A charge nurse is observing a newly licensed nurse provide care for a client who is postoperative.

The newly licensed nurse tells the client that she will insert a urinary catheter if the client will not void.

Which of the following torts should the charge nurse identify as having occurred?

Choice A rationale:

Heart rate 58/min. Clozapine, an atypical antipsychotic medication, can cause bradycardia (slow heart rate) as a side effect. However, the heart rate of 58/min is within the normal range for adults, so it is not a contraindication for clozapine administration.

Choice B rationale:

Fasting blood glucose 100 mg/dL. A fasting blood glucose level of 100 mg/dL is within the normal range (70-99 mg/dL) for adults. It is not a contraindication for clozapine administration.

Choice C rationale:

WBC count 2,900/mm3. Clozapine can cause agranulocytosis, a severe reduction in white blood cell (WBC) count, which can lead to increased susceptibility to infections. A WBC count of 2,900/mm3 is significantly below the normal range (4,000-11,000/mm3) and is a contraindication for clozapine administration due to the risk of severe immunosuppression.

Choice D rationale:

Hgb 14 g/dL. Hemoglobin (Hgb) level of 14 g/dL is within the normal range for adult males (13.8-17.2 g/dL) and females (12.1-15.1 g/dL). It is not a contraindication for clozapine administration.

The correct answer is A. Uses a firm-bristled toothbrush increases the client's risk for injury because it can cause bleeding gums and oral mucosal damage in clients with pernicious anemia, who have reduced platelet count and impaired clotting. The other findings do not increase the risk for injury and may be beneficial for clients with pernicious anemia. Increased intake of green, leafy vegetables provides folic acid, which is essential for red blood cell production. Drinks 2,500 mL of fluid per day prevents dehydration and maintains blood volume. Wears a face mask around others reduces exposure to infections, which can be serious in clients with pernicious anemia, who have impaired immunity due to low white blood cell count.