Ethical & Legal

Refusal of treatment

A client has the ability to accept or refuse care and must consent to all aspects of their care. It is the responsibility of the nurse to ensure the client is fully educated and understands all aspects of their care. In this situation the client needs to fully understand why an x-ray is important to assessing the injury and appropriate treatment. An older adult client fell while walking down the stairs. The client needs an x-ray to assess if the arm is broken but refuses to go. Which nursing actions are appropriate? Select All That Apply Listen to the client's reasons for refusal of treatment. It is important to listen to the client and find out what their concerns are. Notify the client's health care provider of the circumstances. Inform the prescribing HCP in case there is another way to assess and treat client without an x-ray. Re-educate the client on the need for x-ray imaging. Client may need to be re-educated as to why they need to have an x-ray and why it is important to help treat them. NOT: Allow client to walk to the medical imaging department. It would be unsafe to allow the client to walk to the procedure until damage to the arm is assessed. Provide the client with a sedative prior to the arm x-ray. Sedating the client prior to the procedure would be a chemical restraint and is not appropriate. A client has the legal right to refuse any treatment or medication. The nurse should respect the client's decision and encourage the client to explore his or her feelings and emotions. Offering to listen and asking to hear about their concerns strengthens the nurse-client relationship and allows the nurse to identify barriers that may be addressed. The nurse should not respond in a way that causes the client to feel threatened or questions the client's choices as this could damage the nurse-client relationship. The nurse is obligated to contact the health care provider and provide information related to the client's refusal to take prescribed medications. A nurse cares for an older adult client with end stage renal failure. The client refuses to take medications prescribed for treatment. Which statements by the nurse are appropriate? Select All That Apply "You certainly have the right to refuse the medications prescribed by your provider." The client is within legal rights to refuse medication or treatment. "Tell me why you don't want to take the medications prescribed by your provider." This allows the nurse to explore the client's feelings related to medication and prognosis and helps to promote a positive nurse-client relationship. NOT: "You have to take these medications because your provider has prescribed them." The client is not mandated to take medications simply because the health care provider has prescribed them. "These medications are helping you to get better. Your renal failure is causing you to feel bad." This response can result in the the client becoming defensive and negatively impact the nurse-client relationship. "Your daughter will be disappointed when she comes to visit later this afternoon." This is a form of manipulation and is not therapeutic and may damage the nurse-client relationship. Clients have the right to refuse any treatment as long as he/she is competent and aware of the risks. In many circumstances, competency may need to be evaluated and a physician will sit down with them to ensure they are fully informed of the risks of refusing treatment, but refusal is their right. A nurse cares for a client who is prescribed chemotherapy. Which statements by the client requires the nurse to gain additional information prior to administering any treatment? Select All That Apply "My doctor came by yesterday, but we didn't fully discuss the new medication treatment plan." This statement indicates the client has some questions and lack of understanding related to the treatment plan, and the health care provider should be notified. "My husband has some concerns about the medication and he has gone to lunch right now." This statement indicates the client has some hesitation with beginning a treatment plan due to concerns of the spouse. "I discussed with my doctor this morning that I did not want to continue treatment this way." This statement indicates the client has refused a recommended treatment plan, and the health care provider should be notified. NOT: "My doctor came by this morning and discussed this new chemotherapy with me." This statement reflects a discussion with the provider and an understanding of the treatment plan. "My family and I have discussed the value of making these medication changes." This statement indicates that the client has discussed the treatment plan with family and understands and is in agreement with the plan.

Organ Donor

A client who is an organ donor will have their wishes documented. It is the responsibility of the nurse legally to honor the wishes of the client and to follow legal documentation surrounding the end-of-life. An important part of the organ donation is having support in place for the family as they grieve and come to terms with the issues surrounding death and organ donation. Life support is discontinued for a client after a motor vehicle accident. The client has organ donor registration documentation. The spouse objects to the organ donation. How does the nurse best respond? Bring in support services and social work to speak with the spouse. The spouse may need extra support to help deal with the changes in her partner's health, allowing time to grieve and come to terms with organ donation. NOT: Show the spouse the paperwork and restate client's wishes. It is important to honor the client's wishes and legal documentation while communicating with the spouse in a compassionate manner and not be demanding or forceful. Allow spouse time needed to think about organ donation. Yes the spouse needs time to process and come to terms with death and organ donation, but decisions must be made in a timely manner to preserve the viability of the organs. Prepare client for organ donation despite spouse's objection. Spouse needs to be ready and prepared for donation. It is important to honor the wishes of the client but it cannot be a negative and traumatic experience for the spouse. Organ donation is a gift given to many families. It is the responsibility of the nurse to ensure families are fully understanding of the process and what to expect. A client is on life support, and the family is approached about organ donation. What statement from the family indicates the need for further information? "I will be able to hear the heart beat in the new client." While many families are in contact at some point after a transplant it is not necessarily a common practice. Clients are entitiled to privacy, and it is not manadatory that families of transplant donor and transplant recipient meet. It must be mutually agreed upon between parties and arranged by a mediator. NOT: "It was their wish to be an organ donor." Individuals often have their wishes to be an organ donor documented. In many states an individual will have the documentation on their drivers license. "Several organs will be used." When it is determined that a client will be an organ donor, often many of their organs will be viable to tranplant to others. "We will be able to say our goodbyes." Families are given the support they need to grieve the loss of the client. They are given time and space to say their goodbyes to help with their grieveing process. Brain death is the total and irreversible loss of all brain function. The client has met criteria for brain death, so this means that the family does not need to make the decision to let him die because the client has already been pronounced dead with the determination of brain death. The nurse should refocus the family on the issue of organ donation. The nurse should take care in maintaining therapeutic communication with the family and not making statements which could create a defensive response. Laws vary from state to state, but the family may still be required to sign a consent form for organ donation. Other states simply require the family be notified that the client is an organ donor. The nurse should be familiar with policies in the state of employment. A nurse cares for a client who was in a motor vehicle accident with a diagnosis of brain death. The client's driver's license indicates the decision to be an organ donor. The family expresses concern to the nurse regarding allowing the client to die just so organs can be harvested. Which response by the nurse is best? "The provider has established brain death. Will you choose to honor the client's wishes?" This statement restates to the family the facts related to death and reminds them of the client's expressed desires and helps them to re-focus on the decision that needs to be made. NOT: "Since the client has already made this decision, the organs should not be wasted." The nurse does not consider the feelings and emotions of the family and does not address the issue of death already being determined with this statement. "It is not your place to make the decision regarding organ donation for this client." This is a statement that may make the family become defensive. "There is no need for you to be concerned. The harvesting will be painless." This does not address the family's concern related to death.

Violence

A nurse who has been the target of a violent outburst by a client should report the incident immediately to the charge nurse, security personnel, and the health care provider. If the health care provider prescribes an antipsychotic or sedative for the client, the nurse should have the charge nurse and security personnel accompany to the room for safety when approaching the client to administer the injection. The client should never be given a syringe and needle for self-administration when the client has been combative or violent. Even if a client has been violent, it is not acceptable for nurses to physically restrain the client to administer an injection in most hospitals. The client still has the right to refuse treatment. If the client refuses treatment in this situation, law enforcement may be involved to protect the nurse and other members of the health care team. (The exception to this is in a psychiatric emergency in which a client is deemed dangerous or a danger to him or herself. In a Code situation, nurses may administer medication while a client is restrained with an order). A nurse cares for a client with a history of bipolar disorder. When the nurse prepares to administer a prescribed insulin injection, the client throws a chair at the nurse. The nurse contacts the health care provider and receives a prescription for lorazepam 2 mg IM q8h PRN agitation. Which action does the nurse take? Contact security personnel for support during administration of the lorazepam. Due to the nature of the client's behavior and need for medication to calm the client, the nurse should have security and possibly an additional nurse present for medication administration. NOT: Place the client in four point restraints and administer the medication as prescribed. The nurse cannot physically restrain a client for medication administration. Instruct the client to calm down so that the medication can be administered as prescribed. Instructing the client to calm down is not an appropriate intervention for a client with bipolar disorder and expected outbursts of aggression. Wait for the client to calm down before returning to the room to administer the prescribed medications. Waiting for the client to calm down does not address the issue of agitation and the need to administer a scheduled medication. After the nurse calls for assistance and moves all clients from the common area for their own safety, the nurse directs the staff to initiate 4-point restraints. The nurse may initiate seclusion or restraints without a health care provider prescription based on assessment of the client, but the health care provider must then be contacted to obtain a telephone prescription and come to the unit for a face-to-face evaluation within one hour. Prescriptions must specify the type of restraint and the reason for it. For psychiatric clients, the time limit for a prescription for seclusion or restraints is four hours. For nonpsychiatric clients, restraints may be prescribed for 24 hours. After that time, the health care health care provider must write a new prescription. The Omnibus Budget Reconciliation Act (OBRA) clearly states that restraints should be applied only as a last resort and that the least-restrictive restraints should be used. A client on a psychiatric unit becomes violent and attacks a second client. The nurse caring for the violent client is unable to calm or move the client to a secluded area. The client becomes more violent by punching the wall. The nurse calls for assistance. Which action does the nurse take next? Secure the client using 4-point restraints. The nurse needs to protect the client from self, so 4-point restraints are the next level of restriction. NOT: Instruct all clients and staff to remain calm. Although others need to be instructed to remain calm, the priority is to secure the client and move others to an area of safety. Administer PRN medication for agitated behavior. PRN medications should be administered before the situation has escalated to the point where the client and others are at risk for injury. Contact the health care provider to obtain prescriptions. The health care provider should be contacted after the client has been secured and others are moved to safety. The primary goal for client care is safety. When managing clients who become aggressive, interventions should be aimed at preventing escalation. Health care providers will prescribe PRN medication for alleviation of signs and symptoms of anxiety or agitation. When the client becomes unmanageable and poses a threat to self and others, the nurse and other staff place priority on safety of all involved. In this case, the client may require pharmacological restraint that does not require consent. Haloperidol is the most commonly used antipsychotic medication for aggressive or violent incidents. An adult client threatens to kill others and is throwing furniture and large objects. Staff members secure the client in an isolation room. The client continues to yell and headbang forcefully against the locked door. The health care provider instructs administration of haloperidol 10 mg IM x1 time as well as 2 mg lorazepam already prescribed PRN. Which action does the nurse take? Administer the medication immediately with assistance from other staff. It is appropriate to sedate or subdue this client who is dangerous and poses a threat to self and others. NOT: Determine if an alternative PRN medication at a lower dose can be administered. If the client were not at risk for injury or there were no danger to other clients, lower dosages of medication or alternative steps could be taken prior to escalation. Refuse to administer the medication because it is a chemical restraint. Refusing to administer the medication places the client at risk for injury. Verify consent for pharmacologic restraints in the client's health record. There is no need for client consent because the client is dangerous and poses a threat to self and others.

Child abuse

All states in North America have laws requiring mandatory reporting of child maltreatment or suspicion of abuse. The nurse is a mandated reporter and must report to local authorities. It is important for the nurse to complete a complete head to toe assessment and document the objective findings in the client health record without opinion or judgment. The nurse should maintain a therapeutic relationship with both the client and the client's parent and not make statements that may cause the parent to become defensive which could place the nurse and the client in danger. The nurse should notify the health care provider of the physical findings and their consistency with physical abuse. The nurse may interview the child if the parent leaves the child alone but should not request the parent leave the child for questioning. Findings of assessment should be provided to those providing care to the client. Sharing or discussion information with those not involved with direct client care is a violation of client privacy. A nurse cares for a school-age client with pneumonia. Upon assessment, the nurse observes bruises on the child's back and arms. The parents are present in the client's room. Which action does the nurse take? Contact the health care provider regarding suspected abuse. The health care provider should be consulted regarding abuse concerns in order to gather additional data before confronting the parents and/or reporting to local authorities. NOT: Confront the parents regarding abuse of the child. Confrontation may create a situation where the client's parents become defensive and potentially violent, placing the client and nurse at risk. Question the client regarding treatment at home. If the parents leave the room, the nurse can ask the client about feeling scared or unsafe at home. Notify the local authorities regarding suspected abuse. Although the nurse is a mandated reporter, more data should first be gathered, beginning with contacting the health care provider to express concerns of abuse. This information does not imply that the nurse needs the HCP permission or confirmation prior to reporting. The nurse would inform the provider so that the provider could then complete an assessment and all findings could be communicated when reporting the suspected abuse. All states in North America have laws requiring mandatory reporting of child maltreatment or suspicion of abuse. The nurse is a mandated reporter and must report to local authorities. It is important for the nurse to complete a complete head to toe assessment and document the objective findings in the client health record without opinion or judgment. The nurse should maintain a therapeutic relationship with both the client and the client's parent and not make statements which may cause the parent to become defensive which could place the nurse and the client in danger. The nurse should notify the health care provider of the physical findings and their consistency with physical abuse. The nurse may interview the child if the parent leaves the child alone but should not request the parent leave the child for questioning. Findings of assessment should be provided to those providing care to the client. Sharing or discussing information with those not involved with direct client care is a violation of client privacy. A nurse cares for an 8-year-old client with a broken arm. When the parents leave the room, the client tells the nurse the mother has been abusive and the broken arm is the result of the abuse. Which initial actions does the nurse take? Select All That Apply Complete a full assessment, noting physical and behavioral signs that may indicate abuse. The nurse should complete a full assessment and document any physical findings, such as bruises or other abrasions that could be indicative of abuse. The nurse should also document behaviors exhibited by the child that may suggest abuse. Notify the health care provider of the assessment data and information provided by the client. The health care provider should be notified so that additional data may be obtained prior to notification of child protective services and/or the local authorities. NOT: Notify the father of the allegations the client has made regarding abuse from the mother. Discussing the allegations with the father is a breach of the client's privacy and may break the client's trust with the nurse. Document opinions related to physical and behavioral signs that indicate abuse. Documented findings should only include factual and objective data. Contact the local authorities for an investigation related to suspected child abuse. The local authorities will be notified after the physician has obtained additional data. All states in North America have laws requiring mandatory reporting of child maltreatment or suspicion of abuse. The nurse is a mandated reporter and must report to local authorities. It is important for the nurse to complete a complete head to toe assessment and document the objective findings in the client health record without opinion or judgment. The nurse should maintain a therapeutic relationship with both the client and the client's parent and not make statements that may cause the parent to become defensive, which could place the nurse and the client in danger. The nurse should notify the health care provider of the physical findings and their consistency with physical abuse. The nurse may interview the child if the parent leaves the child alone but should not request the parent leave the child for questioning. Findings of assessment should be provided to those providing care to the client. Sharing or discussing information with those not involved with direct client care is a violation of client privacy. A nurse cares for a school-age client admitted for appendicitis. During assessment, the nurse notes multiple bruises on the client's arms, legs, and torso. Which actions does the nurse take? Select All That Apply Document the assessment findings. The assessment findings should be documented in the client's health record. Notify the health care provider. The health care provider should be notified of the findings and the suspected abuse. Report the findings to local authorities. Nurses are mandated reporters and should report suspected abuse to the local authorities. NOT: Question the client's parents. The nurse questioning the mother can cause the mother to become defensive and potentially hostile, creating risk for client and nurse. Discuss the findings with another nurse. Discussing the assessment findings with another nurse is a violation of client confidentiality unless the second nurse is involved in treatment of the client.

Do Not Resuscitate (DNR)

It is the responsibility of the nurse to legally recognize and uphold a client's DNR status. It is important for the nurse to help the family accept the wishes of the client while educating them on end of life and palliative care. The goal is to keep the client comfortable but not prolong their life. The nursing supervisor will help with family conflicts and facilitate any additional support the family will need from social workers and palliative care. The adult child of an older adult client in the end stage of life insists the nurse rescind the client's do not resuscitate status. What is the nurse's first response? Alert the nursing supervisor of the potential conflict. Alert the nursing supervisor that further action and support will be needed. The nurse caring for the client and their family will need extra support from management and social work to help the family come to terms with a client's prognosis and wishes. NOT: Review the client's health status and involve palliative care . Palliative care is important aspect of end of life care but this would not be the first step the nurse would take. Conflict with the family must be resolved first. Ask the client if their wishes have changed. A client is able change their mind on their DNR decision and the nurse must legally honor their decision. In this situation it would be important to that the patient is fully competant and understanding of their decision and not being persuaded by family. Contact social work to provide support to the family. Social work will provide support to the family who may be struggling with the client's wishes as well as their end of life care. A social worker will listen to the family's concerns, explain end of life care and help them to understand the wishes of the client. A do not resuscitate order (DNR) or "no code" requires consultation with a health care provider prior to the form being completed and signed. The health care provider needs to verify client competency and understanding of the consequences associated with signing the form. Both the provider and the client then sign the form. This consultation should be documented in the client's health record. The family may be a part of the consultation if the client wishes for them to be, but it is not required. These orders should be reviewed regularly with the client to ensure the client wishes to continue with the order. DNR protocols vary from state to state. An elderly client diagnosed with respiratory failure insists to the nurse to not be placed on a ventilator. Which action does the nurse take? Contact the client's health care provider. The health care provider needs to determine the client's competency prior to a DNR form being signed by the client. NOT: Consult with the client's immediate family. The client's family may be consulted if the client wishes for them to be involved or if the provider deems the client incompetent to make such a decision. Place a do not resuscitate note on the client's chart. The DNR form has to first be signed by the client and the health care provider. Place a consult for hospice in the client's chart. The hospice team may be consulted after the physician has evaluated the client and written an order for a consult. A do not resuscitate order (DNR), or "no code," requires consultation with a health care provider prior to the form being completed and signed. The health care provider needs to verify client competence and understanding of the consequences associated with signing the form. Both the provider and the client then sign the form. This consultation should be documented in the client's health record. The family may be a part of the consultation if the client wishes for them to be, but it is not required. These orders should be reviewed regularly with the client to ensure the client wishes to continue with the order. DNR protocols vary from state to state. Contact the client's health care provider. The health care provider needs to deem the client competent and review the desires of the client prior to the advance directive being signed. NOT: During a client assessment, the client informs the nurse of the desire to not be placed on a mechanical ventilator. Which action does the nurse take? Consult the client's family regarding these wishes. If the nurse consults the client's family against the client's wishes, this is a violation of client confidentiality. Have the client sign an advance directive. The health care provider first needs to deem the client competent prior to an advance directive being signed. Assess the client for mental competency. Nurses are not authorized to deem client competency. A DNR for a child with cerebral palsy and pneumonia does not mean that they will not receive treatment and care. The nurse would be assessing the client's respiratory status to make sure there is improvement. The nurse follows prescribed orders to make sure the child can breathe comfortably. Focus would be on comfort care for the child and treating the pneumonia and symptoms associated with it. A school-aged client with cerebral palsy and a do not resuscitate status is treated for pneumonia at home. What is the home care nurse's first action when providing care? Assess the client's respiratory status. The breathing of a child with pneumonia, especially one with cerebral palsy would be compromised. Having a DNR would not change the way this client is treated for pneumonia. This would be the priority for this child. NOT: Administer nebulizer treatments. A child with cerebral palsy and pneumonia would most likely be receiving nebulizer treatments as part of their care plan. Nebulizers can be given on a regular schedule and as needed. It would be important for the nurse to first assess the lungs and respiratory status of the child before administering medication. The client's lungs and respiratory status should also be assessed after the treatment is completed to ensure there has been an improvement. Document the client's respiratory status. The nurse will always document the status of the client's health as well as any interventions that were performed. This would not be the first action of the nurse. Documentation will occur throughout the shift as the helath status changes and care is given. Review any new prescriptions. It is always important for a nurse caring for a client in their home to review any newly prescribed or changed medications and intervetions. A child's health status can change quickly, and the nurse must review their health and orders since the last visit. A do not resuscitate order (DNR), or "no code," requires consultation with a healthcare provider prior to the form being completed and signed. The health care provider needs to verify client competency and understanding of the consequences associated with signing the form. Both the provider and the client then sign the form. This consultation should be documented in the client's health record. The family may be a part of the consultation if the client wishes for them to be, but it is not required. These orders should be reviewed regularly with the client to ensure the client wishes to continue with the order. DNR protocols vary from state to state. A client deemed competent by the health care provider has a "do not resuscitate" (DNR) on record. The client informs the nurse of the wish for appropriate measures to be taken to maintain life. Which responses by the nurse are appropriate? Select All That Apply "I will bring the papers by so that you can review your options." This provides the client with the options available in changing the current status. "I will contact your provider so that you can make those changes." The health care provider should be notified as soon as possible so that changes can be ordered without negative consequences to the client. NOT: "A DNR order cannot be changed once it has been initiated." A client can change their code status at any time. "Are you certain your family will be okay with this decision?" The nurse may compromise the trust established with the client if the request is questioned. "I will place a note on the front of the chart for your provider." Placing a note in the chart for the health care provider creates an unnecessary delay for this change to be made.

