A patient received a dose of intravenous pain medication before change of shift.
The oncoming nurse sees no documentation of the medication being given, so she provides another dose.
The patient has a respiratory arrest.
Who is most liable for this situation?
The nurse who gave the first dose of medication.
The person who called the nurse away before documenting the medication.
The nurse who gave the second dose of medication.
The health-care provider (HCP) who prescribed the medication.
The Correct Answer is C
Choice A rationale
The nurse who administered the first dose is accountable for lapses in documentation, a critical failure in the implementation phase of the nursing process. However, the subsequent direct action (administering the second dose) by the oncoming nurse is the proximate cause (the direct, immediate cause) of the patient's respiratory arrest, making the second nurse most liable.
Choice B rationale
While interruptions can contribute to errors, the nurse has a professional and legal duty to ensure care is safely delivered and documented. Interruptions do not absolve the nurse of the accountability for the omission of documentation (first nurse) or the safe administration of medication (second nurse); thus, the person causing the interruption is not the primary liable party.
Choice C rationale
The nurse who administered the second dose is most liable because professional standards dictate verifying the order and the last administration time before giving any medication. By administering a duplicate dose due to a lack of verification, the nurse committed an act of negligence (malpractice) that directly and foreseeably led to the patient's respiratory arrest, establishing a direct causal link.
Choice D rationale
The healthcare provider (HCP) prescribed the correct dose based on the standard order. The error was not in the prescription but in the administration and documentation phases of the medication process, which are the direct professional responsibilities of the nurses. Therefore, the HCP is generally not liable for the execution errors made by the nursing staff.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Asking "Where is the pain located?" addresses the Provocation/Palliative, Quality, Region/Radiation, Severity, Timing (PQRST) assessment framework. Determining the Region is a crucial, immediate next step, as localization of the nociceptive stimulus is essential to begin forming a differential diagnosis and developing a targeted care plan for pain management.
Choice B rationale
The patient has already explicitly stated, "they have pain as their primary problem," making the question "Are you in pain now?" redundant and failing to gather the specific, descriptive data necessary to thoroughly characterize the pain experience and guide appropriate interventions.
Choice C rationale
Asking "Is the pain sharp or dull?" addresses the Quality component of a comprehensive pain assessment. While essential, the location (Region) often takes precedence as it guides physical assessment and initial diagnostic focus before moving to descriptive qualifiers.
Choice D rationale
Asking "On a scale of 1 to 10, how would you rate your pain?" addresses the Severity component. While necessary for determining immediate analgesic needs and monitoring efficacy, gathering objective localization data (Region) first provides critical context for the subjective rating.
Correct Answer is ["A","C","E"]
Explanation
Choice A rationale
Subjective data represents information relayed by the client that cannot be directly measured or observed by the nurse. The client's description of pain as "dull, aching" and its location in the "lower right calf" is a symptom. Pain is a highly personal and subjective sensory and emotional experience, requiring the client's verbal report for its existence and characteristics to be known, thus classifying it as subjective.
Choice B rationale
Objective data consists of factual information that is measurable, observable, and verifiable by another person. A "raised, red rash" on the upper back is a physical sign that can be directly observed and documented by the nurse through inspection. This type of information uses the nurse's senses (sight and touch) and does not rely solely on the client's perception, classifying it as objective data.
Choice C rationale
The sensation of itchiness, or pruritus, is an internal perception experienced only by the client and cannot be independently confirmed or measured by the nurse. Similar to pain, an itch is a symptom that must be communicated verbally by the patient. Therefore, the client's report that the rash is itchy falls under the category of subjective data because it is a personal feeling.
Choice D rationale
An oral temperature of 38.4°C (101.2°F) is a quantitative measurement obtained using a thermometer. This is an example of a sign, which is directly measurable and verifiable by other healthcare providers. Objective data includes vital signs, which have a normal range of 36.5°C to 37.5°C (97.7°F to 99.5°F) for oral temperature, making this entry objective.
Choice E rationale
Nausea is a distressed subjective sensation in the back of the throat and stomach, often leading to the urge to vomit. Because it is an internal feeling or symptom that cannot be outwardly observed or measured by the nurse, its presence must be communicated through the client's verbal report. Therefore, the client's report of nausea after medication is definitively categorized as subjective data.
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