A nurse is caring for a client who had an open cholecystectomy 24 hours ago.

The client’s vital signs have been stable over the last 24 hours, with the most recent temperature

98.6° F(37° C), blood pressure (BP) 118/76 mm Hg, respiratory rate (RR) 16/min, and pulse 78/min, but are now changing.

Which set of vital signs indicates that the nurse should contact the health care provider?

The nurse refuses to care for someone who reminds her of a family member after interviewing the client upon admission. This action is not appropriate in the prevention of liability because it violates the client’s right to receive care and may be considered as discrimination or abandonment. The nurse has a duty to provide care to all clients regardless of their personal feelings or preferences.

Choice A is wrong because establishing rapport with the client in an inpatient psychiatric setting is an appropriate action to prevent liability. It helps to build trust and communication between the nurse and the client and reduces the risk of misunderstanding or conflict.

Choice B is wrong because documenting accurately and honestly in the electronic health record is an appropriate action to prevent liability. It provides evidence of the care provided, the client’s condition and response, and any incidents or complications that occurred.

Choice D is wrong because referring to the policy of the inpatient psychiatric setting when uncertain of a standard of care is an appropriate action to prevent liability. It helps the nurse to follow the best practices and guidelines for providing safe and effective care to the client.

“I apologize for not hearing you say that. Is there a better day for you?”.

This response shows empathy and respect for the client’s feelings and preferences.

It also invites the client to collaborate on finding a solution that works for both parties. Choice A is wrong because it is rude and defensive.

It does not acknowledge the client’s frustration or offer any alternatives. Choice C is wrong because it is dismissive and paternalistic.

It does not respect the client’s autonomy or consider the client’s reasons for not being able to come back on Friday.

Choice D is wrong because it is persuasive and manipulative.

It does not address the client’s concerns or explore other options.

The nurse-client relationship is based on trust, respect, and collaboration.

The nurse should use therapeutic communication skills to maintain a positive rapport with the client and promote their health and well-being.