Elder abuse

Older clients are at risk for elder abuse. A nurse is legally responsible for reporting any incidence of abuse that is witnessed or suspected. The nurse must assess the client to ensure safety and the incident must be reported. The nurse must advocate for the client that may be experiencing abuse. A nurse observes an adult child being forceful to their bed ridden older parent. What is the nurse's response? Select All That Apply Report the situation to a supervisor. It is important to report any issues of abuse to the supervisor. As an advocate for the client, it is the responsibility of the nurse to escalate what was witnessed. In this scenario this would not be the first response, the nurse must first assess the client and ensure safety. Contact the social worker. A social worker can help assess family situations and provide additional support to the family when needed. Assess the client. It would be important for the nurse to assess the client to make sure they have not been physically harmed. The nurse would assess for any bruises or marks that would indicate excessive force had been used. NOT: Ignore family matters. The nurse should not insert self into family matters that do not affect the client and care. In this situation where there is potential harm to the client, it is the nurse's legal responsibility to advocate for the client by making sure the incident is reported and the client is safe. A nurse who witnesses or suspects neglect or abuse is legally responsible for reporting it. Confront the adult child. In this scenario this would not be he best response from the nurse. Confronting the adult child could create additional conflict and be detrimental to the care of the client. The situation must be addressed but supports for the family must be in place and the the client and family should not feel as if they are being attacked. Physical abuse occurs when a caregiver uses physical force such as force-feeding, hitting, biting scratching, or any other type of physical punishment. Clients who are most at risk for elder abuse are over 75 years old, female, physically or mentally impaired, and rely on their abuser for care. The nurse continues to assess the scenario for additional information regarding suspected abuse. Note that even if abuse is suspected or confirmed, a legally competent adult cannot be forced to leave an abusive situation. A nurse cares for a group of clients who are dependent on caregivers. The nurse suspects which caregiver of physical abuse? The caregiver forcibly pushing food into the client's mouth. Physical abuse occurs when a caregiver uses physical punishment or excessive force, such as force-feeding, hitting, biting, scratching, or other causes of physical injury. NOT: The caregiver secretly watching the client undressing. This may or may not constitute a form of abuse, depending on why and how the caregiver is watching, whether the client is competent and consents to the observation, and more. It may represent a type of emotional, psychological, or sexual abuse, but it would not meet the criteria for physical abuse, as there is no physical contact. The caregiver frequently calling the client derogatory names. This indicates emotional abuse and is a form of elder abuse that should be monitored and reported but does not meet the definition of physical abuse. The caregiver failing to address the client's dirty appearance. This may indicate neglect which is a form of elder abuse. Neglect does not involve harmful physical contact so does not meet the definition of physical abuse. All states have statutes requiring mandatory reporting by nurses and other health care workers of any suspected abuse and neglect of children, disabled individuals, and older adults. Clients suffering from abuse and neglect will often have bruising, welts, burns, and weight loss. These clients often appear anxious or have personality changes. The nurse should privately discuss with the client any concerns about the client's safety in a nonconfrontational manner without the suspected abuser in the room. The nurse is also required by law to report any suspected abuse or neglect because all nurses are mandated reporters. The nurse should not confront the suspected abuser with accusations or expect the abuser to seek help voluntarily. A home health nurse makes weekly visits to an older adult client who lives with an adult child. The client has bruises from "bumping into things" and a weight loss of 10 pounds in the past month. How does the nurse proceed? Report suspected abuse to Adult Protective Services so an investigation can be performed. It is important for nurses and other mandated reporters to report suspected abuse to Adult Protective Services in order to conduct an investigation into the client's safety. NOT: Ask the client about any concerns about his or her living situation with the child in the room. Asking the client about his or her safety at home with the suspected abuser is not appropriate and does not ensure client safety. Question the client's child privately about suspicions of possible abuse or neglect. The nurse should not question the client's child about the suspicion of abuse. Confront the child about the abuse, and demand that the child seek help for the abusive behavior. The nurse should not confront the client's child about the suspicion of abuse. Clients most at risk for elder abuse are over 75 years old, female, physically or mentally impaired, and rely on their abuser for care. Nurses are legally mandated in both the US and Canada to report suspected cases of vulnerable adult abuse. This definition of "vulnerable adult" is based on competency and the ability to make informed choices. Unless the older adult has been found legally incompetent, he or she has the right to self-determination and can choose to stay in the current care situation. The nurse completes a physical assessment of an older adult. The assessment findings lead the nurse to suspect the client is a victim of elder abuse by the caregiver. What action does the nurse take first? Initiate assessment of the client's competency. Before initiating any action, the nurse needs to know if the client can competently make decisions. By law, a client has the right to self-determination. Even if the treatment of the client by the caregiver meets the threshold for abuse, the competent client has the right to choose to return to the environment. NOT: Report the suspected abuse to a social worker. Before sharing the suspicion with others, the nurse must fully assess the client including the competence for self-determination versus being incompetent and therefore, a vulnerable person. Confront the client's caregiver about the abuse. The nurse should not bring the topic to the caregiver. If the client is competent and agrees to having protection, or if incompetent, the nurse reports the suspected abuse to the appropriate agency. Observe the caregiver interacting with the client. Observing interactions between clients and caregivers is an important part of a nursing assessment. However, regardless of these observations, the nurse's suspicions must be first be clarified by assessing the client's competence as this will direct the actions taken. Elder mistreatment is "intentional actions that cause harm or create serious risk of harm to a vulnerable elder by a caregiver or other person who is in a trust relationship to the elder." This can by physical, emotional, sexual, or related to finances. Clients with dementia are at higher risk for elder mistreatment or abuse due to the lack of cognitive ability to alert others to the abuse or to report the abuse to providers. They can also be difficult to manage, creating stress for the caregiver, which may result in mistreatment. The nurse is a mandatory reporter and is obligated to report suspected elder abuse within 24 hours of findings. The health care provider should be notified as well. A home health nurse cares for an older adult client with dementia. On a home visit, the nurse notes a bruised eye and abdomen. The client is withdrawn and pulls away when the nurse attempts conversation. Which actions does the nurse take? Select All That Apply Document the physical assessment findings in the client's health care record. The nurse should document physical and behavioral findings consistent with abuse in the client's health record. Contact the health care provider with assessment data and suspected abuse. The client's health care provider should be notified of suspected abuse so that appropriate measures can be taken to remove the client from harm. Contact the local authorities and report the findings as suspected elder abuse. The local authorities need to be notified for further investigation of the event. NOT: Instruct the client to notify the health care provider at the next scheduled visit. A client with dementia is in no condition to remember what has happened or to report any events to the health care provider. Instruct the client's family to monitor for further self-mutilation by the client. These injuries are not consistent with self-injury. Clients most at risk for elder abuse are over 75 years old, female, physically or mentally impaired, and rely on their abuser for care. When a caregiver fails to meet basic needs of a client such as hygiene, nutrition, clothing, and/or shelter, this is known as neglect. The nurse continues to assess the scenario for additional information regarding suspected abuse. Note that even if abuse is suspected or confirmed, a legally competent adult cannot be forced to leave an abusive situation. (CDC)

Consent form

Parents or legal guardians are authorized to give consent for a child. The client's parent has relinquished responsibility of the child, either voluntarily or by force, and is not able to provide consent for the child. A 16-year-old, unless deemed a legal guardian and emancipated, is not able to provide consent. The social worker is involved in the well-being of the child due to being placed under guardianship of someone other than the parent, but is not legally able to provide consent. Written informed consent of the parent/guardian is required for medical or surgical treatment of a minor. Parents/Guardians are responsible for making decisions that are in the best interest of providing optimal care for minor children. Children in the concrete operations stage of development (over age 7) must give assent, not consent. Assent means having knowledge of the surgery and agreement with the parent or other person giving consent. The child does not need to sign anything. Information provided should be age appropriate and communicated in a manner in which the child understands. The nurse cares for a school-age client undergoing a heart transplant. Which information is correct regarding consent for the procedure? Select All That Apply The parent/guardian should be informed of risks and benefits of the procedure and sign a consent form. With surgery or treatment for medical conditions for older children and adolescents, the parents' consent is required after an explanation of risks and benefits. The client should be provided with information regarding the benefits of the procedure. The client should be provided a developmentally appropriate explanation of the benefits of the procedure. NOT: The client should sign a consent form after listening to an explanation of the procedure. The client as a minor does not need to provide consent, but decision making should include the client's assent. The client is a minor and the provider does not need to provide information related to the procedure. Though a minor, the client should be involved in the decision making process. The client should be provided with the option to refuse surgery and seek alternative treatment. Parents have responsibility for providing care for their minor children and determining when medical or surgical treatment is necessary. Before any procedure a client must sign an informed consent form stating they are fully understanding of a procedure and the risks. The parents of a minor child are responsible for signing the informed consent form to have a gastrostomy tube placed. It is the responsibility of the nurse to make sure the correct paperwork has been filled out before the child is prepared for the procedure. A nurse cares for a school-age client who is scheduled to receive a gastronomy tube. What is the first action of the nurse? Ensure the parents have signed the informed consent form. As a minor the parents are legally reponsible for the decision making of the child. The nurse is responsible for making sure consent has been signed by the parents and they understand the procedure. NOT: Educate the parent on the care of a gastrostomy tube. It is important to educate the parents on the proper care gastrostomy tube site. Preparing the parents before the procedure and reinforcing the education after the procedure are important aspects of care. The teaching will mostly happen after the procedure and in this example would not be the first action of the nurse. Prepare the child for the procedure. It is important to fully prepare the child for the procedure and what to expect before, during and after. It would be appropriate for the nurse to involve the child life specialist to help with developmetal appropriate education and activities. Preparing the child is an important aspect of care but the nurse's first responsibility is to ensure parents have signed the informed consent. Obtain vital signs and assess the client's health. It is important for the nurse to assess the child during their shift as well as before any procedure. Checking that all the correct parperwork is signed and filled out is the best first action of the nurse. If the paperwork is not filled out the nurse can bring it to bedside to review with the parents and then assess the child. With informed consent, the client should be informed of the risks and benefits of the procedure as well as alternatives to the procedure and express understanding before signing the form. The health care provider performing the procedure is legally required to provide this information. Even after signing a consent, if the client has questions or doubts, the nurse should contact the health care provider to return and answer any questions the client may have. The nurse may review information provided by the provider but may not provide additional information. It is the nurse's responsibility as client advocate to ensure the client understands the information which has been provided. A client is scheduled for a surgical procedure. The health care provider explains the risks and benefits of surgery, and the client signs the consent. Two hours later, the client discusses the surgery with the nurse and requests information regarding alternatives to surgery. What does the nurse do? Contact the health care provider. The health care provider should be notified regarding the client's questions and provide the client with information requested. NOT: Provide alternative treatment options. The nurse may review the alternative options provided by the health care provider but should first contact the provider to inform of the questions and doubts the client is experiencing. Instruct the client this is the only option. The client has doubts and the health care provider should be contacted to answer any questions and ensure full understanding. Schedule the procedure for another day. Though the procedure may need to be scheduled for another day, the nurse does not do that and must contact the health care provider. The surgeon who performs the procedure is responsible for ensuring the client has enough understanding about risks and benefits to provide an informed decision regarding the procedure and then to have the client sign the consent form before sedation is given.The nurse's role is to assess the client's understanding and clarify information. The nurse also verifies and can serve as a witness that the client signed the consent form. With informed consent, the client should be informed of the risks and benefits of the procedure as well as alternatives to the procedure and express understanding before signing the form. The health care provider performing the procedure is legally required to provide this information. Even after signing a consent, if the client has questions or doubts, the nurse should contact the health care provider to return and answer any questions the client may have. The nurse may review information provided by the provider but may not provide additional information. It is the nurse's responsibility as client advocate to ensure the client understands the information which has been provided. A nurse cares for a client scheduled for surgery later in the day. The surgeon has back to back surgical cases and asks the nurse to explain the procedure and obtain informed consent. Which action does the nurse take? Wait for the provider to provide information to the client and then have the client sign the informed consent. The provider performing the surgery must explain the procedure to the client and obtain written informed consent. NOT: Contact the physician's nurse to discuss the procedure with the client and then have the client sign the informed consent. A nurse cannot provide information related to risks and benefits of a procedure in order to obtain consent for a surgical procedure. Explain the procedure to the client as best as possible and then have the client sign the informed consent. A nurse cannot obtain consent for a surgical procedure. Contact the anesthesia provider to explain the procedure and then have the client sign the consent. The anesthesia provider can explain the anesthesia used for the surgery and obtain written informed consent for anesthesia. The legal responsibility of the nurse in the informed consent process is to witness the consent of the client. It is the responsibility of the health care provider performing the procedure to explain the procedure and the associated risks, benefits, and alternatives. The role of the nurse is to witness that the client is competent to give content and fully understands the procedure. The nurse may clarify information, but the primary responsibility of explanation lies with the healthcare health care provider. A nurse cares for a client admitted for a surgical procedure. When having the client sign the surgical consent, which responses by the nurse are appropriate? Select All That Apply "Tell me what Information the health care provider has given you regarding this procedure." This statement allows the nurse to determine what information has been provided as well as client understanding of the information provided. "Is there anything you don't understand about the procedure before you sign this consent?" This open ended question allows the client to provide information regarding concerns the client may have related to the procedure. NOT: "I'll answer any questions you have regarding surgery before you sign this consent." The nurse cannot guarantee the ability to answer questions related to the procedure and any questions should be directed to the health care provider performing the procedure. "The health care provider explained everything about the procedure to your family last night." The person providing the procedure should provide information regarding the procedure, associated risks, benefits and alternative therapy to the client. "Please sign this consent form so that we can take you for your procedure now." This statement provides no avenue for the client to ask questions nor for the nurse to determine understanding of the procedure. The health care provider performing the procedure is responsible for obtaining the consent and explaining in a clear audible voice. The nurse is responsible for ensuring that the client understands it. The client should be allowed to ask questions to ensure understanding of the procedure, its risks, and alternative treatments. Because the client is unable to read the form, it should be read aloud to the client in a clear audible voice. For a client with visual impairment, it is recommended that an impartial witness is present to observe the consent process or that a recording be made of the consent, but this is not required by law, in addition to the nurse signing the form. This should not be a family member or friend. This could be another health care provider who is not providing care to the client.The Americans with Disabilities Act (ADA) requires health care facilities to ensure that no one with a visual disability is excluded, denied services, segregated, or otherwise treated differently than other individuals because of the absence of "auxiliary aids and services." Offering reading material in alternative formats are one kind of legally required auxiliary aid or service. The health care provider prepares to obtain surgical consent from a client with severe blindness. Which actions are appropriate for the nurse to take in order to ensure the client understands? Select All That Apply Ask the client to verbalize any questions or concerns. The client should be encouraged to ask any questions or voice concerns in order to ensure full understanding of risks and benefits of the procedure. Have a family member read the consent in a clear voice to the client. A family member or friend can read the consent to the client in a clear audible voice. NOT: Have a family member listen and sign the consent form. Unless designated as a durable power of attorney for health care (DPAHC), the client is still responsible for signing the consent form. Remind the health care provider to speak loudly. Speaking loudly is not necessary; simply speaking in a clear, audible voice is sufficient. Have a family member witness and sign after the client. It is best for the witness to be an impartial person and not a family member or friend. The nurse's response explains to the client that informed consent is about understanding the indications, alternatives, risks and benefits, and answers the client's questions accurately and appropriately. With informed consent, the client should be informed of the risks and benefits of the procedure as well as alternatives to the procedure and express understanding before signing the form. A client with severe metabolic abnormalities is prescribed a peripherally inserted central catheter (PICC). The nurse tells the client that informed consent is required. Which response by the nurse is appropriate when the client questions the necessity of signing a consent? Select All That Apply "To be fully informed, you need to be aware of the risk and the benefits of the procedure." This provides an explanation to the client regarding what informed consent entails. "The consent ensures you have been provided with alternatives to the procedure." This provides an explanation to the client regarding what informed consent entails. NOT: "The consent will keep you from filing a lawsuit if you sustain an injury." This is unnecessary information and creates a situation where the client doesn't trust the nurse to complete the procedure. "A consent form is required for any procedure performed in the hospital." This is not a true statement. Consent is required for invasive procedures. "Consents for invasive procedures are required by the hospital's legal department." This is unnecessary information and creates the potential for a non-therapeutic nurse-client relationship. A client is considered to be of majority age and able to make their own decisions after they reach age 18 in most states. Under this age, consent must be provided by a parent or legal guardian. If the client is emancipated, they may give their own consent. These individuals are given the legal capacity of an adult and vary from state to state. Most states recognize an individual to be emancipated with pregnancy, marriage, high school graduation, independent living, or military service. In situations where a minor requires emergency medical or surgical treatment, consent is not required. A nurse cares for a client who is scheduled for a kidney biopsy. The nurse completes a pre-operative checklist. Which information would confirm the client is able to legally consent for the procedure? Select All That Apply The client is in the military. A client in the military is recognized as emancipated. The client is married. The married client is recognized as emancipated regardless of age. NOT: The client understands the procedure. Understanding of the procedure does not gain legal right to consent. The client is 16 years old. 16 years of age is under the age of majority. The procedure is minor. The procedure being minor or major has no impact on the client signing the informed consent.

