Exam 2

What are 5 factors to help strengthen delegation skills with setting priorities with patient care?

1. Airway, Breathing, Circulation 2. Safety 3. Pain 4. Education 5. Feelings

What are the 5 rights of delegation?

1.Right Task 2. Right Circumstances 3. Right Person 4. Right Direction/ Communication 5. Right Supervision/ Evaluation

What is the maximum amount of questions that you could get on the NCLEX?

265 questions

What is the minimum amount of questions that you could get on the NCLEX?

75 questions

This term refers to when a an RN didn't follow a policy and patient died from an infection relation to the nurse's actions

Negligence

Failure to delegate appropriately may be considered *blank*, a criteria for negligence.

Breach of duty

What type of law covers false imprisonment?

Civil

What does the Executive branch consist of?

President, Vice President, Cabinet, Governor

This term refers to the employer being responsible for the act or omissions of their employees

Respondeat superior

You are going to visit your 93 year-old grandfather and upon arrival at his home, you find your mother arrived 5 minutes earlier to find your grandfather unresponsive and she has called 911. After Christmas last year, your grandfather told you about his recent doctor's visit and that he wished to be DNR. What events are likely to occur when the EMS crew arrives? a. They will not respond to the call as your grandfather is DNR b. They will start CPR and stop when you tell them that you know that your grandfather is DNR c. They will start CPR and transport your grandfather to the hospital d. They will arrive, but not perform CPR as your grandfather is DNR

c. They will start CPR and transport your grandfather to the hospital

What is a private law?

civil law; regulates relationships among people

What type of law is the right to bear arms

constitutional

Which of the following legal defenses are the most important for a nurse to develop? a. Dedication b. Certification c. Assertiveness d. Accountability

d. Accountability

What type of law does the State Board of Nursing implement when granting authority for licensing and nursing practice? a. Statutory b. Constitutional c. Criminal d. Administrative

d. Administrative

When being interviewed for a position as a registered professional nurse, the applicant is asked to identify an example of an intentional tort. What is the appropriate response? a. Negligence b. Malpractice c. Breach of Duty d. False Imprisonment

d. False Imprisonment

A LPN is providing nursing care, under the supervision of the RN, who has completed an initial assessment for a patient with Guillain-Barre syndrome. What data by the LPN should the RN instruct the LPN to report back immediately? a. Complaints of numbness and tingling in the lower extremities b. Facial weakness with difficulty speaking c. Rapid heart rate of 105 or > and core temperature of < 37.6 d. Shallow respirations with decreased breath sounds

d. Shallow respirations with decreased breath sounds

A motorist receives a ticket for speeding because the State of Wisconsin has determined that the speed limit in an area is 55mph. What type of law is involved in this case? a. Constitutional b. Criminal c. Case/Common d. Statutory

d. Statutory

What is public law?

government is directly involved; regulates relationships between individuals and government; laws apply to everyone

What type of law is Medicare/ social security?

Administrative

What type of law is nursing licensure?

Administrative

What type of law is the Board of Nursing Regulations?

Administrative

What type of law is the State Board of Nursing?

Administrative

What is the Nurse Licensure Compact?

An agreement between compact states to recognize licensure from member states. The nurse holds one license issued in the state of residence but is also responsible for the laws of the state in which she travels. The nurse must comply with the Nurse Practice Act in which they practice.

What type of law is used when a car accident where you caused injury to someone else?

Civil

What type of law is R vs. R that revoked the 1736 ruling that a man could not be guilty of raping his wife?

Common

What type of law is the right to protest?

Constitutional

What type of law covers murder?

Criminal

What is an example of an intentional tort?

False imprisonment

T/F: When a task is delegated, the person who agrees to perform the task has no legal responsibility, as the task was delegated to them

False!

This term refers to the protection for a healthcare worked who renders emergency care at the scene of an accident

Good Samaritan law

What does the Legislative branch consist of?

House of Representatives and Senate (the 2 houses of Congress)

What is a "but-for" cause of injury?

