29. A nurse is planning care after receiving report for four clients. Which of the following clients should the nurse plan to assess first? A client who has a BP of 118/74 mm Hg and is receiving treatment for hypertension A blood pressure of 118/74 mm Hg is nonurgent for a client who is receiving treatment for hypertension because this finding is within the expected reference range of less than 120 systolic and less than 80 diastolic. Therefore, the nurse should assess another client first. A client who has diabetes mellitus and a fasting blood glucose of 96 mg/dL A fasting blood glucose of 96 mg/dL is nonurgent for a client who has diabetes mellitus because this finding is within the expected reference range of 70 to 110 mg/dL. Therefore, the nurse should assess another client first. A client who is 2 days postoperative and has a urinary output of 500 mL/24 hr MY ANSWER When using the urgent vs. nonurgent approach to client care, the nurse should immediately assess a client who is 2 days postoperative and has a urinary output of 500 mL/24 hr. This indicates an average urine output of about 20 mL/hr, which is less than the expected reference range of 30 mL/hr.
This finding can indicate a fluid volume deficit, impaired kidney function, or impaired bladder tone which requires immediate assessment and intervention by the nurse. A client who has a heart rate of 68/min and is receiving IV fluids A heart rate of 68/min is nonurgent for a client who is receiving IV fluids because this finding is within the expected reference range of 60 to 100/min. Therefore, the nurse should assess another client first. 30. A nurse suspects a client is developing opioid use disorder and reduces the client's dosage of pain medication by 50% without a prescription from the provider. The nurse checks on the client 1 hr later and sees the client sitting up in a chair. The client tells the nurse, "I am in too much pain to reach the nurse call button." The nurse is liable for which of the following legal violations? Gross negligence MY ANSWER Gross negligence is an extreme breach of care with an intentional, reckless disregard of consequences. The nurse's actions were intentional and reckless, in opposition to the provider's prescription, and placed the client at risk for pain and injury. Libel Libel is a false written statement about a client's status that can result in injury. If the nurse documents that the client has a substance use disorder without any evidence to support that allegation, that written statement is libelous. Battery
Battery refers to harmful or offensive touching without consent. There is no indication that the nurse touched the client in an inappropriate or harmful manner. False imprisonment False imprisonment is the unlawful, intentional confinement of a person within fixed boundaries. Although it can be difficult for a client who is in intense pain to rise from sitting or summon help, the nurse did not unlawfully confine the client to the chair or the room.
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- Nursing, AP, Nurse Manager