A nurse is teaching a client who has a new diagnosis of diabetes mellitus about foot care.

Which of the following instructions should the nurse include in the teaching?

The correct answer is choice C. Administering potassium via IV bolus is an example of malpractice in nursing.

This is because potassium is a medication that can cause cardiac arrest if given too quickly or in high doses. A nurse who administers potassium via IV bolus is not providing the standard of care that a similarly trained nurse would have offered under the same circumstances.

This could result in harm or death to the patient.

Choice A is wrong because placing a yellow bracelet on a client who is at risk for falls is not malpractice, but rather a safety measure.

A yellow bracelet indicates that the client needs assistance with mobility and should not be left alone. This is a common practice in many health care facilities to prevent falls and injuries.

Choice B is wrong because leaving a nasogastric tube clamped after administering oral medication is not malpractice, but rather a mistake.

A nasogastric tube is a tube that goes through the nose and into the stomach to deliver nutrition or medication.

It should be unclamped after giving oral medication to allow the medication to enter the stomach and prevent reflux or aspiration. However, this error does not rise to the level of malpractice unless it causes harm to the patient, such as vomiting, choking, or infection.

Choice D is wrong because documenting communication with a provider in the progress notes of the client’s medical record is not malpractice, but rather a good practice. A nurse

The correct answer is choice A, administer a fluid bolus.

Choice A rationale:

Administering a fluid bolus is appropriate when a client’s urine output is low, which in this case is less than the minimum expected output of 30 mL/hr. The dark yellow color of the urine also suggests dehydration or concentrated urine, which can be addressed with increased fluid intake.

Choice B rationale:

Initiating continuous bladder irrigation is typically done to clear the urinary tract of blood clots or debris following urologic surgery, not for low urine output or dark urine. Therefore, this intervention is not indicated based on the given scenario.

Choice C rationale:

Obtaining a urine specimen for culture and sensitivity is an action taken when there is a suspicion of a urinary tract infection. The scenario does not provide evidence of infection, such as fever or cloudy urine with a strong odor, so this would not be the first intervention to anticipate.

Choice D rationale:

Clamping the catheter tubing is done in preparation for catheter removal or to assess if the client can void without the catheter. It is not an appropriate intervention for low urine output or dark urine and could potentially cause bladder distention or discomfort.