If the person performing the task causes injury, but was not assigned or properly supervised- injury could have been avoided-- if not for the task being done, there wouldn't be an injury.

Should you file an incident report under the patient's chart or refer to it in the chart?

NO

Who should the RN contact if they have any questions about their license?

State Board of Nursing

What type of law are the Standards of Care?

Statutory

What type of law are the state statutes affecting nursing practice?

Statutory

What type of law is the Patient's Bill of Rights?

Statutory

What type of law is the Scope of Nursing practice?

Statutory

What type of law is the Wisconsin Nurse Practice Act?

Statutory

What type of law is the nurse practice act?

Statutory

List the 3 steps when taking verbal or telephone orders from a provider

Step 1: Order is communicated verbally Step 2: Order is written verbatim Step 3: Order is read back directly to the person who gave the order for confirmation

What does the Judicial branch consist of?

Supreme Court and lower federal + state courts

What is the National Council of State of Boards of Nursing?

The governing body for NCLEX

What is the definition of delegation?

The transferring of responsibility of performing a task from one person to another

Certain questions are applicable in determining nursing negligence. Select all that apply. a. "Was reasonable care provided?" b. "Was there a breach of nursing duty?" c. "Was there an act of omission that resulted in harm?" d. "Except for the nurse's action, would the injury have occurred?" e. "Did the nurse fully understand the actions would result in harm?"

a. "Was reasonable care provided?" b. "Was there a breach of nursing duty?" c. "Was there an act of omission that resulted in harm?" d. "Except for the nurse's action, would the injury have occurred?"

You have just received report for your upcoming shift and are looking to prioritize your first hours of the day. Which of the following patients would be your first priority? a. 2-hour post-op with saturated abdominal dressing b. COPD patient whose O2 sat is 94% and due for their morning inhalers c. Confused, dementia patient whose family is at the desk with questions re: LTC placement d. Appendectomy patient with a pain of 6/10 and due for pain medication

a. 2-hour post-op with saturated abdominal dressing

In caring for patients with pain and discomfort issues, which task is the most appropriate for the nurse to delegate to a certified nursing assistant: a. Assist the patient with preparation for a sitz bath b. Coach the patient to deep breathe during painful procedures c. Evaluate relief after applying a cold application such as an ice pack d. To assess the patient for signs of discomfort while being ambulated

a. Assist the patient with preparation for a sitz bath

Laura, a LPN on the unit, has just received her patient care assignment and will be responsible for the following four patients. Patient J: a one-day post-op knee surgery patient who will need a dressing change. Patient K: a patient with pneumonia receiving IV antibiotics who needs reinforcement of teaching on their incentive spirometer. Patient L: a chronic CHF patient receiving oral Lasix. Patient M: an incoming observation admission from the ER for an acute asthma exacerbation who is now stable. Which of the patients above would require Laura to "reverse back" the assignment as the patient required RN care? a. Patient M b. Patient L c. Patient J d. Patient K

a. Patient M

You are the RN working with a UAP and LPN today to care for a team of 6 patients. You are working very hard at delegating and perfecting this skill in order to make the most out of everyone's time and scope of practice. Which of the following tasks would be appropriate for you to delegate to either the UAP or LPN? a. Repositioning a patient every 2 hours to decrease skin breakdown b. Caring for a diabetic patient with blood sugars ranging from 110-135 c. Reinforce teaching on urinary catheter care d. Administering oral pain medications after you have assessed new onset pain

a. Repositioning a patient every 2 hours to decrease skin breakdown

The RN is preparing to admit a patient with a seizure disorder. Which of the following actions should the RN delegate to the LPN so they can focus on RN responsibilities? a. Setting up oxygen and suction equipment per protocol b. Completing the initial seizure risk assessment tool until the RN has time to finish it c. Completing the admission assessment d. Placing a padded tongue blade at the bedside

