alert and oriented client has the absolute right to refuse any treatment. Hiding medication in food or drink is an intentional tort, which differs from negligence, where the nurse accidentally forgets a standard protocol or safety procedure.

Choice D rationale

Restraining a client against their will without a specific medical order or emergency justification constitutes false imprisonment. This is an intentional tort where a person is restricted in their personal liberty without legal authority. Negligence involves a lack of proper care or attention to detail, whereas applying restraints to a person who wants to leave is a deliberate restriction of movement. The nurse must follow strict protocols and obtain provider orders to legally apply any restrictive devices.

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Correct Answer is B

Explanation

Choice A rationale

Placing an indwelling catheter is an invasive procedure that carries a significant risk of urinary tract infection, especially in older adults. It should only be performed after less invasive diagnostic measures have confirmed the presence of retained urine and other interventions have failed. Jumping straight to catheterization violates the principle of using the least invasive intervention first and does not provide diagnostic information regarding why the output has ceased over the last eight hours.

Choice B rationale

Performing a bladder scan is the priority action because it is a non-invasive bedside diagnostic tool that immediately quantifies the volume of urine in the bladder. Normal post-void residual is typically less than 50 mL to 100 mL. This assessment helps the nurse differentiate between urinary retention, where the bladder is full but cannot empty, and decreased urine production, which might indicate dehydration or renal failure. Assessment must always precede intervention in the nursing process.

Choice C rationale

Asking the client to increase fluid intake is an intervention that should only be implemented once the cause of the low urine output is determined. If the client is suffering from urinary retention due to an obstruction, such as an enlarged prostate or a blockage, increasing fluids will exacerbate the bladder distension and increase discomfort or risk of bladder injury. The nurse must first use a bladder scan to determine if urine is actually present.

Choice D rationale

Intermittent catheterization is an intervention used to drain the bladder when a client cannot void spontaneously. While it has a lower risk of infection than an indwelling catheter, it is still an invasive procedure. The nurse should first perform a non-invasive bladder scan to confirm that the bladder contains enough urine to warrant catheterization. Without an initial assessment of bladder volume, this action is premature and could cause unnecessary discomfort or risk for the patient.

A. Check the position of a client in soft wrist restraints. B. Sit with a client who has alcohol use disorder and whose last drink was five days ago. C. Assess a client who has hypomania for exhaustion. D. Accompany a client who has depression to occupational therapy. E. Set limits with a client who has mania.

Correct Answer is ["A","B","D"]

Explanation

Choice A rationale

Assistive personnel are trained to observe and report basic physical safety parameters for clients. Checking the position of a client in soft wrist restraints involves verifying that the client is comfortable and that the restraints are not visibly obstructing circulation or causing skin irritation. This task does not require clinical assessment or nursing judgment, provided the nurse has already performed the initial assessment and continues to monitor the client according to facility policy.

Choice B rationale

Sitting with a client who is no longer in the acute phase of withdrawal is a task appropriate for assistive personnel. Withdrawal symptoms from alcohol usually peak within 48 to 72 hours and subside by day five. The AP can provide companionship and safety monitoring for a stable client who is past the high-risk window for seizures or delirium tremens. This task involves observation rather than active medical intervention or complex clinical evaluation by the nurse.

Choice C rationale

Assessing a client for exhaustion requires professional nursing judgment and a deep understanding of the physiological and psychological impact of hypomania. The nurse must evaluate vital signs, mental status, and physical stability to determine if the client is at risk for cardiovascular collapse or other complications. This level of clinical assessment cannot be delegated to assistive personnel because it involves interpreting subjective and objective data to formulate a specific plan of care.

Choice D rationale

Accompanying a stable client to a therapy session is a routine task that falls within the scope of practice for assistive personnel. The AP ensures the client reaches their destination safely and remains supervised during transport. Since the client has depression but is stable enough for occupational therapy, this activity focuses on mobility and safety rather than complex psychiatric intervention. It allows the nurse to prioritize higher-level tasks while ensuring the client is supported.

Choice E rationale

Setting limits with a client who is experiencing mania involves therapeutic communication techniques and behavioral management strategies that require professional nursing expertise. Clients with mania may be impulsive, aggressive, or intrusive, requiring the nurse to use clinical judgment to de-escalate situations and maintain a therapeutic environment. This is an intervention based on the nursing process and psychological theory, making it inappropriate for delegation to assistive personnel who lack advanced training.

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A nurse educator is providing an educational session on negligence. Which of the following situations is an example of nurse negligence?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is ["A","B","D"]

Explanation

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