Advance directives

The Patient Self-Determination Act was enacted in 1991 and mandates that institutions provide information in writing to clients related to rights to refuse treatment or formulate advance directives. There must be documentation in the client's health care record indicating whether a client has a signed advance directive. A nurse completes an assessment on a newly admitted client. With the implementation of the Patient Self-Determination Act, which information is the nurse required to include during admission? Information regarding advance directives Health care institutions are required to provide written information to clients regarding rights to make decisions. NOT: Side effects of medications prescribed Information regarding notification of side effects of medications is not a requirement for this act. Informed consent for medical treatments Informed consent is not a component of this act. Data on number of client fall injuries Providing information to clients regarding number of client fall injuries is not a requirement for this act. Advance directives include living wills, health care proxies, and durable powers of attorney for healthcare. These allow clients to make autonomous decisions regarding the care provided to them at end of life. It allows for a determination of the client's wishes to be expressed and followed through with in the event the client becomes incapacitated or is deemed incompetent without the ability to make decisions regarding care. These need to be discussed fully with the client by the health care provider in order to fully understand the client's wishes. A hospice nurse cares for a client with lung cancer. The client completes an advance directive and expresses concern. The client has concerns regarding not being cared for by the health care provider who now will believe the client simply wishes to die. Which is the best response by the nurse? "Your health care provider will continue to address your needs according to the wishes you have expressed even when you can no longer express them." This statement provides information to the client regarding how the advance directive helps the provider to know how to best meet the client's needs according to his wishes. NOT: "Your health care provider will now have a limited role in the care you receive since you have been placed on our hospice team." This response does not address the client's concerns as expressed or help the client to understand the purpose of the advance directive. "The health care provider leaves all concerns to the management of the hospice team, and there will no longer be a need for involvement in your care." This response provides inaccurate information to the client and does not address the concerns expressed nor help the client to understand the purpose of the advance directive. "Your health care provider is obligated by law to provide the best management of your health needs regardless of your advance directive wishes." Though it is true that the health care provider is obligated to care for the client, this response does not address the client's concerns. An advance directive is a legal document that indicates the healthcare wishes of a client. If the client does not have a completed advance directive and does not have a do-not-resuscitate status on file, the nurse must proceed with life-saving treatment. A client who has cardiopulmonary arrest, despite any comorbidities, should have quick and effective CPR. The nurse should not make personal judgments, clarify with the healthcare provider, or ask the client's family member how to proceed. A client with terminal cancer is in cardiopulmonary arrest. The nurse notes that the client does not have an advance directive. What is the nurse's best action? Perform cardiopulmonary resuscitation. The nurse must perform full CPR on the client, as this aligns with the client's wishes. The nurse may find this an ethical dilemma, but the client's legally expressed wishes are always priority. NOT: Ask the client's family member how to proceed. A client without an advance directive who has cardiopulmonary arrest should receive CPR. Asking the client's family member delays the client's CPR and decreases the chance of survival. Assume implied consent to forgo treatment. Implied consent is appropriate in this situation, but the implied consent occurs because the client is unconscious and implies consent to treatment. Ask the healthcare provider for guidance. Immediate CPR is required. Asking the healthcare provider for guidance decreases the chances of quick and efficient CPR, decreasing the client's chances for survival. The nurse must have knowledge on advance directives in order to educate the client on the importance of the advance directive. According the 1990 Patient Self-Determination Act, health care entities must provide the client with information on advance directives when the client is admitted to the hospital. It is also important for the nurse to understand the difference between a durable power of attorney and a living will; a living will states the client's health care wishes, whereas a durable power of attorney appoints a particular individual to make health care decisions for the client. Advance directives do not expire and do not require an attorney for validity. A nurse manager plans training for staff nurses on advance directives. Which statement does the manager include? "When a client is admitted to the hospital, the client must receive information on advance directives." According the 1990 Patient Self-Determination Act, health care entities must provide the client with information on advance directives when the client is admitted to the hospital. NOT: "Durable power of attorney is another name for a living will." A durable power of attorney and a living will are different. A living will delineates the client's wishes, while the durable power of attorney allows another individual to make health care decisions for the client. "An advance directive document must be signed every five years to remain valid." An advance directive does not expire. "When a client signs an advance directive, the health care facility must provide an attorney." Although an advance directive is a legal document, an attorney is not required for a client when the client signs it.

Incident Report

The incident report is an internal document for the hospital and should not be mentioned in the medical record, nor should a copy be made for the client's record. Only a factual description of the incident and any actions taken (health care provider notified, vital signs stable, orders given, client's response to treatment) are documented in the client's medical record.The incident report is for the institution's own records to help improve policies and procedures via risk management. A nurse precepts a graduate nurse who administers a dose of fentanyl to the wrong client. The preceptor assists the nurse in the completion of an incident report. Which statements by the graduate nurse require additional teaching? Select All That Apply "These go to the board of nursing to maintain a record of the medication errors made." Incident reports are for internal use only and are not sent outside of the hospital. "These reports help nurse managers identify nurses who need additional training." Incident reports are not maintained in the employee file or used as punishment or identification of need for additional training. The error is identified and dealt with at the time of the event and not at a later time in the future. OK: "These are reviewed by hospital risk management and help prevent similar errors in the future." Risk management reviews each incident report to determine how the error occurred and how future similar errors can be prevented. "These reports help to identify policies and procedures that may need to be revised." Errors identified through incident reports often identify policies that are outdated and need revision to improve quality of care. "Identification of common errors helps to ensure quality client outcomes." Incident reports may reveal patterns of error which can be prevented through staff education in order to improve client outcomes. Documentation of an incident involving two clients in a client chart should never name the other client involved and should only provide objective information about the incident. A nurse witnesses an altercation between two clients in a long-term care facility. Which information does the nurse include in the incident report? Select All That Apply Clients are alert and oriented after the altercation. Client response and any injury related to the incident should be included. Clients separated by nursing assistant 30 seconds after altercation began. The incident report should include factual description of what happened during the incident. NOT: Another client states these two clients don't like each other. Subjective information from other clients or personnel should not be included in the incident report. Clients threaten to hurt each other on a daily basis. Only information regarding the incident should be included in the report. Provider was not notified since there is no apparent injury. The provider should always be contacted whenever an incident of any kind occurs and notification should be included in the incident report. The incident report is an internal document for the hospital and should not be mentioned in the medical record, nor should a copy be made for the client's record. Only a factual description of the incident and any actions taken (physician notified, vital signs stable, orders given, client's response to treatment) are documented in the client's chart. The incident report is for the institution's own records to help improve policies and procedures via risk management. A nurse cares for a client receiving a blood transfusion after a major surgical procedure. The nurse fails to verify the client's blood type and transfuses incompatible blood. Which actions is the nurse required to take? Select All That Apply Document a description of the event and client response in the client's electronic health record. A factual description of the event, actions taken, and client's response should be documented in the client's record. Complete a head to toe assessment and document findings in the client's electronic health record. An assessment of the client should be performed to identify any negative consequences related to the incident. Complete an incident report through the risk management department per hospital policy. An incident report is required when there is potential harm to a client due to an error. NOT: Print the completed incident report and place it in the client's chart for review by the health care provider. An incident report is an internal document for hospital use only and is not placed on the client's chart. Document the completion of an incident report in the client's electronic health record. The incident report should not be mentioned in the client's health record. Documentation must stick to objective descriptions of what happened and any assessments and interventions performed. Personal biases or information that implies misconduct should never be documented in the client's chart. If a nurse suspects that a client is being neglected or mistreated, an incident report should be made and the physician informed, but this should never be mentioned in the client's medical record. While completing morning assessments, the nurse enters a room to find an older adult client soiled in bed. The client reports calling to the nurses' station multiple times with no response. Which is appropriate documentation by the nurse in the client's record after cleaning the client, and noting the potential for pressure injury? Select All That Apply Bed, bath, and skin care with emollient applied. Documentation in the client record should include interventions performed. Reddened area on each buttock noted, 5 cm circumference. Documentation in the client record should include an objective description of assessment findings. Client found in bed soiled with urine and feces. Documentation in the client record should include an objective description of client condition. NOT: Client states "nurses ignored call for assistance." This should not be included in the client record but should be included in the incident report. Incident report regarding client condition completed. Completion of an incident report should not be documented in the client's record. Documentation of an incident involving two clients in a client chart should never name the other client involved, only objective information about the incident. Assessment data regarding each client should be included in respective records but not in each other's record. Never document an incident report in a client's chart, only the objective facts of what happened. A nurse who works on a psychiatric unit witnesses two clients involved in an altercation. Which information does the nurse document in the record of the client who initiated the altercation? Select All That Apply Client restricted to personal room after the altercation with another client until health care provider visit. Actions taken regarding the incident should be included in the record. Client was witnessed pushing client from room 219 during an argument. This is objective data and should be recorded. Clients were separated by two staff members without further incident. This is objective data and should be recorded. NOT: Incident report regarding client pushing another client submitted. Completion of an incident report should not be documented in the client's record. Client who was pushed has a laceration on the right arm due to hitting a table corner. Information regarding the other client should not be included in the client's record.

Restraints

When a client is restrained, nurses should assess for the need of restraints, release restraints for a few minutes, and document on restraints every two hours while the client remains restrained. Anytime a restraint order is required, it is used to prevent the client from harming themselves or others. These prescriptions require specific assessment information from the health care provider that explains the exact behaviors that require restraints to prevent the client from harming themselves or others. The prescription should include the name of the health care provider prescribing the restraint, the date and time of the prescription, the specific type of restraint to be used, the indication for use of restraint, and duration of time for the restraint to be used. Restraints are used only when it is necessary for the safety and care of the the client. A nurse must document reasons the restraints are in use and reasses throughout a shift and according to the institutions policies. Restraints must be assesed to ensure they are not too tight and are not causing skin breakdown in the areas they are applied. Best practice would be to avoid the use of restraints if possible but if it is necessary the nurse is responsible for documenting their use and the client's response. The nurse cares for a client in intensive care with a ventilator and intravenous infusions. The client is in a confused and combative state and is restrained at the wrists. Which interventions does the nurse perform? Select All That Apply Check distal pulses and capillary refill frequently. It is necessary to check skin integrity and ensure restraints are not too tight or too loose both which could cause harm to patient. This is done at least every two hours, per restraint protocol. Document why restraints are needed. A client's status can change over time, making it necessary to document why restraints are needed for patient care and safety. Perform frequent skin checks. It is necessary to assess for skin breakdown, blisters, and rashes. NOT: Check restraint placement once a shift. Restraints need to be checked more frequently than once a shift. Allow family to remove restraints when they are present. While family may want to be involved, they should not be responsible for monitoring client at bed side. If needed a hospital trained staff can provided one on one observation. When nurses resort to use of restraints to prevent injury to the client or others, information must be clearly documented in the client's health record regarding steps taken prior to use of restraints. The documentation should be very specific, citing the behaviors observed, threats that have been made, and any violent actions taken by the client. It is important to document less-restrictive interventions that were first attempted and the response to intervention by the client. When restraints or seclusion are utilized, the nurse must document the time that seclusion or restraints began and what time the prescription was obtained over the phone. The health care provider has one hour from the time restraints or seclusion were implemented to come to the unit for a face-to-face evaluation of the client, and a new prescription is required every four hours for seclusion or restraint to continue for psychiatric clients. A nurse cares for a client who is observed pacing their room, talking loudly to themselves and others, punching the wall and self. While attempting to administer prn medications, the client hits a staff member and makes an attempt to hit another client. After placing the client in 4-point restraints, which information included by the nurse reflects accurate documentation in the client's health record? Select All That Apply "While attempting to administer PRN medication at 1315, client kicked nurse KM; client placed in 4-point restraints with the assistance of nurse TD at 1330." This documentation provides specific information regarding interventions attempted, need for protection from injury by use of restraints, and time restraints were applied. "Client observed by nurses KM and TD pacing, yelling at others, and hitting walls. Client threatened to hit another client and then hit nurse KM in the shoulder." This documentation provides specific information related to client behavior. NOT: "With initiation of violent behavior toward staff and other clients, staff removed all other clients to safety and left client alone to continue tantrum." This does not provide specific information related to behavior of client or interventions taken to calm client. "Client has become increasingly erratic throughout the day, displaying frightening behavior without ability to calm with nursing interventions." This provides vague information regarding client behavior and does not state specific threats or interventions performed. "Nurses unable to calm client or administer PRN medication when client became increasingly agitated. health care provider notified and prescription received for 4-point restraints." This does not provide specific information related to client actions or behavior and does not include a time for when the health care provider was notified and prescription received for restraints. Elderly clients with dementia and tremors are more likely to spill water or knock items over, but this is not an appropriate reason to use restraints. It would be unethical to place the client in restraints for these reasons. When presented with this sort of request, the nurse should explain that tremors and spillage are not an appropriate use of restraints. Even if tremors increase the risk of falling, restraints are not appropriate unless other risk factors are present. Client safety is the most important and unnecessary restraints would actually put the client at risk of injury. Nurses should attempt alternatives to restraints before requesting prescriptions for restraints. Using restraints when they are not required is considered unlawful imprisonment. Nurses and health care providers can be held liable if restraints are used improperly. Documentation of an incident involving two clients in a client's chart should never name the other client involved, only objective information about the incident. This is a HIPAA (Hospital Insurance Portability and Accountability Act) violation. Assess the client and record bruises, lacerations, pain, or deformity. Record vital signs and mental status. Document who was notified and any new, related orders or interventions. Also document any client education. A nurse who works in an assisted-living facility witness an altercation between two clients. Which documentation by the nurse is correct? Select All That Apply Client has no visible injuries on the arm that hit the ground during the incident. Objective assessment data should be included in the record. Client vital signs within normal limits immediately and 30 minutes after incident. Vital signs should be included in the record. Client was pushed to the floor by another client at 1500. This is objective data and should be included in the record. NOT: Client is crying and appears to have an arm injury. The record needs to include assessment data of any injury obtained during the altercation. Client is sitting in chair and appears fine after the incident. Use of the word "fine" does not provide specific data regarding client condition. The Omnibus Budget Reconciliation Act of 1987 (OBRA '87) contains the Nursing Home Bill of Rights, which states that residents have "the right to be free from physical or mental abuse, corporal punishment, involuntary seclusion, and any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms" and that "physical or chemical restraints may only be imposed... to ensure the physical safety of the resident or other residents." Administering a medication intended to put the client to sleep other than at bedtime to calm an agitated client is a "chemical restraint". It is also not ethical. The health care provider can meet with the client to discuss symptoms and feelings and get consent for another medication that may help with agitation, or get consent from the DPOA (durable power of attorney) if the client is incapable of giving consent. However, even the DPOA cannot give permission to use chemical restraints for discipline or staff convenience. A nurse cares for a client in a long-term care (LTC) facility who cries loudly, often runs in the halls, and is routinely rude to staff. As the nurse prepares dinner for the client, a second nurse suggests administering a dose of temazepam prescribed PRN for sleep. Which action is most appropriate for the nurse to take? Contact the client's health care health care provider and request an additional PRN prescription for the client. The best action is for the nurse to contact the health care health care provider and request a prescription for the client's agitation. NOT: Remove the client from other staff and clients and place loose arm restraints to immobilize the client. The client should not be isolated nor should the nurse use physical restraints without a prescription unless the client, staff, or other residents are at risk for injury. Document the client's agitation in the health care record but do not administer medication. The nurse is not addressing the client's agitation needs by simply documenting without taking any action to prevent continued agitation. Administer the temazepam immediately and assist the client to bed early. The nurse should not administer a PRN medication that is prescribed for sleep to calm a client for staff convenience. Administering a medication intended to calm a client or intended to aid with sleep other than at bedtime is a "chemical restraint." Medications should not be used for discipline or convenience but only to treat medical symptoms. Chemical restraint involves use of a drug to restrict a client's movement or behavior, where the drug or dosage used is not an approved standard of treatment for the client's condition. The nurse may consider contacting the health care provider to discuss the client's symptoms and behavior to determine if other prescriptions or treatment may be indicated. A nurse cares for a client in a long-term care (LTC) facility who is restless and has been using obscenities. A nurse administers 10 mg haloperidol IM prescribed PRN for severe agitation. Which is true regarding the administration of this medication by the nurse? The nurse administered the medication for staff convenience, failing to follow the health care provider's prescription. The nurse uses the medication prescription for staff convenience, making it a chemical restraint and not for the reason indicated by the health care provider prescription. NOT: The nurse administered the medication to calm the client who was severely agitated. The client shows no indication of severe agitation for which the health care provider has prescribed this medication. The nurse used the medication as a means of discipline for the client's obnoxious behavior as prescribed by the health care provider. Using a medication for discipline is considered a chemical restraint and is considered abuse. This nurse followed guidelines with administration in order to provide safety for staff and other clients. The client's behavior gives no indication of risk for injury to the client, other residents, or staff, which are indicators of severe agitation Doctors may order certain medications like lorazepam (Ativan) for clients who suffer from anxiety, but these medications have the potential to be used for other purposes. Medications used to treat anxiety will often "fall off" the client's medication orders after 72 hours and will need to be reordered, but when a client requires a chemical restraint, the order has to be renewed every 24 hours. All restraint orders must be renewed every 24 hours. If the nurse deems the client to be a danger to their own safety or the safety of others, this should be discussed with the doctor. In this situation, the doctor will decide if any restraint, whether chemical or physical, is necessary. A nurse working on the medical-surgical floor is caring for an elderly client who is confused. The client is repeatedly trying to climb out of bed and is at high risk for falling. The client has an order for lorazepam 0.5 mg orally (PO) every 8 hours as needed for anxiety. The nurse gives a dose of lorazepam to help make the client drowsy so the client will sleep and stop climbing out of bed. The nurse should know which of the following regarding the use of this medication in this situation? Using this medication as ordered for anxiety as needed is not appropriate in this situation because it is being used as a chemical restraint. NOT: Using this medication in this situation is appropriate because the client is most likely having anxiety which is causing them to climb out of bed. Using this medication to cause drowsiness and keep the client in bed is appropriate to maintain client safety. Using this medication in this situation is appropriate as long as the correct time frame of every 8 hours is followed. The nurse will assess the client at change of shift and then at least every hour. Vital signs are taken hourly, and range of motion exercises are performed every two hours for clients in restraints. At the hourly assessment, the nurse evaluates the client's response to seclusion or restraints, offers support or reassurance, and attempts to work with the client to formulate a plan to expedite release. This may include utilizing PRN prescriptions, considering coping skills to use, and contracting for safe behavior on the unit. Seclusion or restraint only continues if the nurse feels the client is not yet able to be safe on the unit and would benefit from more time for medication to become effective or to be free from the stimulation of the unit. Every four hours, a health care provider must write a new prescription to continue the seclusion or restraint. The nurse is also responsible for assigning a mental health worker or another nurse to continuously monitor the client who is in seclusion or restraints. The client is never left unattended due to risk of injury. A nurse receives report for an evening shift. One of the clients assigned for care is in 4-point restraints. Which actions are required by the nurse? Select All That Apply The nurse verifies a timed prescription for the restraints in the client's health record. Clients who are in restraints should have a new prescription for restraints every four hours. The nurse evaluates continued need for restraints at least every hour. At each hourly assessment, the nurse evaluates the client response to and continued need for restraints. The nurse assesses the client at change of shift during report. Clients in restraints should be assessed at change of shift and hourly. NOT: The nurse performs range of motion exercises on the client every four hours. Range of Motion exercises should be performed every two hours for clients in restraints. The nurse assigns a client care assistant to obtain vital signs every two hours. Vital signs should be obtained hourly on clients in restraints.

