The acute care nurse is caring for a client with an infection. Which nursing action would
be considered negligent?
A. Not administering the client's
... [Show More] prescribed dose of antibiotic medication
B. Taking a picture of the client's stage II ulcer located on the sacrum
C. Keeping the portable oxygen on while the client smokes at a designated area
D. Talking about a client's condition to another nurse in the elevator - CORRECT
ANSWER C --> Negligence is considered conduct that deviates from what a reasonable
person would do in a particular circumstance. The nurse must take measures to protect
the client if imminent danger or harm is evident.
Not administering a prescribed antibiotic may be warranted if the client is allergic to the
medication or has experienced an adverse effect from the drug. Options II and IV are
examples of violating the client's privacy and confidentiality but are not considered
negligent actions.
A client is scheduled to have surgery, and has signed the consent form, but refuses to
have a Foley catheter placed, saying, "That's not part of the surgery." How should the
nurse respond to this situation?
A. Explain that this step is part of the surgical prep and continue with the procedure.
B. Explain that the client has already signed the consent and place the catheter.
C. Respect the client's wishes, notify the physician, and document accordingly.
D. Notify the charge nurse but do not document the client's wishes. - CORRECT
ANSWER C --> Consent is required before procedures are performed. Depending on
the invasiveness of the procedure, a written consent may be required. The client signed
a consent form for surgery, and the refusal for placement of a catheter should be
respected because it is the client's right to refuse. The nurse should document the
incident and not continue with the procedure. Battery exists when there is not consent,
even if the client was not asked. In this case, the client has the right to refuse other
treatment surrounding pre- and postoperative care.
A nurse is caring for an older adult client in the emergency department (ED) who was
brought in by an adult child for vague flulike symptoms. While helping the client change
into a gown, the nurse notices numerous bruises on the client's back and arms. When
questioned, the client is distracted and ambiguous with answers. The nurse should
prioritize which action?
A. Report the situation to law enforcement.
B. Report the required information through the administrative chain of the institution.
C. Question the adult child who brought the client to the ED.
D. File a written report in the client's chart. - CORRECT ANSWER B --> Nurses are
considered mandatory reporters. Reporting of abuse or suspected abuse of vulnerable
individuals is mandated in most states. As a general rule, the nurse reports the required
information through the administrative chain of the institution, beginning with the nurse's
immediate supervisor and the primary healthcare provider.
The nurse completes an incident report on a client's hypoglycemic event related to
intravenous (IV) insulin. Which information should the nurse be careful to exclude from
the incident report?
A. Language regarding liability
B. Client's account of the incident
C. Name and dose of the medication
D. Date, time, and location of the incident - CORRECT ANSWER A -->The nurse should
completely and accurately document the facts without assumptions, conclusions, or
blame. Language regarding liability may be subject to legal action. The other options
are information that should be included in the incident report form. [Show Less]