A charge nurse is observing the actions of the facility staff on the unit. Which of the following actions should the charge nurse identify as a possible legal issue?
A nurse does not provide an interpreter for a client who speaks a different language than the nurse.
A provider who suspects partner violence asks to speak with the client alone.
A dietitian prescribes a kosher meal tray for a client who practices the Orthodox Jewish faith.
A client requests that a nurse provide information by telephone to their partner.
The Correct Answer is A
A. Not providing an interpreter for a client who speaks a different language may violate the client's right to understand their care, leading to potential legal issues regarding informed consent and patient safety.
B. A provider speaking to a client alone about suspected partner violence is appropriate as it ensures the client's privacy and safety during a sensitive discussion.
C. Prescribing a kosher meal tray for a client who practices the Orthodox Jewish faith is respectful and meets the dietary needs of the client, which is not a legal issue.
D. A client requesting that a nurse provide information to their partner is not inherently a legal issue, but the nurse must ensure that the client has consented to share their information to protect confidentiality.
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Correct Answer is D
Explanation
A. While paranoia in a client with dementia can be concerning, it is not immediately life-threatening and may require additional support or medication adjustments.
B. Itching after receiving a dose of cefaclor may indicate an allergic reaction, but further assessment would be needed to determine the severity.
C. A weight gain of 1 kg (2.2 lb) in a client with heart failure should be monitored, but it is not an immediate concern unless accompanied by other symptoms of fluid overload.
D. The progression of a pressure ulcer from stage II to stage III indicates a worsening condition that requires urgent intervention to prevent further complications and potential infection, making it the highest priority to report.
Correct Answer is A
Explanation
A. Providing postmortem care is a task that can be delegated to assistive personnel, as it involves following established protocols and does not require clinical judgment.
B. Reinforcing discharge instructions requires clinical knowledge and assessment, making it inappropriate for delegation to an AP.
C. Interpreting deviations in a client's vital signs necessitates nursing judgment and clinical expertise, which an AP does not possess.
D. Inserting an NG tube is a skilled nursing procedure that requires assessment and decision-making, thus it should not be delegated to an AP.