Missed Meds

When scheduled medications are missed, the health care provider (HCP) should be notified as soon as the error has been noted. The purpose of this is to obtain a new prescription for dosing and scheduling of medication in order to get the client back on schedule. Scheduled medications are designed to maintain a therapeutic level of medication within the client's system. The nurse would not administer the missed dose of medication until communicating with the health care provider in the event the dosage needs to be adjusted due to the missed dose. A nurse prepares to give handoff report on a client at 1900 and realizes the client did not receive a scheduled dose of 60 mg enoxaparin SC at 0900 which is prescribed BID after an acute ST-elevation myocardial infarction (STEMI). Which action does the nurse take first? Contact the health care provider regarding the missed medication dose. The health care provider should first be notified and informed of the missed dose of medication and then a prescription obtained for dosing and scheduling moving forward. NOT: Adjust the medication schedule based on the new administration time. After speaking with the health care provider, the nurse will adjust the new medication schedule based on prescription. Document the time the medication was administered. Once the health care provider has been notified, the nurse will administer the medication and document the time of administration. Administer the correct dose of the missed medication. The client will likely need the missed dose of medication, but the health care provider first should be notified to determine dosing and schedule adjustment times. It is important to administer medications on time but there are occasions when a dose may be late. If a timed medication, such as a blood pressure medication, has not been given at the appropriate time, the nurse's first repsonsibility is to assess the client. If adjustments need to be made to administration times the prescribing health care provider must be notified. The nurse is late with a client's blood pressure medication. The next dose is scheduled to be given in an hour. What is the nurse's response? Assess the client and their blood pressure. The nurse's best response is to assess the client and make sure their blood pressure is within normal limits. If a medication dose is missed it could lead to an increase in blood pressure and cause the client to have symptoms that might need immediate attention. The first priority is assessing the health status of the client. NOT: Hold the medication until the next dose. A medication can not be held because it is late. Medications can be held if there are clear paramaters written by the prescribing health care provider. The nurse must assess the client and contact the appropriate prescriber to make any adjustments that are needed. Ask another nurse to administer the medication. It would not be appropriate to ask another nurse to asminister the medication for a client in your care because a medication is late. If the nurse is faling behind with patient care on their shift it would be appropriate to reach out to the supervisor for support. Contact the client's family. The nurse would not need to contact a client's family if medications are late. The first action the nurse should take is to ensure the client receives the ordered therapy by notifying the health care provider and seeking a prescription for the timing of the next dose of antibiotic. Antibiotics are most effective when there is a therapeutic level in the client's system. The most important thing the nurse can do in this situation is to make sure that the health care provider is aware of the missed dose so that the antibiotic schedule can be adjusted if needed. After contacting the health care provider, administering the correct dosage of medication, and adjusting the medication schedule, the nurse should complete an incident report in the facility's incident reporting system. A nurse receives a bedside report and notes an IV antibiotic not administered hanging on the IV pole at the client's bedside. The tubing is disconnected from the client's saline lock, and the IV pump is turned off. The nurse reports the client received the last scheduled dose six hours earlier. Which action does the receiving nurse take first? Contact the health care provider to inform regarding the missed dose of medication. The health care provider should first be notified and informed of the missed dose of medication and then a prescription obtained for dosing and scheduling moving forward. NOT: Complete an incident report in the facility's incident reporting system regarding the missed dose of medication. An incident report should be completed due to the missed medication. Adjust the medication administration schedule to reflect new times for administration. The nurse will make adjustments to the medication schedule based on prescriptions from the health care provider after notification. Document the time of administration of the medication and the previous dose as not given. The nurse will correctly document the time of medication administration and note the previous dose was not administered.

Circumcision

Circumcision of an infant requires local anesthesia so that the child is not in pain during the procedure. The nurse must advocate for the infant and address the orders with the doctor. It is the nurses's legal responsibility to advocate for the infant and ensure they have proper care. A newborn client is undergoing a circumcision. The health care provider has not prescribed an anesthetic. What is the nurse's first responsibility? Question the prescription. The nurse is responsible for advocating for the infant and questioning the order. Infants must be given an anesthetic when undergoing a circumcision so that they do not experience pain. NOT: Educate the parents. The parents of the child need to be educated on the procedure and the care of the infant following the procedure. This would not be the first action of the nurse. In this situation the nurse must first address the lack of orders for the infant. Prepare the client for the procedure. It is important to prepare the infant for the procedure with swaddling or other comfort methods. This would not be the nurse's first action. Continue with the procedure. If the nurse does not advocate for the infant, then they are not providing adequate care. It is negligent of the nurse to not advocate for anesthetic for an infant. The procedure continues once pain prevention is addressed.

Confidentiality

Clients of all ages are entitled to confidentiality with their health care and medical chart. Often there is a conflict in families and one parent may be the sole caretaker and decision-maker. When this information is communicated and the request is made to exclude certain family members the nurse and providers should work to maintain this request and allow the family to manage unless it creates a confrontation. Clients can choose to have no information released, sometimes referred to as "confidential"; to have "status only" information released, which includes name, room number, and a statement of client condition such as good, fair, serious, or critical; to allow any relevant information to be given to designated family members. In situations such as this, the nurse may also inform the nursing supervisor or manager to make them aware of potential conflict should the excluded parent choose to come to the hospital. so that they are prepared to deal with communication with the parent. There is a note in the adolescent-age client's documentation stating only one parent may receive medical information related to the client's condition. The excluded parent calls the nurse and asks about the client's status. How does the nurse best respond? Instruct this parent to contact the other parent. The best response is to encourage this parent to contact the other parent. The nurse must continue to create a positive working relationship with the family that does not affect client care. In this scenario, it is best to first deflect to the family. NOT: Allow the client to explain the situation to the parent. If medical information is not to be released to a parent then it is not advisable to allow the parent to speak with the child unless the child's immediate decision maker and guardian has approved the contact. Tell the parent that they are not on the approved list. It is appropriate for the nurse to be honest with the parent, but it could create a conflict and take the nurse away from patient care. Give the parent general information and updates. If there is documentation that medical information is not to be released to one parent then the nurse must legally follow what is documented and not give any information to the parent. This might include condition status statements. Privacy and confidentiality are the two expectations of the Health Insurance Portability and Accountability Act (HIPAA) most relevant to nursing practice. Health related data can only be provided to the client, those directly involved in the care of the client, and those individuals or health care agencies the client has provided authorization to. Health care providers are obligated to maintain confidentiality of client health data by being aware of surroundings and not discussing specifics of client care in public locations. Even unintentional sharing of confidential information is a breach of client confidentiality. Giving out information over the phone to an unknown person is in violation of Health Insurance Portability and Accountability Act (HIPAA) regulations. A nurse cares for a young school-aged client with full thickness burns on 34% of the total body surface area. An individual who claims to be the client's parent calls the nurse and asks for information. How does the nurse respond? Select All That Apply "I am unable to provide you with information over the telephone." The nurse correctly informs the caller that information that is client protected cannot be provided over the telephone. "Please come to the hospital as soon as you are able to do so." The nurse is correct to instruct the mother to come to the hospital so that identity can be verified and she can be provided with information regarding the child. NOT: "You will need to talk to your client's health care provider." Verification of identity cannot take place over the telephone. "Your child has severe burns and may not survive the night." Providing information to an unknown caller is a violation of client confidentiality. "I will transfer you to the charge nurse to provide information." No health care provider can provide information to an unknown caller over the telephone. Transferring the caller to a charge nurse or supervisor is appropriate if the caller becomes aggressive, but not for the purposes of providing information.

Organ Donation and Transplantation

Donating an organ to another individual is a gift but it also comes with risks. An individual must be in good health and fully understanding of their risks in donating an organ. Any time an individual has an operation they are putting themselves at risk and must also understand the process of recovery. In order to begin the process of donating an organ the donor must provide proof that they are legally of age to donate. It would then be important for them to receive an overall assessment of their physical health. Once a donor is able to document their age and have not significant health issues it would be important for the donor to undergo an assessment with a social worker to document that they are emotionally ready and have supports available for recovery. The final step in preparation for organ donation would be to sign the appropriate paperwork acknowleding the risks involved in surgery. A client plans to receive a donor kidney from their sibling. What steps does the sibling take to prepare for donation? (Place each option in order, from first task to last.) Correct Answer Provide proof they are over 18 years of age. Provide documentation of their health. Undergo a social work assessment. Sign paperwork acknowledging risks.

Change of assignment

Nurses need to be able to prioritize care and manage time in order to be able to complete tasks required with client care including documentation. When the nurse has a client that is requiring one on one attention due to a complication from surgery or from an emergent condition, it is appropriate to remind the charge nurse that she is not able to provide care to another client due to priority needs of a current assignment. Client needs or treatments that are non-urgent should not provide the nurse the right to refuse to receive a new client assignment. Nurses should always advocate for client safety when placed in a situation where census is too high for adequate nursing care. A charge nurse informs a staff nurse of a new admission from the emergency department. Which situations would warrant the staff nurse to request the charge nurse assign the client to another nurse? Select All That Apply The nurse is caring for a client who is three hours post-operative and in need of a blood transfusion. This client is priority for the nurse and requires one on one care as well as assistance from the charge nurse when administering blood products. It is appropriate to request another nurse be assigned the new admission. NOT: The unlicensed assistive personnel has not communicated the morning vital signs on the already-assigned clients to the nurse. This is not a legitimate reason for refusing to receive an additional assignment. It may be an indication of poor time management since the nurse has not sought out the nursing assessment to receive this information. The nurse has not completed documentation of assessments on the already assigned clients. The nurse's lack of documentation is not a valid reason to refuse to receive a new client admission. The nurse is caring for a client who is scheduled for surgery a few hours after the admission would arrive. This client does not have immediate needs since the surgery is much later in the shift. The nurse has scheduled medications that need to be administered during the time the admission would arrive. Receiving a new admission should not prevent the nurse from administering scheduled medications that are due. The nurse can administer these medications prior to the new admission arrival from the emergency department.

4 point restraints

The 4-point restraints placed on clients should be assessed and released for a few minutes every two hours while the client is restrained. Assessing the client's skin for decubitus ulcers should be done each shift. There is no need to check for decubitus every two hours if the client's restraints are being released every two hours per the standard protocol. When a client is restrained, nurses should assess for the need of restraints, release restraints for a few minutes, and document on restraints every two hours while the client remains restrained.

Health Insurance Portability and Accountability Act (HIPAA)

The Health Insurance Portability and Accountability Act (HIPAA) regulations prohibit those not directly involved in client care from accessing client information. This includes looking up information about any client if not directly involved in their care. The client only can provide authorization to an individual by providing a code provided by the hospital which allows an individual to obtain information related to client care. A nurse discusses the client's plan of care via telephone with the health care provider at the nurse's station. After completing the telephone call, a nursing colleague who is a friend of the client asks for information related to the client's lab results. Which statements by the nurse to the colleague are correct? Select All That Apply "You can visit your friend and ask about the lab results." The client can provide any information they choose to family or friends or any other individual. "I cannot provide you with that information." Only those providing care to the client should have access to client health data. NOT: "Log into the computer and review the results yourself." Those not providing care to the client are in violation of client privacy when accessing information about health data. "The lab results are within normal limits except the hemoglobin A1C." The nurse who provides information about client health data to an unauthorized person is in violation of client privacy. "I can give you that information with the health care provider's permission." The provider is not authorized to choose to provide client health data to unauthorized persons. Privacy and confidentiality are the two expectations of the Health Insurance Portability and Accountability Act (HIPAA) most relevant to nursing practice. Health related data can only be provided to the client, those directly involved in the care of the client, and those individuals or health care agencies the client has provided authorization to. Health care providers are obligated to maintain confidentiality of client health data by being aware of surroundings and not discussing specifics of client care in public locations. Even unintentional sharing of confidential information is a breach of client confidentiality. A group of nurses meet in the cafeteria for lunch. Which situations describe a breach of client confidentiality? Select All That Apply While riding the elevator to the cafeteria, the nurses compare two client diagnoses and specific treatment plans. When providing specific information related to client care, the nurses could be overheard by someone who knows or is related to the client and inadvertently provide information to unauthorized individuals. While sitting at a table in the dining hall, they discuss the behaviors of one of the manic clients on the unit. The nurses are providing data that could be overheard by someone who could know or be a relative of a client. NOT: When leaving the cafeteria, the nurses discuss how the manager has changed the way assignments are made each shift. Discussion of how client assignments are made does not violate client privacy or confidentiality. While waiting in line, the nurses discuss the new assignment board and the type of information they think should be included. Discussion of general types of client information to be included on an assignment board is not a violation of client confidentiality. In the hallway, they discuss the holiday rotation and complain about the holidays they have to work. The holiday rotation and individual nursing schedules have nothing to do with client confidentiality. This is generally unprofessional behavior, though. The HIPPA privacy rule recognizes the need for public health authorities and others responsible for ensuring public health and safety to have access to protected health information. This allows public entities to disclose protected health information without authorization for specific public health reasons, as in reporting certain STD's. A client is treated for chlamydia. When reporting the client's results to the state board of health, which action does the nurse take? Include the client's full name and date of birth. Chlamydia is a reportable sexually transmitted disease (STD) that must be reported to the CDC. Once a client with this disease is identified, the laboratory results will be sent to the state board of health and must include the client's full name and date of birth. This does not violate HIPAA laws because findings related to communicable public health diseases must be reported. NOT: Ask the client to sign a consent for the release of information. Because chlamydia is a reportable disease, HIPAA laws are not violated by reporting this information. The client does not need to sign a consent as this will be reported regardless of the client's consent. Avoid using personal or identifiying information. While it is true that the client's laboratory results will be sent to the State Board of Health, the client's full name and date of birth must also be reported. Refer the client to the board of health for follow up. It is not the responsibility of the client to call the state board of health regarding these results. The health care provider must report this to the state board of health as this is a reportable disease. Privacy and confidentiality are the two expectations of the Health Insurance Portability and Accountability Act (HIPAA) most relevant to nursing practice. Health related data can only be provided to the client, those directly involved in the care of the client, and those individuals or health care agencies the client has provided authorization to. Health care providers are obligated to maintain confidentiality of client health data by being aware of surroundings and not discussing specifics of client care in public locations. Even unintentional sharing of confidential information is a breach of client confidentiality. Giving out information over the phone to an unknown person is in violation of Health Insurance Portability and Accountability Act (HIPAA) regulations. A nurse cares for a client on a medical-surgical unit. The client's sibling is in nursing school and requests to view the client's electronic records for the purposes of learning medical record navigation. Which action does the nurse take? Communicate to the sibling that viewing the electronic health record is not allowed. The nurse is not able to allow the sibling access to the electronic health record as this is a violation of client privacy. NOT: Show the sibling how medications are documented in the client's personal record. Showing the sibling how medications are documented not only violates the client's privacy but potentially privacy of other clients. Log into the computer in the room and allow the sibling to practice navigation. The nurse would be violating client privacy and institutional policies by providing access to the electronic health record for the sibling. Ask the client if it is okay for the sibling to practice "documenting" in the electronic record. A nursing student should only document in the electronic record of those for whom care is provided. Privacy and confidentiality are the two expectations of the Health Insurance Portability and Accountability Act (HIPAA) most relevant to nursing practice. Health related data can only be provided to the client, those directly involved in the care of the client, and those individuals or health care agencies the client has provided authorization to. A durable power of attorney for health care (DPAHC) designates an individual chosen by the client to make health care decisions when the client is unable to do so. This individual has authority to provide authorization for those who can receive information related to client care. Even revealing the client's DPAHC status is a Health Insurance Portability and Accountability Act (HIPAA) violation without approval from the DPAHC. A nurse cares for a client who has a skull fracture and is unconscious. When a group of friends come to visit, how does the nurse respond? "I cannot discuss the client's condition with you." The nurse cannot discuss confidential client health data without client or DPOHA authorization. NOT: "The client is in serious condition and may not survive." Providing information related to the severity of the client's condition to unauthorized individuals is a breach of client privacy. "If tonight goes well, there will be a full recovery." The nurse should not provide information that is not based on actual facts, such as assuring a prognosis, and should not provide information at all to unauthorized individuals. "The family will have to authorize you to receive information." If the client has a designated durable power of attorney for health care (DPAHC), this individual is authorized to provide information, but not just any member of the family. The Health Insurance Portability and Accountability Act (HIPAA) regulations prohibit those not directly involved in client care from accessing client information. This includes looking up information about any client if not directly involved in their care. The client only can provide authorization to an individual by providing a code provided by the hospital which allows an individual to obtain information related to client care. A nurse cannot release any information to unauthorized people. A client diagnosed with renal failure was admitted to the hospital one week ago. The nurse caring for the client receives a telephone call from the client's employer requesting information related to diagnosis. Which responses by the nurse are correct? Select All That Apply "I cannot provide you with confidential client information." The nurse is not able to release client protected data to unauthorized individuals. "I suggest you contact the client for this information." The client can provide any information they choose to family or friends or any other individual. NOT: "We do not have a client by that name at this facility." The nurse would only need to make this statement if the client has chosen to also be a "no information" or "confidential" client, in which case the nurse would not be able to confirm or deny the client's presence at the hospital. "With a formal written request, I can send the information." A written request from the employer does not authorize the employer to receive information. "The client is being treated for complications related to renal failure." This would be a violation of client privacy by the nurse if she provided confidential client information to an unauthorized individual.

