A nurse is preparing to administer a soap suds enema to a client who has constipation. As the nurse explains the procedure, the client states, "The doctor didn't tell me I was supposed to receive an enema." Which of the following nursing actions is appropriate at this time?

Rationale:

A. Applying restraints to prevent an alert, oriented client from leaving AMA: This is an example of false imprisonment, not negligence.

B. Negligence is the failure to act as a reasonably prudent nurse would under similar circumstances. Notifying the provider hours after discovering absent peripheral pulses shows a delay in appropriate action, which can lead to serious complications (e.g., compartment syndrome, tissue ischemia). This failure to act promptly meets the definition of negligence.

C. Administering medication without the client’s knowledge after refusal: This constitutes battery, as it involves intentional, unauthorized physical contact.

D. Threatening to apply restraints if the client continues eating chips: This is assault, since it is a threat of harm without physical contact.

Rationale:

A. Ask the AP about her concerns with the assignment is appropriate as it allows the nurse to understand and address any potential issues or reasons for refusal.

B. Report the AP to the charge nurse should only be done if the refusal cannot be resolved through discussion.

C. Take the specimen to the laboratory should be done if needed, but it is important to first understand why the AP refused.

D. Complete an incident report might be premature without understanding the reason behind the refusal.