The nurse caring for clients recognizes that there are several areas of potential liability in nursing practice. These include: (SELECT ALL THAT APPLY)

transferring a client to ICU without giving report.

completing the admission assessment.

documenting vital signs taken by another nurse.

calling the physician to request an order for pain medication for the client.

using an IV pump with a frayed cord.

Answer and Explanation

Correct Answer : A,C,E

A. This action could pose a significant liability risk as it violates the standard of care, which includes providing thorough and accurate handoff communication to ensure continuity of care. Failing to provide a report before transferring a client to ICU could lead to miscommunication, errors in treatment, and compromised patient safety.

C. Documenting vital signs taken by another nurse is generally acceptable as long as the nurse ensures the accuracy of the information and documents according to institutional policies and standards. However, if the nurse knowingly documents false or inaccurate vital signs, it could pose a liability risk.
E. Using equipment with a frayed cord poses a significant liability risk as it could lead to electrical hazards, equipment malfunction, or patient injury. Nurses have a duty to ensure the safety and integrity of equipment used in patient care and should promptly report any defects or safety concerns to prevent harm to patients.
B. Completing the admission assessment is a standard nursing responsibility and is not inherently a liability risk. However, liability could arise if the assessment is incomplete, inaccurate, or not documented appropriately, leading to errors in care or failure to identify and address the client's needs

D. Calling the physician to request an order for pain medication is a routine nursing responsibility and is not inherently a liability risk. However, liability could arise if the nurse fails to communicate important information about the client's condition or medication history, resulting in inappropriate or unsafe prescribing practices.

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Correct Answer is A

Explanation

A. Infiltration occurs when the intravenous solution leaks into the surrounding tissue instead of flowing into the vein. This can cause discomfort, swelling, and potential tissue damage. Stopping the infusion immediately helps prevent further infiltration and minimizes the risk of complications such as tissue necrosis or damage.
B. While documenting the findings is important for the client's medical record, it is not the first action to take when suspecting infiltration. Immediate intervention to stop the infusion and assess the site for complications takes precedence over documentation.
C. Flushing the catheter with normal saline may be necessary after stopping the infusion to ensure patency and clear any remaining solution from the catheter. However, this step should follow the immediate cessation of the infusion to prevent further infiltration.
D. Removing the catheter may be necessary if significant infiltration has occurred or if there are signs of tissue damage. However, this should be done after stopping the infusion to prevent further infiltration and should be based on the assessment findings and healthcare provider's instructions.

A. Assisting the physician with documentation on the death certificate. B. Locating the client's clothing and personal belongings. C. Providing culturally and religiously sensitive care in body preparation. D. Calling the orderly to transport the client's body to the morgue.

Correct Answer is C

Explanation

C. Respect for the deceased person's cultural and religious beliefs is crucial. Care should be provided in a manner that aligns with their customs and traditions. This may involve specific rituals, prayers, or practices depending on the individual's cultural or religious background.
A. While completing documentation on the death certificate is important for legal and administrative purposes, it is not the priority during post-mortem care.
B. While it's essential to handle the deceased person's belongings with care and ensure they are returned to the family, this task can typically wait until after the immediate post-mortem care has been provided. It's not the priority during the initial stages of post-mortem care.
D. This task is important, but it should be carried out after the completion of post-mortem care. Once the deceased person has been respectfully prepared, the next step is to transfer them to the morgue or the designated location.

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The nurse caring for clients recognizes that there are several areas of potential liability in nursing practice. These include: (SELECT ALL THAT APPLY)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse suspects that a client's intravenous solution has infiltrated. What action should the nurse take first?

Correct Answer is A

Explanation

The nurse is performing post-mortem care on a client who has just died. What nursing care should be given priority?

Correct Answer is C

Explanation

The client's IV. placed near the right antecubital space, is running very slowly but does not appear infiltrated and does not have evidence of phlebitis. Which measure should the nurse implement to attempt to improve the flow rate of the IV?

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