Nursing Documentation

The legal medical record provides a record of interactions with clients. The nurse documents nursing interactions with clients. The healthcare provider documents summary of procedures performed by the HCP, reasons for treatments ordered by HCP and diagnoses, such as septic shock. The nurse's role in documentation includes timely and accurate documentation of vital signs, response to treatments and education, client assessment. Nursing documentation includes the nursing process and responsibilities of nurses. • The HCP dictates a brief summary of procedure performed. A nurse may summarize actions or treatments performed by the nurse. • Documentation of vital signs before, during, and after a procedure is a nursing responsibility. • The reason for central line insertion is a diagnosis from the HCP. The nurse may document assessments describing missed IV starts, but the formal reason for central line is the role of the HCP. • The time of septic shock identification is a HCP diagnosis. The nurse may document a nursing assessment describing symptoms of septic shock. A client with septic shock requires a central line insertion. After assisting the provider with insertion, what does the nurse document regarding the central line insertion? Pre- and post-procedure vital signs. The nurse is responsible for documenting pre - and post - procedural status and care. Documenting how the client tolerated the procedure includes vital signs. NOT: A brief summary of the procedure. The health care provider documents a summary of the procedure, providing any required details. Reason for central line insertion. The health care provider documents the reason for the central venous access device insertion. Time of septic shock identification. The nurse will document client symptoms and nursing interventions. The health care provider may document the time that septic shock is suspected and medical interventions. A client's medical record is utilized in a variety of ways. It is an essential resource for interdisciplinary communication, provides a legal record of care that can be used in a court, is used to justify billing or insurance reimbursement, and is used to audit and monitor the care being given. Documentation should be done in a timely manner and should always include the date and time that care was provided along with the name of the nurse who provided the care. Proper documentation is a critical nursing responsibility and limits liability by proving safe and effective care was provided. Good example by student: "Client rates surgical incision pain as two out of ten and describes it as aching when lying in bed." All documentation should be factual and objective. Documenting the client's pain score and description of pain including location and any provoking factors demonstrates proper documentation. Documentation must be clear, accurate, and non-judgmental, reflecting only facts and observations, not judgements made by the nurse. Documentation should not include terms that point to errors. Documentation should support what the nurse assessed and actions taken. Must be able to defend actions by supporting documentation. Medication documentation should include date, time, dosage, route and reason for administration. If a medication error occurs, requiring health care provider notification, documentation should include medication prescribed and dosage, actual medication administered with dosages, routes and times and any client assessment data as well as the time health care provider was notified. "Medication error" should not be included in documentation. A nurse precepts a newly hired nurse and reviews documentation by the new nurse after care provided to 5 clients. Which notations reflect correct documentation? Select All That Apply BP 90/40 mmHg. Client reports dizziness and lightheadedness. This documentation describes client complaint and provides objective assessment data. Hydrocodone 10mg PO administered for pain 6/10 at 1330. Provides medication name, dosage route, time and reason for administration. NOT: Client drunk and angry on admission to unit, appears hostile. This is a judgmental statement and provides no clear factual assessment data. Metoprolol prescribed. Toprol XL administered. Health care provider notified. This does not provide dosing or route information for medication and does not have times associated with administration of medication or health care provider notification. Client fell out of bed. No complaints of pain or other discomfort. Should provide clear factual data regarding if fall was observed or if client was found in a position which could indicate a fall as well as objective assessment findings. The client's chart is a legal document, so the nurse should use a black or blue ink pen for all documentation. Each entry should be signed with the nurse's full name and title and date and time for intervention or assessment. There should be no empty space between completion of entry and nurse signature in order to not provide opportunity for another health care worker to make additions. When errors are made in data entry, a single line should be marked through the error and the correct entry documented immediately following. White out or blacking out is not permitted. Errors should not be erased in a medical record as it is a legal document. A nurse precepts a graduate nurse. During a computer downtime event, the graduate nurse completes required paper documentation. When evaluating the graduate nurse's entries, which of the following requires the nurse to review documentation policies and procedures with the graduate nurse? Select All That Apply Abnormal assessment findings are documented in red ink. Red ink is not used in client records. Black ink is preferred, and most hospitals allow blue ink. Assessment entries have blank lines before the signature. Blank lines should not be left in the client's record. NOT: An incorrect entry is marked through with a single line. A single line should be marked through incorrect entries. Entries are signed with the nurse's full name and credentials. The nurse should sign entries with full name and title. Each entry includes a date and a time for the intervention. Each entry should have a date and time.

Use of Emergency Services

Use of emergency services for unecessary medical interventions drives up the cost of health care. Going to the ED for medication refills is costly and not an appropriate way to obtain medication refills. Clients need to be educated on the appropriate ways to obtain their medications through their primary care or specialist doctors. Maintaining communication with the primary care providers allows for monitoring of the client's health status and is a more cost effective way to obtain medications. It would be appropriate for the nurse to assess the medications the client has, determine if they need refillls, and re-educate them on the process. Teaching the client to take responsibility of their medications and refill them before they run out as well as in the most cost effective way is part of the role of the home care nurse. A home care nurse visits a client who reports they were seen in the emergency department the previous day because they ran out of medication. What nursing action is most important? Assess client's understanding of medication use and refills. The nurse determines what the client understands about medication use and obtaining refills first. If the client does not understand the correct procedure to refill their medications and continues to use the ED it creates unnecessary expense and waste. The nurse must continually assess the client's understanding of the their health and the medication process. NOT: Assess the client's understanding of use of emergency services. Urgent care and emergency departments are not appropriate ways to refill routine medications. Using them in that way creates added expense to the health care system, and the client is not receiving quality care. Assess client's understanding of primary care provider services. It is important that the client know the correct and most efficient way to get their medications filled. Using the ED for medication refills is not cost effective and not an appropriate use of resources. Primary care providers provide medication management and refills. Assess client's current physical and mental health status. It is important for the home care nurse to assess the health of the client but this would not be the most important action. The nurse must address appropriate and cost effective ways for the client to refill their medication prescriptions.

Seclusion room

A client who expresses urges to harm self or others and is agitated or paranoid should be placed in a secluded room with a locked door and continuously monitored. Clients in seclusion should never be left alone or unmonitored for any period of time. The physical presence of someone in the room or within view of the client may increase anxiety or paranoia. A client on a psychiatric unit reports paranoid delusions with increasing anxiety. The nurse administers PRN olanzapine as prescribed. As the nurse administers the medication, the client reports urges to harm a roommate. The nurse and client make a plan for seclusion as the medication takes effect. Which interventions does the nurse perform? Select All That Apply Delegate a staff member to monitor the client via camera. The client should be continuously monitored when secluded. Assist the client to the seclusion room and lock the door. Because the client has verbalized the urge to harm another and is paranoid, the client should be secluded behind a locked door. NOT: Remove the client's roommate and leave the client alone for an hour. The roommate's safety should be considered, but the client is the one who should be moved to a secure location for seclusion. Delegate a staff member to monitor the client through the door window. The client's agitation may be increased by the presence of someone watching through the window. Instruct a staff member to check on the client in an hour. Leaving the client unattended for an hour could result in self-injury due to the paranoid delusions.

Mitten Restraints

While some guidelines on the use of restraints are specific to a given jurisdiction, universally nurses are expected to try to minimize the use of restraints in practice. This includes using the least-restrictive restraint needed in a given situation. In this case, mitten restraints that allow for arm movements but restrict the ability to grip and remove the NG tube are less restrictive than 2-point restraints and should be advocated for. A confused client has pulled out the nasogastric (NG) tube required for gastric rest, and the health care provider prescribes the use of 2-point restraints. What actions related to this does the nurse take? Contact the health care provider and recommend the use of mitten restraints in place of 2-point restraints for this client. Because the issue is the potential for pulling out the NG tube, mitten restraints are more appropriate for this client. NOT: Contact the health care provider and advocate for the client's right to refuse treatment, and do not apply the restraints. The client is confused in this case, so he or she is unable to make the informed choice to refuse this treatment. Direct the nursing assistant assigned to the client to assess the client every 15 minutes while the client is restrained. Monitoring of a client while restrained cannot be delegated to unlicensed assistive personnel but must be performed and documented by the nurse. Assess the client's need for restraints and obtain another telephone order each hour. Rather than carrying out the order, even if following protocols, the nurse should advocate for the least-restrictive restraint needed in this situation. Physical restraints may be prescribed by the health care provider when the they are deemed medically necessary due to the need to immobilize an extremity, to prevent harmful client behavior, or to allow prescribed treatments to be performed without client disruption. Alternatives should be attempted before restraints are implemented and the least restrictive restraints should be utilized to achieve desired effect. A soft limb restraint can be applied to the client's wrists to prevent him or her pulling at the endotracheal tube while the restraint maintains client safety and prevents skin breakdown. A nurse cares for a client suffering from respiratory failure who requires mechanical ventilation. The provider prescribes client restraints. Which action indicates the nurse has applied the correct restraint? The nurse secures padded mittens on the client's hands and secures the attached straps to the client's bed using quick release knots. This is a soft limb restraint and is the least restrictive to keep the client from attempting to remove the ventilation tube. NOT: The nurse fits the client with a vest that has attached straps that the nurse secures to each side of the client's bed using quick release knots. This is a vest restraint and is used to keep a client in bed and is not useful for a client who may attempt to remove the ventilation tube. The nurse raises all four side rails on the client's bed, places arms to the client's side, and tucks a sheet and blanket securely around the client. Tucking a sheet is a minimal restraint and not effective or safe for the client who may attempt to remove the ventilation tube. The nurse raises all four side rails on the client's bed and turns on the bed alarms to detect when the client moves arms or legs in the bed. This does not address the issue of the client's attempts to remove the ventilation tube and simply alerts the nurse of the client's movement in bed.

Medication error

Documentation of med errors should be factual without stating that an error was made. The time of the event as well as the details such as the drug, dose, and any effects observed should be noted. Always document what you did (calling the physician) and any new orders if there are any. Objective assessments pertaining to the effects or lack of observable effect can be added. A provider prescribes lorazepam 1 mg PO qhr prn anxiety for a client. The nurse administers lorazepam 2 mg PO to the client. Which information does the nurse include in the client's health record? Select All That Apply Client sitting in chair watching television 1 hour after medication administration. The client is awake and alert, which indicates factual representation of client response to medication. Health care provider notified of client administration of lorazepam 2 mg PO at 1315. The nurse should document that the health care provider was notified, what the client's response was, and additional orders if indicated. Client vital signs WNL at 1330 and 1400 after medication administration. Documentation of vital signs WNL 30 minutes and 1 hour after medication administration shows no adverse effect to the client with medication error. NOT: Medication error: 2 mg of lorazepam administered po for anxiety at 1300. The words "medication error" should never be documented in a client's health record. Client appears fine after administration of lorazepam 2 mg PO. Use of the word "fine" does not provide objective data regarding client condition. When a possible medication error is reported, the first action by the nurse is always to assess the client for adverse effects. In this scenario, the possible adverse effect would be unrelieved pain. The next action is to verify the current amount of medication on the unit. The unit manager should be notified, and an incident report completed if a medication error did occur. A client states that the previous nurse only administered one narcotic tablet for 8/10 pain. The nurse who administered the dose documented that two tablets were given. Which action does the charge nurse take first? Inventory the narcotic tablets with another nurse. The priority action is to determine the number of narcotic tablets currently on the unit. Narcotic counts should always be done with 2 licensed nurses. NOT: Notify the unit manager about the client's statement. The unit manager should be informed of the situation, after other actions are taken. Review recent transactions in the dispensing machine. This step will help determine if an error was made, but is not the first action the nurse should take. Print a narcotic count report and call the pharmacy. A report should be printed, but does not replace an actual count of the narcotics currently on the unit. A nurse must administer medications per the hospital policy and use a bar code scanner if it is applicable. If a client reports that they had an adverse reaction to a medication, the nurse must investigate further. While the bar code ensures correct client and medication, there could be a nurse error if a client experienced a reaction and the medication adminstration record (MAR) system was not updated. A nurse is administering morning medications. Which statement by a client indicates a medication error may have occurred? "Yesterday I had a reaction to that pill." If a client reports that they had a reaction to a pill the nurse must not administer it and must find out why it is still on the medication adminstration record. It is important to investigate the client's comments to ensure a medication is not given if it will cause an adverse effect. NOT: "You scanned my bracelet yesterday." Scanning a bar code must occur with every medication administration in a facility using such a system. The nurse must identify the client and the scan will also identify the client and medications to help prevent errors. The client just needs re-teaching. "That machine hurts my hand." The hand held scanner used to scan the bar code on a client's arm will not cause any harm. A client may need further education as to what the machine does and how it ensures that they get the correct medications. The client should not be afraid of the scanner. "The last nurse did not use a scanner." This does not mean a medication error occurred. There are safe ways to administer medication without the scanner, such as methods used during "down time" when computers are not accessible. The nurse investigates this client statement, though. All health care providers must use equipment and medication administration systems in the same way to ensure safety of the client. Every hospital has an incident reporting system either online or on paper forms. These incident reports are not meant to place blame but are used to identify process issues that can lead to errors. Adverse drug reaction information is collected by hospital pharmacies to watch for trends in reactions to medications. Near misses, medication errors, and adverse drug reactions must all be documented in the facility's incident reporting system. A nurse precepts a newly hired graduate nurse and reviews the incident reporting system regarding medication administration. Which medication administration situations does the graduate nurse identify as required reporting? Select All That Apply The nurse administers an 0800 scheduled medication at 1200 because the client was asleep. This is a medication error because the medication was not administered at the correct scheduled time. It should be reported using the facility's incident reporting system. When retrieving prescribed hydroxyzine from the medication dispensing system, the nurse finds hydralazine in the compartment. This is a near miss and should be reported using the facility's incident reporting system. A client receives an IV infusion of penicillin g and develops an itchy rash on arms and face. This is an adverse reaction and should be reported using the facility's incident reporting system. NOT: A client reports feeling drowsy after receiving a scheduled dose of hydrocodone. Drowsiness is an expected effect from a narcotic medication such as oxycodone. A nurse administers a PRN medication for itching to a client who is receiving a narcotic after surgery. This is a common side effect of the narcotic medication. The health care provider should be notified for a prescription for the itching. When a medication error is made, the nurse should complete an incident report per facility policy and file with the risk management personnel, who will complete an investigation for the root cause of the error and any client injury. The goal of root causes analysis is to identify the factors that led to an error (such as miscommunications, understaffing, lack of staff education, and the need for extra check systems) rather than to place blame on an individual. This report should not be included in the client's MAR or medical record. Only a factual statement about the drug that was given, the effect, and any further physician orders are noted in the client's chart, but never a statement about an error being made. The nurse should document factual data regarding the error in the client's chart including client assessment data and should contact the primary care provider for notification and to receive any follow-up prescriptions. A nurse administers 40 mg of propranolol PO to a client. The nurse then reviews the prescriptions and notes the client should have received levothyroxine 0.125 mg PO. The propranolol is prescribed for the client in an adjacent room. Which actions does the nurse take? Select All That Apply Contact the client's health care provider. The health care provider should be notified of the incorrect medication administration, the client's response to the medication, and questioned regarding next steps. Document the propranolol in the client record. The nurse should document the administration of the propranolol in the client record. Administer the levothyroxine as prescribed. The client still needs the scheduled medication. NOT: Document the medication error in the client record. The nurse should complete an incident report per facility protocol and should document factual data in the client record, but should not document it as an error. Instruct the family to watch for adverse reactions. The nurse should assess the client for adverse reactions to the medication administered in error. The nurse is obligated to ensure client safety by bringing this situation to the charge nurse's attention. The charge nurse must be notified of near misses and errors that occur as soon as possible after the incident. The charge nurse along with nursing leadership will investigate whether the previous nurse is providing safe client care or if there is reason to suspect abuse of narcotics. A nurse cares for a postoperative client on day 2. At 2000 the client requests pain medication and reports to the nurse the medication hasn't seemed as effective as it was the day before. When administering the prescribed medication, the client states, "These pills are different than the ones the nurse gave me earlier." Which action does the nurse take? (See exhibit.) View Exhibits Notify the charge nurse of the client's concern regarding ineffectiveness of administered medication. The charge nurse should be alerted to the client's concern to investigate the care provided by the previous nurse. NOT: Instruct the client that the health care provider has adjusted the pain medication for the second day after surgery. According to the client's health record, there has been no change in the client's medication prescriptions. Inform other staff to be alert to suspicious behavior of the nurse previously caring for the client. Informing other staff diminishes the credibility of the previous nurse and insinuates narcotic abuse, which could be considered slander or lateral violence. Recognize the client is likely confused due to frequency of pain medication administration. According to the health record, the client's frequency of medication administration had decreased and then increased again during the day and is not a likely cause for the client to question what the pills administered looked like. The nurse is responsible for carefully reviewing the prescriptions left by the provider. A nurse should document medications given including medication name, route of administration, reason for administration, time of administration and if indicated (IM or subcutaneous), location of administration. Medications may be given 30 minutes prior to or 30 minutes after scheduled time due before an error is documented. Failure to administer a medication or administration of the wrong medication or at the wrong time is a medication error and should be documented and the provider notified. Nurses should document their own assessments, medication administration, and procedures completed. When procedures are completed, nurses should document time, assessment findings, and the procedure completed with any client response as indicated.If a nurse fails to document information required to be included, this is an omission and is a documentation error. A nurse cares for 3 clients scheduled for care tasks to be completed before 8 am. After reviewing prescriptions, the nurse completes all tasks and documents them on each client record. Which documentation entry indicates an error? (See Exhibit.) Select All That Apply View Exhibits Flow Sheet C -- Late entry: 6am -- Administered cephalexin 500 mg PO The nurse has documented correct information but has made a medication error as the cephalexin po was not to be initiated until 8 hours after completion of the IV cefazolin. Flow Sheet B -- Administered insulin 4 units with breakfast tray The nurse has omitted the type of insulin, the route and location where the insulin was administered. NOT: Flow Sheet C -- 8:00 am -- Administered cefazolin 2 GM IVPB The client has an order for cefazolin (Kefzol) and the nurse has correctly documented time, medication, dose, and route Flow Sheet B -- Late entry: 6:30am -- Glucometer finger stick 135 mg/dL This client has an order for a glucometer prior to breakfast and the nurse has correctly documented the findings as a late entry note after the fact. The documentation is late, but the finger stick was done at the correct time. Flow Sheet A - 7:45 am -- Administered ondansetron 4 mg po for nausea The client has an order for ondansetron (Zofran) for nausea and the nurse has correctly documented time, route, dose, and reason for administration

Heart Transplant

It is important for a nurse working with transplant clients to be able to recognize common medications that will be given. A client who is a heart recipient will be on steroids, immunosuppressants, and diuretics to decrease the risk of rejection and overloading the heart. It is important for the nurse to teach the client about their medications so they are understanding of why they need them. The nurse cares for a heart transplant recipient. The nurse administers which medications to the client? Select All That Apply Furosemide A diuretic, such as Lasix, would be given to a heart transplant client to make sure fluid their heart is not overloaded with fluid. Mycophenolate mofetil Immunosuppressant medications, such as CellCept, are given to transplant clients to decrease the risk of rejection of the organ. Prednisone Steroids are given to transplant clients to decrease inflammation. NOT: Divalproex sodium Depakote is used for neurology clients, it would not be a common medication used after a client receives a heart transplant. Metoclopramide While the client may be experiencing nausea and receive Reglan to help with the symptoms, it would not be one of the standard medications a heart transplant receives.