a. Setting up oxygen and suction equipment per protocol

What should the nurse consider when obtaining an informed consent from a 17-year-old adolescent? a. Whether the client is allowed to give consent b. That the client cannot make informed decisions about healthcare c. Whether the client is permitted to give voluntary consent when parents are not available d. That the client probably will be unable to choose between alternatives when asked to consent

a. Whether the client is allowed to give consent

A nursing student is listing the different aspects of obtaining informed consent from clients. Which point mentioned by the nursing student needs correction? a. "Informed consent should be obtained in all situations except during extraordinary circumstances." b. "Informed consent is an important part of the nurse-client relationship; it is a vital part of the nursing duty." c. "Informed consent is provided by clients based on the full disclosure of risks, benefits, alternatives, and consequences of refusal." d. "The primary healthcare provider legally has to disclose facts in terms that the client is able to understand to make an informed choice."

b. "Informed consent is an important part of the nurse-client relationship; it is a vital part of the nursing duty."

A registered nurse is educating a nursing student about nursing malpractice. What information should the nurse provide? Select all that apply. a. "Nursing malpractice includes willful acts that violate a client's rights." b. "Nursing malpractice takes place when nursing care falls below the standards of care." c. "Nursing malpractice may be prevented by developing a caring rapport with the client." d. "Nursing malpractice may occur even when the nurses do not intend to harm the clients." e. "Nursing malpractice refers to the publication of false statements to damage a person's reputation."

b. "Nursing malpractice takes place when nursing care falls below the standards of care." c. "Nursing malpractice may be prevented by developing a caring rapport with the client." d. "Nursing malpractice may occur even when the nurses do not intend to harm the clients."

Which patient would be the most appropriate to assign to a new graduate nurse who has just completed their unit orientation? a. A patient who is being discharged with a newly surgically implanted venous access catheter b. A patient who is second day post-op and needs pain medication one hour prior to wound dressing changes c. A patient with HIV who reports headaches, abdominal and sharp, pleuritic chest pain that is rated at 7/10 d. An anxious patient with chronic, uncontrolled pain who frequently uses the call light for 'more meds'

b. A patient who is second day post-op and needs pain medication one hour prior to wound dressing changes

You have just received report and will be caring for the following 4 patients on this day shift. Which patient would be your FIRST priority? a. A patient who had a cholecystectomy yesterday who needs assistance ordering his first post-op meal b. A patient who was admitted last night to r/o Crohn's flare up who is now vomiting and having 9/10 abdominal pain c. A patient who is confused and continues to try to get out of bed to use the bathroom without their walker d. A patient who needs discharge teaching and will be leaving to go to a rehab unit in 1 hour

b. A patient who was admitted last night to r/o Crohn's flare up who is now vomiting and having 9/10 abdominal pain

You are working on the Med-Tele unit at your local hospital. Which of the following patients would you prioritize after receiving report for your upcoming shift? a. A 3-day post-op CABG patient with 94% O2 sats and rating their pain a 4/10 b. A patient who was admitted overnight to observation to r/o MI who the UAP notes to be sweaty and anxious c. A patient with CHF with +4 edema and lung crackles who is due for their 0800 Lasix d. A 1-day post-op stent placement patient with scant amount of bright-red draining on their dressing, which is due to be changed

b. A patient who was admitted overnight to observation to r/o MI who the UAP notes to be sweaty and anxious

Nurses are held responsible for the commission of a tort. What is the definition of a tort? a. The application of force to the body of another by a reasonable individual b. An illegality committed by one person against the property or person of another c. Doing something that a reasonable person under ordinary circumstances would not do d. An illegality committed against the public and punishable by the law through the courts

b. An illegality committed by one person against the property or person of another

The nurse has just received SBAR shift report. Which patient should the nurse assess first as being the highest priority? a. Patient diagnosed with pancreatitis who wants the naso-gastric (NG) tube removed now and is becoming more irritable b. Patient diagnosed with a deep vein thrombosis who is complaining of dyspnea and coughing c. Patient diagnosed with gallbladder disease who refuses to eat the food sent on the meal tray d. Patient diagnosed with osteoarthritis who is complaining of extreme pain in both knees

b. Patient diagnosed with a deep vein thrombosis who is complaining of dyspnea and coughing

