A nurse is reinforcing teaching about torts with a newly licensed nurse. The nurse should include which of the following as an example of negligence?

Restraining a client without a provider's prescription

Threatening to administer a medication a client has refused

Failing to notify the provider after a medication error

Documenting false information in a client's medical record

Answer and Explanation

The Correct Answer is C

A) Restraining a client without a provider's prescription:

This action represents assault and false imprisonment rather than negligence. Assault involves the threat of harm or unwanted touching, while false imprisonment involves the unlawful restraint or restriction of a person's freedom of movement.

B) Threatening to administer a medication a client has refused:

Threatening to administer a medication against a client's wishes may constitute assault or battery, depending on the circumstances, but it does not directly relate to negligence unless the threat results in harm due to the nurse's failure to adhere to the standard of care.

C) Failing to notify the provider after a medication error:

Negligence involves a breach of duty of care resulting in harm to another person. Failing to notify the provider after a medication error represents negligence because it breaches the duty of care owed to the client and may result in harm if appropriate actions are not taken promptly to mitigate the error's effects.

D) Documenting false information in a client's medical record:

Documenting false information in a client's medical record is a form of falsifying documentation and can have serious consequences, including legal and professional repercussions. However, it does not directly relate to negligence unless the false documentation leads to harm or adverse outcomes for the client.

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Correct Answer is D

Explanation

A) Place the client in a supine position:

Placing a client with pulmonary edema in a supine position can exacerbate symptoms by increasing venous return and worsening fluid accumulation in the lungs. Instead, positioning the client upright or in a semi-Fowler's position is more appropriate to facilitate respiratory mechanics and decrease venous return.

B) Weigh the client every other day:

Daily weight monitoring is crucial for clients with pulmonary edema to assess fluid balance accurately. Weighing the client every other day may not provide timely information on fluid retention and response to treatment. Therefore, daily weight measurement is typically recommended.

C) Encourage the client to ambulate three times per day:

While mobility is essential for overall health, clients with pulmonary edema may experience dyspnea and fatigue, limiting their ability to ambulate. Ambulation should be encouraged but should be tailored to the client's tolerance level and may need to be adjusted based on their respiratory status.

D) Report urine output less than 30 mL/hr:

Monitoring urine output is vital in clients with pulmonary edema to assess kidney perfusion and fluid balance. A urine output of less than 30 mL/hr may indicate decreased renal perfusion and impaired fluid clearance, which can exacerbate pulmonary congestion. Therefore, it is crucial to report such findings promptly for further evaluation and intervention.

A. Turn off electrical equipment in the client's room. B. Use a Class A fire extinguisher to contain the fire. C. Close the door to the client's room. D. Activate the alarm outside the client's room.

Correct Answer is D

Explanation

A) Turn off electrical equipment in the client's room: While turning off electrical equipment can help prevent the spread of fire if the source is electrical, it may not be the most immediate action to take after removing the client from the room. The priority is to activate the alarm to alert others and initiate the fire response protocol.

B) Use a Class A fire extinguisher to contain the fire: Using a fire extinguisher is a potential action, but the type of fire extinguisher needed depends on the type of fire. Class A fire extinguishers are suitable for ordinary combustibles such as wood and paper. However, since the source of the fire is a trash can, the fire may involve combustible materials beyond Class A. Therefore, activating the alarm takes precedence over extinguishing the fire.

C) Close the door to the client's room: Closing the door can help contain the fire and prevent its spread to other areas. While this action is important, it is secondary to activating the alarm, which alerts others to the fire and initiates the response process.

D) Activate the alarm outside the client's room: This is the most appropriate action to take first. Activating the alarm alerts others to the fire, enabling them to respond promptly and effectively. It initiates the facility's fire response protocol, including evacuating occupants and summoning the fire department. This action ensures the safety of everyone in the vicinity and allows for a coordinated emergency response.

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A nurse is reinforcing teaching about torts with a newly licensed nurse. The nurse should include which of the following as an example of negligence?

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