Patient with No Insurance

It is the responsibility of a nurse to ensure a client can be successful with their medication regimen. If a client is unable to afford their medication the nurse must act as their advocate and connect them to services to help them obtain their medications. The nurse can advocate for a generic medication or a different medication with the same action that the client will be able to afford. A client contacts a nurse after going to the pharmacy and finding they are unable to afford their new cardiac medication. The client does not have health insurance to cover the cost. What actions does the nurse take? Select All That Apply Contact the prescribing doctor to request a more affordable medication. Often there are other medications within the same drug family or older medications that are more affordable than newer medications. Many older medications will have more side effects but will be just as effective treating the client and are often more affordable. Connect the client with resources to enroll in Medicaid and Medicare. Medicaid and Medicare are available to clients who qualify and will provide health insurance as well as prescription coverage to clients. A client must qualify and enroll in each program to use the services. Hospitals have staff that are able to help process information for the client and help with enrollment. Contact the pharmacy to see if there is a generic form of the medication. The nurse can call the pharmacy to find out if the medication the client was prescribed comes in a generic form. Often the generic drugs are less expensive than the brand names and contain the same active ingredient. NOT: Instruct the client to wait to discuss the medication with the doctor at the next appointment. The client should not wait until their next appointment to discuss their medication. The nurse can connect the client to resources to help them to afford their medication. Not taking a prescribed medication is dangerous to a client's health. Inform the patient that they must find a way to pay for the medication. If a client does not feel like they are supported then they will be less likely to follow through with their plan of care. A nurse who dismisses their financial concerns may find that they are not compliant with their medications.

Affordable Care Act (ACA)

The nurse must understand the implications and laws pertaining to the Affordable Care Act in order to correctly answer client concerns about coverage. Women services that are covered under the Affordable Care Act include the cost of a breast pump, all FDA-approved contraceptive methods, and pregnancy. ervices for this client? The cost of a breast pump during or after pregnancy must be covered. Under the Affordable Care Act, the cost of a breast pump must be covered. Depending on the individual coverage, the health plan may provide a rental or a new breast pump. Additionally, the health plan may choose if the client will receive a manual or mechanical breast pump. NOT: The cost of all contraceptive methods must be covered, regardless of method. The Affordable Care Act mandates that all FDA-approved contraceptives are covered. Any contraceptive method that is not FDA-approved does not need to be covered under the Affordable Care Act. Pregnancy is covered, but is usually charged at a higher rate. Under the Affordable Care Act, pregnancy is covered and is covered at the same rate of any other health condition. Additionally, pregnancy is not a pre-existing condition and coverage begins at the time of enrollment. BRCA testing for breast cancer is covered for all women. Genetic testing for breast cancer, known as BRCA testing, is covered under the Affordable Care Act; however, the coverage is for women at high risk and is not a universal coverage for all women.

Telephone order

The nurse should minimize receiving verbal or telephone and seek to obtain written orders when possible. Sometimes verbal or telephone orders are necessary due to provider or client circumstances. When they occur, the nurse should always read a verbal or telephone order back to the prescriber to ensure accuracy and client safety. This type of order is commonly referred to as a TORB (telephone order read back) due to this protocol. Some institutions do not allow verbal or telephone orders except in an emergent situation. The nurse should be familiar with protocols in the employed facility. When TORB protocol is followed, there is no need for additional verification by other colleagues. The nurse can proceed with the plan of care as prescribed. A nurse admits a client sent from the health care provider's office. The nurse calls the provider to obtain prescriptions. Which action does the nurse take? Read each prescription back to the provider prior to ending the call. The nurse is required to repeat verbal and telephone orders to the provider. NOT: Have the provider provide the prescriptions to another nurse as well. This is an unnecessary step. Hold treatments until the provider signs the prescriptions received. The nurse may move forward with treatments prescribed over the telephone when telephone order read back (TORB) has been performed. Verify the prescriptions with the charge nurse before beginning treatment. Though the nurse may wish to review prescriptions with the charge nurse, it is not required.

durable power of attorney for health care (DPAHC)

A durable power of attorney for health care (DPAHC) designates an individual chosen by the client to make health care decisions when the client is unable to do so. These decisions are made based on the client's wishes and often are made in reference to advance directives in place. When a plan of care has been initiated based on client wishes and the status of the client has changed where the client is no longer able to make decisions, the DPAHC can change decisions regarding care after consulting with the health care team and determining client wishes based on information in advance directives. A nurse cares for a client who is terminally ill. The client's husband, who is listed as the durable power of attorney for health care (DPAHC), insists that the nurse have a new health care provider take over the client's care. Which response by the nurse is appropriate? Select All That Apply Ask the client's husband to explain his reasons for requesting a new provider. Asking this question allows the husband to express his concerns regarding the care his wife is receiving and provides the nurse with additional information for taking next steps. Contact the nursing supervisor to discuss the client's husband's concerns. Contacting the nursing supervisor will allow the client's husband to voice his concerns, and the client's care can be transferred if deemed appropriate. NOT: Contact the social worker related to the client's husband's denial of care. The husband is seeking the best care for his wife and there is no need for a social worker to be contacted. Consult with the client's children regarding decision to change providers. The client's children do not have authority to make decisions regarding the client's care. Inform the husband that changing providers is not within his rights as DPAHC. The husband has the right to make this decision if he feels it is in the best interest of his wife. A durable power of attorney for health care (DPAHC) designates an individual chosen by the client to make health care decisions when the client is unable to do so. These decisions are made based on the client's wishes and often are made in reference to advance directives in place. When a plan of care has been initiated based on client wishes and the status of the client has changed where the client is no longer able to make decisions, the DPAHC can change decisions regarding care after consulting with the health care team and determining client wishes based on information in advance directives. A nurse cares for a client on mechanical ventilation through a tracheostomy after a motor vehicle accident (MVA). The client's durable power of attorney for health care (DPAHC) requests the ventilator be removed. Which is the best response by the nurse? "You will need to discuss the legal steps necessary to do so with the health care provider." The DPAHC can make decisions for the client when the client is unable to do so. The nurse should inform the DPAHC of his rights and contact the health care provider to allow this discussion. NOT: "The client's wishes regarding resuscitation were addressed and followed at the time of injury." The client's wishes may have been addressed at time of injury, but the circumstances may have changed and evaluation regarding continuation of treatment may be applicable. "A mechanical ventilator cannot be discontinued once initiated by the health care team." This is not correct or a helpful statement to make and does not address the concern of the DPAHC. "This is a decision that needs to be made by the entire health care team providing care to the client." The health care team will be a part of providing information in order for the DPAHC to make an informed decision regarding what is in the best interest of the client, but they are not a part of the actual decision making.

Living will

A living will is a written document providing information regarding the client's wishes with a terminal illness or event. The client is able to determine ahead of time the treatments desired, including organ donation, mechanical ventilation, pain management, and other end-of-life concerns. Each state has specifications regarding living wills and their interpretation, and nurses should be familiar with their state's requirements. This document requires a witness and in some states notarization in order to be considered a valid document. The living will includes what circumstances are needed in order for the living will to be executed, documentation requirements, health care worker immunity from liability, and witness requirements. A client requests information regarding a living will from the nurse during the admission assessment. Which information regarding a living will does the nurse give the client? Select All That Apply Determination of time frame or events for execution of the living will The living will identifies a specific time frame or event for which the client wishes the document to be executed. Wishes regarding treatment in the event of a terminal illness or condition The client is able to specify treatments desired or desired to not be included in the event of a terminal illness or condition. NOT: Choices of how to disburse valuables to be included in the document A last will and testament is a document that identifies which items and how these are to be distributed among family members at death. Requirement for the document to be notarized in order to be valid A living will needs a witness, but the requirement to have a notarized document varies from state to state. Identification of persons the client authorizes to make healthcare decisions A Durable Power of Attorney for Health Care (DPHAC) designates an individual of the client's choosing for making health care decisions according to the client's wishes when the client is unable to do so.

Malpractice

A nurse performing telephonic triage must listen to what the client is reporting. If the client is a frequent caller and reports the same symptoms consistently then it is the responsibility of the nurse to provide non-judgemental care and triage the client as they would any client. If the nurse does not follow through with this then they are liable for malpractice. A nurse answers inbound calls on an after-hours triage line. Which statement by the nurse indicates they have committed a malpractice offense? "You called about chest pain last week. Call your doctor in the morning." This would indicate that the nurse has been negligent in care and is liable for malpractice. If the client is complaining of chest pain the symptoms must be taken seriously and triaged appropriately. The nurse has not followed through with their commitment to provide care for the client. The triage nurse might have a relationship with a frequent caller but they must continue to provide unbiased care. NOT: "It sounds like you have a sunburn. Call your doctor if symptoms worsen." Most sunburns do not require medical attention. The nurse should provide the client with education for home care and the client would be advised to seek further medical attention if any symptoms worsened. "You report difficulty breathing. You must go to the emergency department." If a client is reporting increased difficulty breathing the triage nurse must recommend being seen immediately by a medical professional. Since most triage calls happen after hours it is most appropriate for the client to be seen in the emergency department. "It sounds like you have a cough. Call your doctor early tomorrow." If the nurse triaging the client has identified that the client is not having priority symptoms, then it is appropriate to recommend following up with their doctor the following day.

Tort

A tort is a wrongful act or omission against a person or property. Torts are classified as intentional, quasi-intentional, and unintentional. Negligence and malpractice are considered unintentional torts. The obstetric nurse removes penicillin and a spinal epidural bag from the medication cabinet. The nurse administers the prescribed intravenous penicillin via the epidural route, resulting in the client's transfer to intensive care. The nurse is subject to which tort liability? Select All That Apply Malpractice This scenario demonstrates malpractice by the nurse. Malpractice is an unintentional tort in which the nurse does not follow the standard of care, and the client is injured. Negligence The scenario demonstrates negligence by the nurse. Negligence is an unintentional tort in which the nurse does not follow the accepted standard of care, and the client receives sub-standard care. NOT: Assault This scenario does not demonstrate assault. Assault is an intentional tort in which the nurse intends to harm the client. Battery This scenario does not demonstrate battery. Battery is an intentional tort in which the nurse intends to injure the client, using touch. Confidentiality breach This scenario does not demonstrate a confidentiality breach. The nurse did not violate the client's privacy by sharing protected client information with persons not involved in the client's care.

Liberalization of Visitation

ALS is a long-term disease and the family needs to be able to care for themselves as well as the client. Liberalization of visitation policies is warranted in this situation. Family presence is important to healing. The nurse advocates for the client by ensuring exceptions are granted as needed. A client with amyotrophic lateral sclerosis (ALS) is on a ventilator and communicated minimally with the use of eye blinks. The client's family is unable to visit and assist with communication during the day due to work conflicts. The client's family requests to visit outside of the posted visiting hours. How does the nurse best respond? Discuss an exception for the client's family with the unit manager. Liberalization of visitation policies may be warranted in this situation. Family presence is important to healing and allowing off-hours visitation can reduce the burden of caring for a family member with a disease that progresses over years. The nurse should not make this decision alone but should confer with the unit manager to make an exception in this case. NOT: Suggest that the family members take turns missing work. The nurse does not suggest family request time off from work obligations. ALS is a long-term disease and the family needs to be able to care for themselves as well as the client. Explain that the rules must be the same for everyone. It cannot be the nurse's default position to refer to policies without reasonable consideration of extenuating circumstances, though some exceptions will need additional approval by administration, the nurse advocates by ensuring these permissions are granted as needed. Schedule a volunteer to spend time with the client each day. A hospital volunteer can assist with communication and social presence, but it is not a correct replacement for family.

Adult Protective Services (APS)

Abuse is against the law and is required to be reported by mandatory reporters. A nurse is a mandatory reporter and should report any suspected or actual physical abuse, including hitting, pushing, or molesting, to the appropriate agency. Any suspected activity should be reported and investigated within five days of the incident according to the Centers for Medicare and Medicaid Services. Nursing homes and hospitals should not isolate clients using physical or chemical restraint without just cause. The agency that investigates abuse may be Adult Protective Services or the State Survey Agency. The nurse should be aware of where actions that constitute abuse should be reported. A nurse cares for a client who is rude and frequently screams obscenities to other clients and staff. A second nurse passes by the client's room and witnesses the assigned nurse slap the client after a rude comment. Which action does the second nurse take? Report the nurse's actions to the Bureau of Adult Protective Services. The nurse is a mandated reporter for abuse when it is witnessed; therefore, the nurse is required to directly report the action. NOT: Ask the charge nurse to report it to the Bureau of Adult Protective Services. The nurse should not delegate reporting to an individual who did not witness the behavior. Inform the abusing nurse the action will be reported if the behavior occurs again. Failing to report the witnessed abuse is a violation of the law. Call the client's family and inform them of the incident with the nurse. It is not the responsibility of the witness to notify the family of an incident. This would be the responsibility of the supervisor.

Visitation

Both the American and Canadian Nurses Associations promote shared decision-making which promotes client involvement with treatment decisions and the plan of care. In keeping with this principle, it is essential to consult with the client as to the preferred visitation. From there, a dialogue can begin and if there is disruption for other clients, the nurse can include this in the discussion. A client who belongs to a Latino culture often has several family members at the bedside. A colleague says to the nurse, "We have to enforce some limits to visitors. It's disruptive!" How does the nurse respond? "I will speak to the client about what visitation is preferred." In keeping with culturally-congruent practice, the nurse engages in shared decision making and allows the client to have input. Even though the client is of Latino culture, the client is an individual and the only way to know the client's wishes, is to engage with the individual. NOT: "They are Latino so it is normal to have a lot of family around." This is a general statement that does not address either the nurse's concern's nor the client's preference related to visitations. Rather than making assumptions based on a client's culture, the nurse speaks with the client to determine the actual preference. "The client should have family support while in the hospital." Family support in general is promoted but some clients may wish for more or less family presence so the nurse needs to consult with the client about the preference. "I will remind the family about our policies regarding visitation." The nurse's priority is to the client so the nurse should speak with the client about the preference related to visitors prior to engaging with the family.

Against Medical Advice (AMA)

Clients of sound mind cannot be forced to remain in a hospital. The nurse can ask the nursing supervisor or health care provider to intervene, if this is warranted. Improper use of chemical or physical restraints is considered false imprisonment. If the nurse has reason to doubt the client is competent and cognitively sound, ask the client to explain the risks and benefits of leaving and document the conversation. Clients do not need a formal discharge to leave the hospital, but may sign an AMA form if client desires to immediately leave the hospital. The client admitted for a lupus exacerbation states, "I'm leaving this hospital right now!" The nurse takes what action? Provide the client with an Against Medical Advice form (AMA). Providing the client with sound mind an AMA form protects the client's rights, and protects the nurse and hospital from lawsuits. NOT: Administer a dose of intravenous ativan to reduce anxiety. Administration of intravenous ativan without due cause is considered a chemical restraint. This may be considered battery in a court of law. Tell the client that a discharge is necessary in order to leave. Telling the client that a formal discharge is necessary to leave is a fraudulent statement, which misrepresents the situation. The client of sound mind may leave the hospital at any time. This statement places the nurse at risk for a lawsuit. Threaten to apply restraints if the client attempts to leave. Threatening to apply restraints to a client is a form of assault or a threat of inflicting harm. Actually applying the restraints to the client of sound mind is considered battery. Both place the nurse and hospital at risk for a lawsuit.

Domestic abuse

Clients who are admitted for instances of suspected spousal abuse are not listed in the hospital client directory for safety purposes. If someone calls to request information about a client admitted after a spousal assault, they may be "fishing" for information in an attempt to locate the client. In order to protect these clients, no information should be provided that would indicate that the client is currently admitted to the hospital. The nurse should not tell the caller anything about the client, nor will the nurse tell the caller to come to the hospital. A nurse cares for a client admitted to the hospital after being assaulted by his or her spouse. The nurse is paged for a phone call. The caller requests information on the status of the client. Which action does the nurse take? Explain to the caller that there is no client admitted matching the description. The nurse will explain to the caller that there is no client admitted with that information. This protects the client's identity and promotes safety. NOT: Request that the caller come to the hospital in person to discuss the client's status. The nurse will not request that the caller come to the hospital in person. This admits the client is there and places the client in danger. Inform the caller that the client is "stable" with no further elaboration. The nurse will not inform the caller of the client's health status, including the standard status update, such as "stable" condition. Inform the caller of the client room number and anticipated discharge date. The nurse will not inform the caller that the client is at the hospital or reveal the client's room number. The nurse who cares for a client with an injury that is a typical abuse injury should look for signs that could be indicators of abuse. The nurse should watch for verbal and nonverbal clues from the client that may give an indication regarding the true nature of the injury. It is important for the nurse to establish trust with the client so that the client will feel comfortable providing information and answering questions the nurse may ask. When the client expresses fear or concern related to how the partner may respond to the treatment or the injury itself, this should raise a red flag for the nurse, prompting further exploration of the event. The nurse should ask questions directly, but in a non-threatening way. A nurse cares for a client in the emergency department for a right radial fracture. Which statements by the client require the nurse to take further action? Select All That Apply "Can you list me as 'no information' so my significant other won't know I'm here?" This response signals there is an issue of concern and should raise a red flag for the nurse "I'm afraid I'm going to lose my job. My significant other will be really angry if I do." This response signals the client has a fear of the significant other and should raise a red flag for the nurse. "My parents want me to come back home and live with them after this." This response indicates the parents have concern for the client in the current living situation and should raise a red flag for the nurse. NOT: "I'm going to have a hard time getting things done since this is my dominant hand." This response is normal considering the nature of the client's injury. "My mother is parking the car. My significant other was at work when I fell down." This response does not give any cause for concern for the client.

