A nurse is leading an in-service about legal issues. Which of the following examples should the nurse use to demonstrate an incidence of negligence?
A nurse administers the wrong medication to a client.
A nurse applies wrist restraints to a client in violation of the facility's restraint use policy.
A nurse touches a client in an offensive manner.
A nurse shares information about a client with family members without the client's consent.
The Correct Answer is A
A. A nurse administers the wrong medication to a client. – This is an example of negligence, as it represents a failure to follow the standard of care, potentially causing harm to the client. Nurses are expected to follow the "five rights" of medication administration to prevent errors.
B. A nurse applies wrist restraints to a client in violation of the facility's restraint use policy. – This is an example of false imprisonment, not negligence, as it involves restricting a client’s movement without proper justification.
C. A nurse touches a client in an offensive manner. – This is an example of battery, which is the intentional act of touching someone without their consent in a harmful or offensive way.
D. A nurse shares information about a client with family members without the client's consent. – This is an example of a breach of confidentiality, violating HIPAA regulations.
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Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}
Explanation
The first client the nurse should assess is Client 3 (Pulmonary Edema) followed by Client 1 (Hip Fracture).
Rationale:
Client 3 (Pulmonary Edema) – Highest Priority:
-
- Pulmonary edema is a life-threatening condition that can impair oxygenation.
- The client has a history of congestive heart failure (CHF) and a chest x-ray confirming pulmonary edema.
- Immediate assessment is required to evaluate for respiratory distress, oxygenation status, and potential need for diuretics or oxygen therapy.
Client 1 (Hip Fracture) – Second Priority:
-
- The x-ray confirms a fractured femoral neck, which can cause severe pain, bleeding, and immobility.
- The nurse must assess for circulation, sensation, and movement (CSM) of the affected limb and manage pain.
- While this is urgent, it is not as immediately life-threatening as pulmonary edema.
Priority Order (Using ABCs & Maslow’s Hierarchy):
- Client 3 – Pulmonary Edema (Airway/Breathing concern)
2. Client 1 – Hip Fracture (Risk for bleeding, pain, mobility issues)
3. Client 4 – Low Potassium (Risk for cardiac arrhythmias, needs electrolyte management)
4. Client 6 – Poor Diabetes Control (HbA1c 9%, requires education & glucose monitoring)
5. Client 5 – Malnutrition (Prealbumin 12 mg/dL, needs nutrition support for wound healing)
6. Client 2 – Hyperlipidemia (Not an immediate concern, requires long-term management)
Correct Answer is C
Explanation
A. Give the adolescent a short story pamphlet about puberty. While educational materials about puberty can be helpful, they do not provide specific information about a pelvic examination.
B. Describe the steps to the adolescent's guardian. The explanation should be directed to the adolescent to ensure they understand and feel comfortable. The guardian may be included if the adolescent prefers.
C. Show an online video that demonstrates what to expect. A visual demonstration can help reduce anxiety by familiarizing the adolescent with the procedure in a clear and informative way.
D. Use an anatomically correct puppet to demonstrate. Puppets are more appropriate for explaining procedures to younger children, not adolescents.
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