A nurse on a medical-surgical unit is notified that a mass casualty event has occurred in the community.

Which of the following actions should the nurse plan to take

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

Choice A rationale: Testing skin turgor on the abdomen is common in infants and young children, but in older adults, abdominal skin often loses elasticity due to aging, making it an unreliable site for assessment.

Choice B rationale: The skin over the sternum or the subclavicular area (shoulder/chest) is the most reliable site for older adults. These areas typically maintain more elastic tissue, providing a more accurate reflection of hydration.

Choice C rationale: Assessing the stomach is essentially the same as the abdomen. This site is prone to skin sagging and loss of subcutaneous fat in elderly patients, which can lead to false-positive signs of dehydration.

Choice D rationale: The skin on the neck is thin and highly susceptible to wrinkles and sun damage. Lifting the skin here in an older adult will often show "tenting" even if the patient is well-hydrated.