Coping Behaviors

Clients with critical illness cope in a variety of ways from stoic, to withdrawn, to manipulative. The nurse suspects the client and family who breaks the hospital rules is using this as a coping style to attempt to feel safe and in control of a fearful situation. Understanding this coping mechanism allows the nurse to better respond to the client and family. The family of the client with an acute myocardial infarction (MI) continues to bring in chewing tobacco for the client, despite knowing that chewing tobacco is prohibited. What action does the nurse take? Document this as a coping behavior. Documentation of these actions lets the health care team know what is happening. Recognizing this as a coping behavior allows the nurse to understand and empathize with the client and family's situation. This understanding enhances the relationship of the medical staff with the family. The nurse could then discuss with the healthcare provider and the rest of the team the best way to approach the situation. NOT: Search the family's belongings at visits. Searching the family's belongings before visits decreases the trust between the nurse and the family of the client. This action would likely increase manipulative behavior from the family. There are also legal and ethical implications to this action. Offer to help the client quit chewing. Offering to help the client quit chewing may be beneficial or may increase the client's stress. It is important to assess the client and family's needs, and tailor communications to what best enhances their ability to cope. This action would likely not decrease manipulative behavior. Monitor all visitations for the client. Monitoring all client visitations may increase family and client manipulation and deception toward staff. The goal is to improve the client and family's ability to cope and reduce their stress.

Clinical Pathway

Clinical pathways are used to evaluate the quality of care and outcomes for groups of clients with similar health needs. Using a clinical pathway uses established guidelines for client care while recovering from a heart attack and ensures care is not delayed. Clinical outcomes look to improve the quality of care the client is receiving while at the same time evaluating costs of care. A client with a recent myocardial infarction (MI) is admitted to the hospital. The nurse caring for the client follows the MI clinical pathway to guide the client's care. What does the nurse document? Select All That Apply Medications administered Documenting the medications ordered by the HCP will help evaluate the progress the client is making. The clinical pathway guides the treatment plan. Client and family education Educating client and family of procedures and interventions is important, with the goal being independence of care at discharge with family having an understanding of care. Activity level tolerance It is important to document client's activity as they recover. The clinical pathway will provide guidelines as to how and when the client should progress. NOT: Insurance coverage While it is always important to consider what a client's insurance covers, it is not a part of a clinical pathway to providing care. Advanced directive status It is always important to have advanced directives updated but it is not something the nurse will be documenting regularly while caring for the client.

Core measures documentation

Core measures are standards of care used for groups of clients requiring evidenced-based interventions that ensure positive client outcomes. A nurse that cares for a client must appropriately document any care given to the client. Electronic medical documentation has the ability to create standard checklists and documentation for core measures so that it is efficient for the nurse as well as a way to track and measure the quality. The nurse cares for a post-operative client. The nurse follows the core measures for deep vein thrombosis (DVT) prevention. Which action represents best DVT documentation? The nurse chooses the check box for DVT prevention. Electronic documenting systems have the ablility to pre-populate commonly used processes and procedures. Deep vein thrombosis prevention after surgery is a standard of care and core measures would be in place. For tracking purposes the nurse could check the box after following appropriate care or to plan care. This would document that the care was given or is planned, and act as a quality tracking control to ensure hopsital policies are being followed. NOT: The nurse documents compression stockings were applied. It would be important for the nurse to document this action, but it is not the best answer because it is not the most complete action addressing core measures. Core measures include many interventions. Document a nurse's note in the client's chart. The use of core measures is to create a standard of care. Documentating the care of core measures is often checking a box on a list and there is no need to create a free standing note. If the nurse needs to open and create a note for each client to document core measures this will be time consuming and not an efficient way to track data. The nurse documents completion of prescribed interventions. Core measures includes both HCP prescribed measures such as heparin or enoxaparin doses, and also nursing interventions that are performed unless specifically prohibited by the HCP. A nurse must document all care that is given. Even if care is standard for all clients, it must be documented. Core measures need to be documented as they are a standard of care used to measure quality and patient outcomes.

Ending racism in health care

Ending racism in health and health care is not possible without the universal advocacy from all nurses. Shifting costs and mindsets, as well as client advocacy groups help to eliminate racism in health and health care; however, these actions do not have as great of an impact as universal advocacy among nurses. The nurse advocates to eliminate racism in health and health care by lobbying for fair and equal treatment among all ethnicities. Which concept best supports the goal to eliminate racism in health and health care? Advocacy from all nurses. All nurse must advocate for the end of racism in health and health care. This action must be a priority for all nurses, in order to successfully end racism. NOT: Shift in nursing costs. Health care cost management is an important task to attempt to achieve; however, this does not directly impact ending racism in health and health care. Advocacy from client activists. Advocacy from client activists is beneficial to helping change unfair laws; however, the universal advocacy of nurses has a greater impact to stop racism in health and health care. Shift in mindset of health care workers. A shift in mindset of health care workers is essential to help eliminate racism; however, this is not the action that best supports the goal of eliminating racism in health and health care.

cultural competency

Health care providers must provide culturally competent care to the diversity of clients they will encounter within the health care system. A nurse must have a basic understanding of communication preferences such as touch and personal space to effectively and respectfully care for a client. The health of a client is the priority but if aspects of their culture such as food, prayer and family can be integrated into their care then there will be greater compliance and more positive responses. A nurse cares for a client with a different cultural background than their own. What are the ways the nurse demonstrates cultural competence? Select All That Apply The nurse will make eye contact with the client if appropriate. In some cultures it is a sign of respect to make eye contact while in other cultures it is disrespectful to make eye contact. It is the reponsibility of the nurse to understand the best ways to communicate with the client and respect their culture. The nurse will begin a procedure after the client has prayed. Prayer is an important aspect of a client's culture. The nurse must repect a client's need to pray and allow them to do so in a way that will not delay or harm their care. The nurse will ask the client if it is acceptable to hold their hand. In some cultures it is appropriate to demonstrate affection and caring through touch while it is inappropriate to demonstrate public affection in other cultures. It is appropriate for the nurse to ask the client before offering them support by holding their hand in order to respect their cultural background. NOT: The nurse allows only one family member in the room. In many cultures extended family is an important and part of a client's support system. Keeping in mind the needs and health of the client, the nurse should allow for multiple family members to visit with a client. The nurse will allow the client to eat hospital food only. In some cultures food is an important part of the healing process. When appropriate the nurse must allow the client to eat food that are important to their culture. In Chinese medicine, for example, hot and cold foods play a role in health and the nurse should be respectful of the importance of food in a culture for healing.

Dog Bite

Health care providers, nurses, and other health care personnel that are presented with a client suffering from an animal bite must report the incident to the community health department. This reporting is required in order to ensure that the animal can be quarantined and monitored for signs of rabies infection. Animals with verifiable rabies vaccinations will still be quarantined to be certain that the animal has no active rabies infection. After the quarantine period, the animal may be returned to the family as long as the animal is found to pose no threat. Mandatory reporting includes reporting of family pets if necessary. A nurse triages a pediatric client with injuries sustained from a dog bite to the right arm. The client's parent states that the client awoke the family's sleeping dog, who then bit the client when startled. What does the nurse understand is required when reporting a dog bite? All dog bites must be reported to the community health department for verification of current rabies vaccination. The community health department should be notified of any dog bite in order to verify current rabies vaccination and to quarantine the dog. NOT: Dog bites that occur from family pets are excluded from mandatory reporting requirements. Mandatory reporting does not exclude family pets. A dog bite does not need to be reported if the family can present current rabies vaccination documentation. Presenting current rabies vaccination does not prevent the need for reporting of the dog bite. All dog bites must be reported to the community health department so that the dog can be euthanized. A dog that bites a human does not necessarily need to be euthanized.

Negligence

If a nurse walks into a client home and suspects that there has been negligence in their care then they must legally document and report the incident. The first responsibility of the nurse will be to ensure the client is safe. The nurse must follow the correct procedures for documenting and reporting after assessing the client. A visiting nurse finds a home bound client has not been cleaned in several days. The client has been assigned a home health aide for assistance at home. What is the nurses first response? Assess the client. The first responsibility of the nurse is to assess the client and ensure they are safe and unharmed. The nurse walking into the home assess negligence but must ensure he health and safety of the client as the first priority. The nurse must assess to see if any harm or abuse has happened to the client. NOT: Document the scene. It is important for the nurse to document the environment she finds but this is not the first action in this situation. The nurse must be accurate with documentation as it could be investigated and the nurse's legal documentation is important. Report the home health aide. The nurse is responsible for reporting any negligence and abuse to the home care company for further investigation. While this will be an important action by the nurse it is not best first response. The nurse's first responsibility is the care of the client and making sure they are safe. Contact the home care company. it would be important for the nurse to contact the home care company to alert them to any negligence that may be suspected. In this case the home care company would need to follow up with any home health aides that may have been caring for the client. the home care company would be responsible for investigating the situation as well as making sure the client is receiving safe and appropriate care in their home.

Discharage

It is the responsibility of the nurse that a client will be independent of their care at discharge. A client being discharged with a dressing change must be able to safely complete the task to ensure their wound does not become infected leading to more health issues. If a nurse does not advocate for the client then legally the nurse is negligent to the client's care. A nurse cares for an older adult client who is unable to independently change their wound dressing. The client is being discharged without skilled nursing and has no family support. What action does the nurse take? Update the health care provider on the client's inability to perform the dressing change. It is the nurse's legal responsibility to update and inform the HCP of a client's status. The HCP may not realize that the client is unable to independently perform a dressing change and is therefore not ready for discharge. NOT: Continue with the discharge process knowing the client will be able to manage better at home. The nurse should not assume the client will be able to manage better at home. If the nurse identifies a problem with the discharge plan then they must speak up and advocate for the client. Contact home health agencies that might be able to provide services to the client. The nurse can contact local home health agencies proactively but a prescription written by the health care provider is needed. The client's insurance will need to approve of the services prior to anything being implemented. Continue to work with the client on the correct way to change the dressing. It is important to continue to educate client regarding their wound and dressing change. The client should not be discharged if they are unable to do so independently.

Alprazolam (Xanax)

Medications prescribed by the health care provider to be used for anxiety as needed are only to be administered as directed for anxiety. Using these anxiolytics as a means to keep a client in bed is considered a chemical restraint. Any restraint prescription, whether chemical or physical, requires assessment by a health care provider for necessity every 24 hours. An order for alprazolam at bedtime for anxiety should not be used to keep a client in bed. Other alternatives should be attempted, like diversionary measures, rest breaks for the family member, or a hospital-provided sitter for client safety. It is appropriate to administer the alprazolam to the client at bedtime only if the client is agitated or anxious. If other medications are required, the health care provider should be called to discuss the situation. At that time, new prescriptions can be given for chemical restraints if needed. A nurse cares for a client with dementia whose condition worsens at night. The client's daughter requests the client receive a dose of alprazolam at 1730 because the client has been pacing the room for an hour. When reviewing the prescriptions, the nurse notes the prescription is written alprazolam 1 mg PO QHS PRN anxiety. Which action does the nurse take? Contact the health care provider for a different prescription. The client is agitated and may need an alternative prescription for anxiety before bedtime. NOT: Wait until 2100 and administer the alprazolam. Waiting a few hours will only increase the client's anxiety and may worsen behavior. Assist the client to bed and administer the alprazolam. Giving the alprazolam early to keep the client in bed is using it as a chemical restraint. Administer the alprazolam now as requested. Giving the alprazolam early to keep the client in bed is using it as a chemical restraint.

Risk for legal action from client's family

Negligence is the failure to use ordinary care as a nurse according to professional standards of care. Failing to respond to a client situation according to these standards or to foresee outcomes that another provider with like skills and training would see can place a nurse at risk for liability related to professional negligence, or malpractice. In situations where negligence is suspected and the nurse is liable, five elements are required to prove negligence: duty, breach of duty, cause in fact, proximate cause, and damages. In this situation, the nurse failed to notify the health care provider of assessment data and treatments provided. The health care provider may have provided additional prescriptions which could have resulted in a different outcome. Select All That Apply The nurse fails to assess the client's status after administering the prescribed medication. The nurse is responsible for assessing the response to treatment and reporting to the health care provider. The nurse fails to notify the client's health care provider of assessment data and treatments administered. The nurse should notify the health care provider of client assessment data, treatment provided based on prescriptions, and client response to treatment. NOT: The nurse fails to notify the client's family of the event leading to administering the medication. The nurse is not required to notify the family regarding treatment. The nurse fails to react to the client's condition and administer appropriate prescribed treatments. The nurse has initially recognized the client's condition and administered appropriate treatment according to prescriptions. The nurse fails to notify the charge nurse of the client's assessment data and prescribed treatments. Though a good idea to notify the charge nurse of client condition, the nurse is not required to do so.

organ rejection

Organ rejection and infection are priority symptoms the nurse nurse must address when caring for transplant clients. Chills and a headache may indicate fever and elevated blood pressure which are symptoms of organ rejection and this client would require immediate attention. Other symptoms such as decreased urine output, wound infection and nausea are important to address but are not the priority symptoms. The nurse cares for a group of clients. Which client requires the immediate attention of the nurse? A heart transplant client reporting chills and a headache. This client would require immediate attention as chills could be from a fever and a headache could be from increased blood pressure both symptoms would indicate possible organ rejection or infection. Transplant clients are at a higher risk of developing infections due to immunosuppressants they are prescribed after receiving a new organ. NOT: A lung transplant client reports drainage at the incision site. It is important for the nurse to assess the incision site to make sure that it is not infected a frequent complication. While it is important to address any signs of infection this would not be the priority client in this situation. A liver transplant client reports that they are nauseous. A client can be nauseous from the medications they are taking. It is important for the nurse to asses this patient and review their symptoms but they would not be the priority. A kidney transplant client reporting they are not urinating. While this patient would require attention it is not the priority client. Many times a client receiving a kidney from a live donor may not urinate for several weeks. It is important to assess this client and educate them but in this situation they would not need immediate attention.

Pain Control

Pain is a subjective experience, and all clients will experience pain individually from others. When a client complains of pain, it is the nurse's duty to address the pain. If a client has a PCA pump and orders for breakthrough pain medication, this is because pain medications provided through a PCA are shorter-acting while breakthrough pain medications are longer-acting to help achieve better pain control. Any nurse who refuses to administer pain medication as ordered or who threatens clients with withholding pain medication can be charged with abuse and neglect. The appropriate course of action is to discuss the accusations with the charge nurse and file an incident report. Further action will be pursued with the accused nurse by appropriate hospital personnel as required, possibly up to and including the state board of nursing. A nurse on the cardiovascular step-down unit is caring for a client who is postoperative day 2 after arterial bypass surgery. The client has a patient-controlled analgesia (PCA) with hydromorphone infusion and has hydrocodone 10 mg po Q4 hours ordered for breakthrough pain. During morning assessment, the client complains of pain with a rate of 10 on a scale of 0 to 10. The nurse offers the client the hydrocodone for breakthrough pain. The client states, "I asked for pain medication from the other nurse and was told no because I have a PCA." On further questioning, the client stated that the other nurse threatened to disconnect the PCA if the client continued to complain. The nurse knows the next appropriate action is which of the following? Discuss the accusations with the charge nurse and complete an incident report. NOT: Investigate the client's past medical history for possible substance abuse. Ignore the client's claims since the client should have adequate pain control with the PCA. Call the other nurse at home to confront them about the client's accusations.

Pre-op assessment

Pre-op assessments should always include any skin tears or lacerations, bruises, rashes, and pressure ulcers, so they can be documented and will not be misattributed to a surgical injury or complication. A nurse should never alter documentation after the fact or alter the documentation of another nurse (this is illegal). So if something is missed, a note should be made in the periop documentation to detail the pre-existing injury. Altering the documentation of another nurse is illegal. A nurse should document assessment findings and not ask another nurse to do so. The circulating nurse in the operating room (OR) positions a client on the operating table and notes a small laceration on the client's hip not documented in the pre-operative assessment. Which action does the nurse take? Document a pre-existing skin laceration in the client's peri-operative note now. The finding should be documented as a pre-existing skin laceration prior to the surgical procedure being completed. NOT: Document the laceration as an injury while moving to the operating room. The nurse should not document this as an injury that occurred without facts that support an injury. Report to the recovery room nurse after the procedure for inclusion in the post-operative notes. The nurse should not ask another nurse to document assessment findings previously discovered. Change the documentation of the previous nurse to include the laceration. A nurse should not alter documentation from another nurse's assessment.

hip replacement

Prior to surgery, the client must receive education about what to expect in the post-op period when they are recovering. The nurse is responsible for teaching and assessing the clients understanding of the procedure and recovery phase. A client is getting ready to undergo a hip replacement surgery. Which client statement alerts the nurse that the client does not understand the procedure? "I will be able to cross my legs." After hip surgery a client cannot cross their legs while sitting. The hip's position must not cross the midline and must not be bent more than 90 degrees. The surgeon will give the client specific guidelines regarding proper positioning but crossing the legs will always be contraindicated. NOT: "I will have to practice deep breathing." Teaching a client to take deep breaths and use an incentive spirometer are important aspect of post op care to prevent pneumonia and atelectasis. "I will need to eat food with iron." Blood loss during surgery is common and a client's hematocrit and hemoglobin are often low during the post op period. While some clients may require a blood transfusion most are encouraged to increase iron rich foods after surgery. "I will need to take a blood thinner." Anticoagulant medications, blood thinners, are used after surgeries to help prevent the development of DVT and blood clots. These are common side effects of orthopedic surgery as well as the patient being sedentary for a prolonged period of time. The use of an anticoagulant after a hip replacement is expected and the client is educated on this prior to surgery.

Policy change

Quality of care and improved client outcomes should be the center of any institutional change or policy change. The nurse who is advocating for additional staff to reduce nurse-to client ratio should provide rationale for how this will impact quality of client care and improve client outcomes. Although reducing the nurse-to-client ratio would increase recruitment, reduce stress, and boost morale, quality of client care should come first. A nurse approaches the nurse manager to advocate for the hiring of more nurses to reduce the nurse-to-patient ratio. Which statements best support the nurse's proposal? Select All That Apply "Last week when four nurses worked two additional shifts each, clients received all medications on schedule." This is a demonstration of improved client outcomes with more staff working. "When nurses are able to complete full assessments without rushing, client needs are identified and care is improved." This places the emphasis on quality of care that should be the emphasis on a client care unit. NOT: "Nurses who don't have to complete as many assignments go home better rested at the end of the day." The focus should be on the client and not on the nurse. "Nurses are constantly bickering due to the unfairness of assignments made each week." A focus on nurses bickering does not address quality care to the client or improvement of client outcomes, which should be the focus. "The nurses on our unit have helped to create a safe environment so that other staff want to work here." Creating a safe environment is important for recruitment and retention but does not support the need for additional staff.