You are caring for a team of 4 patients with an UAP on your med-surg unit. After receiving report, you start to plan out your day. Which of the following patient needs would you not want to delegate to the CNA? a. Calculating I & O for a CHF patient who is on Lasix b. Providing discharge teaching to a 85 year-old with pneumonia c. Ambulating a 78 year-old who is 2 days post-op hip replacement d. Collecting a urine specimen to rule out UTI

b. Providing discharge teaching to a 85 year-old with pneumonia

You are the charge nurse making out patient-nurse assignments for the next shift. Which patient should you assign to a new graduate nurse who is orienting to the neurology unit? a. A patient with dementia who will be transferred to a nursing home today b. A new admission with a spinal cord injury c. A patient with Parkinson's disease who needs assistance with bathing d. A patient with a stroke four days ago with left-sided weakness

c. A patient with Parkinson's disease who needs assistance with bathing

Greta is a 78 year-old patient that you are caring for in the LTC setting. One day, she states to you, "Oh, my daughter Betty takes care of all of my financial stuff. It's so nice to not have to worry about that anymore." Upon hearing this information, you recognize that Betty has what relationship to Greta? a. Since Betty and Greta live in Wisconsin, Greta does not need a POA for Healthcare because WI is a "Next of Kin State" and Betty will make Greta's healthcare decisions b. Betty is Greta's Durable POA for Healthcare c. Betty is Greta's POA for Finances but you are unsure about being the POA for Healthcare. You write yourself a note to remind Betty and Greta about this at the next care conference meeting. d. Betty is Greta's POA for Finances and would make any healthcare decisions that are needed

c. Betty is Greta's POA for Finances but you are unsure about being the POA for Healthcare. You write yourself a note to remind Betty and Greta about this at the next care conference meeting.

A nurse caring for a client post-surgery takes necessary steps to achieve quality client care. Which nursing actions satisfy the Quality and Safety Education for Nurses (QSEN) competency called informatics? Select all that apply. a. Washing the hands before handling the client's incision site b. Implementing a new method of monitoring the client's incision site for infections c. Documenting in the electronic health record (EHR) after performing wound debridement d. Locking the electronic health record (EHR) after every entrance of necessary information e. Using computer-assisted instruction (CAI) program to provide better quality of care to the client

c. Documenting in the electronic health record (EHR) after performing wound debridement d. Locking the electronic health record (EHR) after every entrance of necessary information e. Using computer-assisted instruction (CAI) program to provide better quality of care to the client

The nurse is admitting a patient with a spinal cord injury at the C3-4 level. What is the priority assessment, by the RN, for this patient? Hint: keep in the mind the location of this injury and its effect on the body's functioning. a. Monitoring blood pressure and pulse for beginning signs of spinal shock b. Determining the level at which the patient has intact neurological sensation c. Monitoring respiratory effort and oxygen saturation levels d. Assessing the level at which the patient has retained mobility

c. Monitoring respiratory effort and oxygen saturation levels

What type of law is responsible for the nursing agency in the previous question? a. Constitutional b. Common c. Statutory d. Standard

c. Statutory

A patient with migraine headaches has a seizure. After the seizure, which task can the RN delegate to the certified nursing assistant to do first? a. Placing restrains on the patient, for protection, from additional seizures b. Documenting the characteristics of the seizure on the neuro flow sheet c. Taking the patient's vital signs per policy post-seizure d. Performing neuro checks q 4 hours and PRN based on the patient's condition

c. Taking the patient's vital signs per policy post-seizure

As a RN, we are required to renew our nursing licenses every two years in the State of Wisconsin. Which agency is responsible for Nursing licensure? a. The National League for Nursing (NLN) b. The American Nurses Association (ANA) c. The U.S. Department of Justice on Nursing Licensure (DOJNL) d. The State Board of Nursing (BON)

d. The State Board of Nursing (BON)