The nurse caring for clients recognizes that there are several areas of potential liability in nursing practice. These include: (SELECT ALL THAT APPLY)
transferring a client to ICU without giving report.
completing the admission assessment.
documenting vital signs taken by another nurse.
calling the physician to request an order for pain medication for the client.
using an IV pump with a frayed cord.
Correct Answer : A,C,E
A. This action could pose a significant liability risk as it violates the standard of care, which includes providing thorough and accurate handoff communication to ensure continuity of care. Failing to provide a report before transferring a client to ICU could lead to miscommunication, errors in treatment, and compromised patient safety.
C. Documenting vital signs taken by another nurse is generally acceptable as long as the nurse ensures the accuracy of the information and documents according to institutional policies and standards. However, if the nurse knowingly documents false or inaccurate vital signs, it could pose a liability risk.
E. Using equipment with a frayed cord poses a significant liability risk as it could lead to electrical hazards, equipment malfunction, or patient injury. Nurses have a duty to ensure the safety and integrity of equipment used in patient care and should promptly report any defects or safety concerns to prevent harm to patients.
B. Completing the admission assessment is a standard nursing responsibility and is not inherently a liability risk. However, liability could arise if the assessment is incomplete, inaccurate, or not documented appropriately, leading to errors in care or failure to identify and address the client's needs
D. Calling the physician to request an order for pain medication is a routine nursing responsibility and is not inherently a liability risk. However, liability could arise if the nurse fails to communicate important information about the client's condition or medication history, resulting in inappropriate or unsafe prescribing practices.
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Related Questions
Correct Answer is D
Explanation
D. Denial is often the initial stage of the grieving process, characterized by disbelief or avoidance of the reality of the situation. Clients may refuse to accept the diagnosis or its implications, clinging to the hope that it is not true. The client's statement of "This cannot be happening to me" is consistent with denial, as they are expressing disbelief or resistance to the reality of their diagnosis.
A. This stage involves feelings of sadness, despair, and hopelessness. While depression is a common response to a terminal diagnosis, the client's statement of "This cannot be happening to me" suggests that they may still be in an earlier stage of grief.
B. Anger is another common stage of the grieving process, characterized by feelings of frustration, resentment, and hostility. Clients may direct their anger towards themselves, others, or even a higher power. While anger can be a prominent reaction to a terminal diagnosis, the client's statement does not explicitly express anger but rather disbelief or resistance.
C. Bargaining is a stage in which individuals may attempt to negotiate or make deals in an effort to change or postpone the inevitable outcome. For example, a client may pray for more time or promise to change their behavior in exchange for a better outcome. The client's statement of "This cannot be happening to me" does not reflect bargaining but rather denial or disbelief.
Correct Answer is ["C","D"]
Explanation
C. Providing relief from pain and other distressing symptoms is a fundamental aspect of hospice care. The nurse should assess the client's pain level and other symptoms such as dyspnea, coughing, and restlessness, and intervene accordingly. This may involve administering analgesics, antitussives, or other medications as appropriate to alleviate discomfort and promote comfort and quality of life.
D. Placing the bed in semi-Fowler's position (with the head of the bed elevated) can help improve respiratory mechanics, ease breathing, and reduce respiratory distress in clients experiencing dyspnea. This position allows for better lung expansion and can facilitate the drainage of respiratory secretions, thereby promoting comfort and alleviating symptoms. This intervention does not typically require a medical order and can be implemented by the nurse based on clinical assessment.
A. Calling for transportation to the hospital may not be necessary or appropriate in this situation, especially considering that the client is under hospice care and experiencing changes in respiratory status and restlessness, which could be indicative of end-of-life processes. Hospice care focuses on providing comfort and symptom management in the home setting, and hospitalization may not align with the client's goals of care at this stage.
B. Initiating low-flow oxygen per nasal cannula may be appropriate to provide comfort and relieve hypoxia if the client is experiencing respiratory distress. However, this intervention would typically require a medical order, as oxygen therapy should be prescribed based on assessment findings and clinical indications.
E. Administering anti-anxiety medications may be considered if the client is experiencing significant anxiety or agitation that is distressing and impacting their comfort. However, the decision to administer anti-anxiety medications should be based on thorough assessment and consideration of the client's overall condition, goals of care, and potential risks and benefits. This intervention would typically require a medical order.
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