A nurse in an emergency department is caring for a client who is unconscious and requires surgery. There is no one available to give consent for the treatment. Which of the following actions should the nurse take?

A. A nurse administers a medication without first identifying the client.

Negligence refers to the failure to provide care that a reasonable and prudent person would normally perform in a similar situation, resulting in harm to the client. In this scenario, administering medication without first identifying the client constitutes negligence because it violates the standard of care expected of a nurse. Proper identification of the client is essential to ensure that the correct medication is administered to the right individual, preventing medication errors and potential harm.

B. A nurse begins a blood transfusion without obtaining consent from a client:

This situation involves a failure to obtain informed consent, which is a violation of the client's rights but does not necessarily constitute negligence. Negligence typically involves a failure to provide proper care rather than a failure to obtain consent.

C. An assistive personnel prevents a client from leaving the facility:

While preventing a client from leaving the facility without appropriate authorization may be inappropriate or a breach of the client's rights, it does not necessarily constitute negligence. Negligence involves a failure to provide care that meets the standard of care expected in a given situation.

D. An assistive personnel discusses client care in the facility cafeteria with visitors present:

This situation may involve a breach of confidentiality or privacy but does not constitute negligence unless the discussion leads to harm or adverse consequences for the client. Negligence typically involves a failure to provide care that results in harm or injury to the client.

A. "I will remove my antiembolic stockings while I am in bed": Antiembolic stockings, also known as compression stockings, are worn to prevent deep vein thrombosis (DVT) by promoting venous return. Removing them while in bed would compromise their effectiveness in preventing blood clots.

B. "I will perform ankle and knee exercises every hour."

Performing ankle and knee exercises every hour helps prevent complications such as muscle atrophy, contractures, and thromboembolism associated with immobility. These exercises promote circulation, maintain joint mobility, and prevent stiffness.

C. "I will hold my breath when rising from a sitting position": Holding one's breath while rising from a sitting position can increase intra-abdominal pressure and potentially cause dizziness or fainting. It is not a recommended practice and may lead to orthostatic hypotension.

D. "I will have my partner help me change positions every 4 hours": Changing positions every 4 hours is important for preventing pressure ulcers and promoting comfort, but it may not be frequent enough to prevent other adverse effects of immobility, such as joint stiffness and muscle weakness. Frequent position changes, at least every 2 hours, are recommended to maintain circulation and prevent complications.