The nurse is providing care for four clients. Which best provides an example of the clinical judgment term failure to rescue (FTR)?
The client with a respiratory problem expresses interest in smoking cessation, but the nurse waits to put in a consult until the next day.
The client with pneumonia develops a fever of 101.9°F (38.8 °C), and the nurse does not notify the health care provider.
The client with chest pain develops pain while ambulating in the hall; the nurse immediately has the client sit down, checks HR and blood pressure, then notifies the provider.
The client with an altered level of consciousness experiences a fall while trying to go to the bathroom alone. The nurse first assesses the patient, then reports the Incident.
The Correct Answer is B
Failure to rescue reflects systemic inefficiency and clinical oversight where healthcare providers fail to recognize or act upon impending deterioration. This phenomenon correlates with mortality rates, emphasizing the necessity of early detection of physiological instability and rapid intervention to prevent adverse outcomes.
Rationale:
A. Delaying a smoking cessation consult is a missed opportunity for preventative health, but it does not constitute failure to rescue. Failure to rescue specifically refers to life-threatening clinical complications that occur while a patient is under professional medical supervision.
B. Failing to notify a provider about a high fever in a pneumonia patient illustrates clinical negligence. Ignoring signs of sepsis progression or worsening infection prevents timely intervention, directly leading to a failure to rescue from a potentially fatal condition.
C. Immediately assisting a client with chest pain and assessing hemodynamic status demonstrates competent clinical judgment. This proactive response facilitates early intervention, which is the exact opposite of failure to rescue, as the nurse actively manages the acute event.
D. While a fall indicates a lapse in safety protocols, reporting the incident and assessing the client after the fact is standard procedure. Failure to rescue typically involves missing clinical cues that lead to death or major permanent disability from complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","D"]
Explanation
Informed consent requires cognitive competence and legal capacity to authorize medical interventions. This ethical-legal framework ensures autonomy, requiring the disclosure of procedural risks, benefits, and alternatives to a patient who is not incapacitated.
Rationale:
A. Clients with progressive dementia lack the cognitive capacity to understand complex surgical risks. In such cases, a legal guardian or a designated power of attorney must provide consent to ensure the patient's best interests are protected.
B. Visual impairments like macular degeneration do not affect a client's legal or mental competence. As long as the procedural details are explained verbally, the client retains the autonomy to sign their own surgical consent forms.
C. Minors generally lack the legal standing to provide informed consent for invasive surgeries. For a 7-year-old, a parental guardian must sign the authorization after the surgeon explains the surgical plan and potential complications.
D. Marriage typically grants a minor emancipated status, allowing them to make independent healthcare decisions. This legal emancipation permits the 17-year-old to sign the surgical consent for their own cholecystectomy without requiring parental involvement.
E. A 16-year-old is legally a minor and cannot provide independent consent for elective procedures. Unless they are an emancipated minor, the signature of a legal guardian is mandatory before the medical team can proceed.
Correct Answer is A
Explanation
Animal bites constitute high-risk traumatic wounds with potential exposure to polymicrobial infection, including Pasteurella multocida, anaerobic bacteria, and possible rabies virus transmission. Immediate wound care is critical to reduce bacterial inoculation, prevent cellulitis, and limit systemic infectious complications.
Rationale:
A. Immediate irrigation with soap and water reduces bacterial load and mechanically removes contaminated debris from the wound. Application of antibiotic ointment decreases risk of localized infection and cellulitis. This is the first priority to prevent rapid microbial proliferation following animal bites.
B. Contacting the veterinarian provides information on animal health status, but it does not address immediate tissue contamination or infection risk. Wound cleansing must occur first to reduce pathogen burden before epidemiologic investigation. Delaying care increases infection risk.
C. Determining vaccination status of the dog is important for rabies risk assessment, but it is not the immediate priority. Infection prevention requires prompt wound decontamination. Exposure history is secondary to initial physical management of the bite injury.
D. Completing an occurrence report is an administrative requirement related to risk management documentation. It does not provide immediate clinical benefit to the injured nurse. Reporting must occur after appropriate wound care and stabilization measures have been implemented.
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