A nurse is admitting a client for an elective surgical procedure. During the client interview. one of the client's family members faints. Which of the following actions should the nurse take first?

A) Restraining a client without a provider's prescription:

This action represents assault and false imprisonment rather than negligence. Assault involves the threat of harm or unwanted touching, while false imprisonment involves the unlawful restraint or restriction of a person's freedom of movement.

B) Threatening to administer a medication a client has refused:

Threatening to administer a medication against a client's wishes may constitute assault or battery, depending on the circumstances, but it does not directly relate to negligence unless the threat results in harm due to the nurse's failure to adhere to the standard of care.

C) Failing to notify the provider after a medication error:

Negligence involves a breach of duty of care resulting in harm to another person. Failing to notify the provider after a medication error represents negligence because it breaches the duty of care owed to the client and may result in harm if appropriate actions are not taken promptly to mitigate the error's effects.

D) Documenting false information in a client's medical record:

Documenting false information in a client's medical record is a form of falsifying documentation and can have serious consequences, including legal and professional repercussions. However, it does not directly relate to negligence unless the false documentation leads to harm or adverse outcomes for the client.

A) A newborn has an Apgar score of 7 at 5 min after birth:

An Apgar score of 7 at 5 minutes after birth is within the expected range and does not require an incident report. Apgar scores are used to assess a newborn's overall condition at birth, and a score of 7 indicates the infant is in good condition.

B) A newborn has respiratory distress and requires oxygen:

This event warrants completing an incident report because respiratory distress in a newborn requiring oxygen may indicate a significant clinical issue that needs to be investigated further. An incident report allows for documentation and investigation of the event to ensure appropriate actions are taken to address the newborn's condition and prevent similar incidents in the future.

C) A newborn receives erythromycin ophthalmic ointment 4 hr after birth:

Administering erythromycin ophthalmic ointment to newborns is a routine procedure to prevent ophthalmia neonatorum and does not require an incident report unless there is an adverse reaction or error in administration.

D) A newborn receives a heel stick on the outer aspect of the heel:

Heel sticks are commonly performed for newborn screening tests, such as blood glucose or bilirubin levels. Unless there is an error in the procedure or an adverse event related to the heel stick, it does not necessitate an incident report.