SBAR

SBAR stands for situation, background, assessment, and recommendation. The goal of SBAR communication is concise and accurate communication among healthcare professionals. The assessment statement includes changes in the condition of the client. • Any statements including past medical history are part of the background. Some other elements of the background include diagnosis, current medications, vital signs and treatment summary. • The client is becoming diaphoretic and pale communicates a change in condition and indicates that the client may be deteriorating. Assessment includes changes in the client's condition from previous nursing assessment and possible deterioration. • The client is reporting severe chest pain is the situation statement. The situation statement briefly explains the concern or problem the client is experiencing. • A stat tropinin and EKG are recommendations for treatment. Recommendations include specific treatment, tests needed, or requesting the client be seen by the healthcare provider. The client reports to the nurse new onset, severe pain in left chest radiating to the jaw. Using the SBAR format, the nurse communicates assessment information to the healthcare provider with what statement? "The client is diaphoretic and pale." SBAR. The nurse's assessment data is crucial to assisting the health care provider in estimating the nature of the situation, particularly when the health care provider is not available to see the client with an urgent situation. NOT: "The client has a history of unstable angina." SBAR. The client's background includes unstable angina. This is relevant information, but is not assessment data. "The client needs a stat tropinin and EKG." SBAR. The nurse's recommendation to the health care provider is essential. Even though nurse's do not prescribe therapies, it is essential to be able to suggest first steps to assist the client. "The client reports severe chest pain." SBAR. The client's current situation is that the client reports chest pain. This is an urgent situation. SBAR stands for situation, background, assessment, and recommendation. The goal of SBAR is concise and accurate communication. The background statement is a summary of the pertinent health history. For this client, the summary would include date of hip fracture, any surgery performed, and pain medication history. "Client takes pain medication at home." The health history, such as "The client takes pain medication at home", is part of the background. A client who takes narcotics at home may require increased doses of pain medications.

Autonomy

Self-determination is the ability to make one's own decisions. Autonomy in health care refers to the client's abiity to accept or refuse treatment. Beneficence is the desire to do good. Nonmaleficence is the idea of "do no harm". Utilitarianism is the concept of doing the best for "the greater good'. Autonomy is the right to make your own decisions. The client is able to make decisions regarding care after being informed of all available options. It includes the client's ability to make decisions in advance regarding end-of-life decisions and completing appropriate forms in consultation with the health care provider.Justice refers to the appropriate and fair distribution of resources. When clients observe policies in place that they feel conflict with information that has been provided to them, they feel they are being treated unjustly.Beneficence refers to actions that promote the well-being of others. The nurse who is exemplifying beneficence takes positive actions to help clients.Fidelity refers to the agreement to keep promises. The nurse is obligated to be an advocate for her client and makes promises to do so. A nurse cares for a group of clients in a long-term care facility. Which situation represents a situation in which the nurse supports the client's autonomy? A client wishes to have a do not resuscitate (DNR) order to prevent heroic measures by the health care team in the event of cardiac or respiratory arrest. This is an example of recognizing the client's ability to make autonomous decisions regarding end-of-life care. NOT: A client reports to the nurse regarding observing staff smoking on facility grounds when it was banned for residents and family members. This is an example of justice. A client falls and fractures a hip. The nurse contacts the health care provider for a prescription for pain medication prior to transfer for treatment. This is an example of beneficence. A competent client who has received a terminal diagnosis requests the nurse to not reveal the diagnosis to the family due to fear of them seeking long-term mechanical ventilation. This is an example of fidelity.

Allergy documentation

Skin reactions are the most common form of allergic reaction. This client is experiencing an allergic reaction to ceftriaxone. It is important for pharmacists to have that information to be able to track if there is a sudden increase in reactions after changing drug manufacturers. Adverse drug reaction information is collected by hospital pharmacies to watch for trends in reactions to medications. This could indicate contamination in the medication or that the formula used by the new manufacturer causes a higher rate of reactions. This is important for the safety of additional clients who could receive this medication. When a client experiences an allergic reaction to a medication, the nurse should contact the health care provider to obtain prescriptions for treatment of the reaction and a change in medication. The client should be informed to notify other health care providers of the allergic reaction and information should be documented in the client's health record. A nurse administers ceftriaxone IV as prescribed to a client. Twenty minutes after initiation, the client develops a generalized red, itchy rash. The nurse discontinues the infusion and contacts the health care provider (HCP). Which additional actions does the nurse take? Select All That Apply Add a new allergy to the client's permanent health record. The client's record should be updated to include this medication as an allergy with the noted reaction. Complete an adverse drug reaction report per facility protocol. Adverse drug reaction information should be reported per facility protocol. Document the client's reaction to medication in the client's health record. The client is having an allergic reaction, and this should be documented. NOT: Inform the client this is a normal side effect of the medication. This is not a normal expected side effect of the medication. Discontinue the IV line and restart at a new site. There is no need to discontinue the client's IV line.

Client's rights

The AHA's Patient Care Partnership replaces the AHA's Patients' Bill of Rights and uses plain language to inform clients about what to expect during their hospital stay. Various rights listed include the rights to high quality care, help when leaving the hospital, help with paying the hospital bill, and involvement in health care decisions. When admitting a client to the hospital, the nurse reviews the client's rights. What is included in the nurse's teaching? Select All That Apply Help with paying the hospital bill. According to the AHA's Patient Care Partnership, every client has a right to help with paying the hospital bill. This help may be in the form of providing assistance in payment plans or other assistance. Involvement in health care decisions. According to the AHA's Patient Care Partnership, every client has a right to involvement in his or her own health care decisions. Resources when leaving the hospital. According to the AHA's Patient Care Partnership, every client has a right to help when leaving the hospital. This may include quality discharge instructions, access to home health care, and additional community resources. High quality hospital care access. According to the AHA's Patient Care Partnership, every client has a right to high quality hospital care. NOT: Alternatives to the current health care plan. While the client has a right to help with paying for the hospital bill, the AHA Patient Care Partnership does not explicitly state that the client has a right to alternatives to the current health care plan.

Incivility

The American Nurses Association (ANA, 2015) defines incivility as "rude and discourteous actions, gossiping and spreading rumors, and of refusing to assist a coworker" (p. 2). The best choice given is to discreetly share this incidence of incivility with the charge nurse. As a new graduate, the power differential between the graduate nurse and senior nurse makes the new graduate more vulnerable, so the new nurse should seek out guidance prior to interacting with the senior nurse. The ANA also encourages nurses to "Speak directly to the person with whom one has an issue" to help reduce incivility. Therefore, the senior nurse should have had a professional exchange with the nurse believed to be making errors rather than spreading gossip to the new graduate. A colleague says to the new graduate nurse, "Double-check all your orders and MARs (medication administration records) before you get started. The nurse who cared for your clients before you is a total screw up." The new graduate nurse takes what action in response? Discreetly describe the interaction with the senior nurse to the charge nurse. Rather than confront the senior nurse directly, the new graduate should seek guidance from the charge nurse and communicate the concerns about the colleague's communication in a professional manner so it can be followed up. NOT: Tell the senior nurse all nurses should be supported in their work, not criticized. A blanket statement such as this does not inform the senior nurse what was improper in the comment. While nurses need to be supported in their practice by their colleagues, they are also held accountable for that practice, which sometimes requires criticism of their performance. Call the nurse who cared for the clients previously to discuss what the senior nurse said. Informing the nurse who previously cared for the client and whom the senior nurse criticized is not productive and would amount to gossiping. Complete an incident report for all errors made by the previous nurse. While any errors detected would have to be properly addressed, this does not deal with the unprofessional interaction with the senior nurse. The new graduate should ensure the interaction is communicated for follow-up.

Tuberculosis (TB)

The Centers for Disease Control (CDC) and the World Health Organization (WHO) require reporting cases of highly infectious communicable diseases such as TB. The reporting system lets CDC and WHO track and monitor diseases to prevent their spread in at-risk populations and uncontrollable transmission worldwide (i.e., a pandemic). Once a client has TB, the PPD (Mantoux) skin test will always be positive, so repeating the test is unnecessary. Treatment of known TB cases lasts for at least six months. Clients are not placed in contact isolation for the duration of treatment. Close monitoring and follow-up is done throughout treatment to ensure compliance with the medication regimen. Family members and others exposed to TB will often be given short-term prophylactic antibiotic treatment to prevent the development of the disease. Educating clients, family members, and others about TB is also important for preventing its spread. The client with TB would remain on airborne precautions would be maintained until the client has received appropriate medical therapy for at least 2 weeks, in addition to the improvement of symptoms and three negative sputum results. A client presents to the emergency department with reports of a cough that has lasted for two weeks, low-grade fever, and night sweats. A nodule is noted in the left lower lung field on x-ray, and the Mantoux test is positive for tuberculosis (TB). Which actions does the nurse perform? Select All That Apply Educate family members regarding the spread of disease. Education to the client and client's family members on disease spread helps to prevent the spread of disease to others. Report the condition to the community health department. Reporting of communicable disease (such as TB) is necessary to help prevent the spread of disease. NOT: Plan the client's next follow-up skin test. The skin testing will always be positive in a client with TB. This will not be repeated. Institute transmission-based precautions until treatment is completed. Treatment for TB lasts months, and the client is not placed on isolation for the duration of treatment. Plan the client's next follow-up assessment in six months. Monitoring of disease occurs more frequently than every six months.

Release of Information (ROI)

The Health Insurance Portability and Accountability Act (HIPAA) protects privacy of clients. Discussing health information of a client with the client's family without the client's written consent may be considered an invasion of privacy and have legal ramifications. Best practice includes a signed release of information (ROI), but verbal permission with a second witness is also acceptable, if a signed ROI is not possible. The nurse admits an adult client after a drug overdose. The client's parents call asking for information about the client. What initial action from the nurse is best? Check the release of information (ROI) in the medical record. Checking the ROI is the best initial step. If there is no ROI, check with the client about sharing confidential information, and have the client sign a ROI. NOT: Allow the client to update the parents, if desired. Before asking the client to update parents, check if the client wishes to speak to the parents. An adult client may choose not to communicate current health issues with family. Transferring a call without permission may be considered an invasion of privacy. Give the location within the hospital and condition. Giving the parents condition and location is HIPAA compliant, unless the client is "confidential". In either case, the nurse should start with verifying the ROI prior to answering the parents. Refer the parents to the health care provider (HCP). The HCP adheres to the same HIPAA privacy rules as the nurse. The HCP should not reveal personal health information without a ROI.

Legal Abbreviations

The Joint Commission (TJC) created a National Patient Safety Goal detailing a list of prohibited abbreviations for written and verbal communication in all organizations, as these abbreviations have been misinterpreted and resulted in medication errors. A nurse administers medication to a client on the medical unit. Which prescription does the nurse clarify with the health care provider? Metoprolol 25 mg PO QD The abbreviation QD (daily) is on the list of prohibited abbreviations created by The Joint Commission. QD and q.d. can be mistaken for QID, which is an abbreviation for four times daily. NOT: Zofran 4 mg IV Q6h PRN nausea IV (intravenous) and PRN (as needed) are both acceptable abbreviations, and the prescription is written correctly. Aspirin 325 mg PO BID The abbreviations PO (by mouth) and BID (two times daily) are acceptable, and the prescription is written properly. Glycopyrrolate 0.4 mg IM once The abbreviation IM (intramuscular) is acceptable to use, and the prescription is written appropriately.

Omnibus Reconciliation Act of 1986

The Omnibus Reconciliation Act of 1986 requires that all hospitals participating in Medicare and Medicaid programs refer all potential organ donors to their local organ procurement organization (OPO). It further mandates that all families of potential organ donors become aware of their option to donate. In addition, legislation further requires all hospitals to discuss organ donation with families of deceased patients. Hospitals are mandated to establish protocols for identifying potential tissue and organ donors. The nurse cares for a client with a poor prognosis after suffering brain damage from a motor vehicle accident. Which statement is true regarding information required due to the Omnibus Reconciliation Act of 1986? The family should be notified and provided options related to potential for organ and tissue donation. The Omnibus Act mandates that all hospitals establish protocols for identifying potential tissue and organ donors and that families are provided information. NOT: The nurse is required to contact the medical examiner for determination of organ donor potential. The medical examiner is notified if directly involved in care or after death and has no role in organ donation determination. The family should be informed of the need to make a decision quickly regarding organ donation. The Omnibus Act has no guidelines related to time frame for a family to make a decision related to organ donation. The provider should contact the organ donation organization within two hours of death for viable donation options. The Omnibus Act has no guidelines related to time necessary for notification of organ donation.

Physician Order for Life-Sustaining Treatment (POLST)

The Physician Orders for Life-Sustaining Treatment (POLST) form translates goals of care into actionable orders that can be implemented universally at all health care facilities. The POLST form is not federally mandated; rather, it is regulated and designed on a state by state basis. The POLST form provides information on medical wishes for the client but does not provide information on who the client chooses to make health care decisions for the client; this is generally reserved for a durable power of attorney. A nurse provides end-of-life care to a client with terminal cancer. When teaching the client and client's family member on the use of the Physician Orders for Life Sustaining Treatment (POLST) form, what does the nurse include in the teaching? "It is used across all health care settings." The POLST form is designed to be used across all settings of health care in order to ensure the client's wishes are maintained among all facilities and providers. NOT: "It is used for emergency medical responders only." The Physician Orders for Life-Sustaining Treatment (POLST) form is used across all settings care in order to make sure that the client's wishes are maintained, regardless of the setting. "It states who can make health care decisions for you." A durable power of attorney provides information on who can make health care decisions for the client, not the POLST form. "It is a federally mandated self-determination form." The POLST form is not federally mandated; rather, the form is developed on a state by state basis.

Professional Boundaries

The client can be encouraged to access appropriate supports once discharged after the nurse addresses professional boundary education. The nurse cannot extend the professional relationship into the personal life and should inform the client for future interactions with other health care professionals. A nurse prepares a client for discharge. The client asks for the nurse's personal email address, saying, "Talking with you helps me." What is the best response by the nurse? Remind the client that social contact is not allowed. As part of nursing ethics, professional boundaries for communication mean that any communication should be for the purpose of delivering client care. NOT: Tell the client it is illegal to give this information. Though it is unethical for the nurse to have social contact with a client, it is not illegal. Offer the client information on support groups. This response does not address the client's request; the nurse should take this opportunity to explain the boundaries of the nurse-client relationship. Provide the address with limits on the communication. Providing the client with the address exceeds the boundaries of the nurse-client relationship. Client safety is the nurse's first priority. Professional sexual misconduct is a criminal offense. As a mandated reporter, the nurse must document and report this situation to the hospital and to the required authorities in their jurisdiction. A client in a mental health facility cannot reliably provide consent for sexual conduct as the client-staff dynamic places the client in a vulnerable position. All health care providers are responsible for maintaining appropriate boundaries to avoid sexual misconduct with both current and former clients. When entering a client room on a mental health unit, the nurse witnesses kissing between the client and staff member. The client immediately requests the nurse not divulge this information. Which is the best response by the nurse? Report the staff member's behavior to the appropriate authorities. The nurse is a mandated reporter and must report this behavior as professional sexual misconduct. NOT: Reassign the staff member to a separate unit until the client is discharged. Reassigning the staff member to a separate unit does not address the issue of misconduct and does not guarantee client safety. Remind the client and staff member to maintain appropriate boundaries. Reminding the client and staff member of appropriate boundaries does not guarantee client safety. Document the incident as consensual in the client's electronic health record. Because a client on a mental health unit has a vulnerable relationship with staff, true consent cannot be reliably obtained. Regardless, boundaries must be maintained.

Impaired health care worker

The impaired health care worker poses a risk to self, clients, and other staff members. When suspected, the health care worker should be confronted in a private setting and questioned regarding the suspected abuse. The worker will often deny the allegation. The charge nurse should contact the supervisor, and a drug screen may be requested if the worker denies the allegation and the charge nurse believes the employee to be impaired. The worker should be sent home pending further investigation. A charge nurse helps an unlicensed assistive personnel with transferring a client from bed to chair. The charge nurse smells alcohol and notes the assistant is slurring words during conversation with the client. Which actions does the charge nurse take? Select All That Apply Take the unlicensed assistive personnel to a private location and and ask about the reason for the alcohol odor and slurred speech. This provides privacy for the unlicensed assistive personnel to keep from "shaming" in front of clients or other staff. Instruct the unlicensed assistive personnel to report off to another staff member and go home for the remainder of the day. The charge nurse has reason to think the unlicensed assistive personnel is impaired and cannot allow continued UAP-client interaction. If there are additional staff to escalate the situation to, that can be done. This would include the nursing supervisor or unit nurse manager. Report the findings and concerns to the nursing supervisor on duty for the current shift. The supervisor needs to be informed of the unlicensed assistive personnel intoxication, results of confrontation, and that the assistant was sent home. NOT: Instruct the unlicensed assistive personnel to report to the emergency department for treatment of alcohol abuse. There is no indication the assistant needs to be treated for alcohol abuse, just is intoxicated. Assign the unlicensed assistive personnel to non-client care activities for the remainder of the scheduled shift. An intoxicated employee poses a threat to staff and clients and should not remain on duty.

Lateral Violence

The nurse has an opportunity to model supportive behavior for the colleague and address this example of lateral violence. The American Nurses Association defines "lateral violence" as "overt or covert acts of verbal or nonverbal aggression that occur between colleagues. Gossiping about the new graduate's performance and predicting failure is a covert act of verbal aggression that the nurse should address in a constructive manner. A nurse is with a group of colleagues discussing a new graduate's performance when one states, "She will last one week on this unit if she's lucky." How does the nurse respond? "What do you think we can do to help her be successful?" The nurse should respond by modeling behavior that is required of nurses in supporting new graduates. NOT: "You should be supportive of new graduates rather than critical." Dictating behavior to the colleague is not the best action by the nurse. Instead, modeling supportive behavior is preferable. "You have to report any unsafe practice you have witnessed to a manager." There is no indication that there have been incidents of unsafe practice by the new graduate. "If you feel she is not doing well, you should speak to her directly." Given the colleague's unsupportive position, it would not be advised that the nurse tell the colleague to speak directly to the new graduate.

Client beliefs

The nurse has no reason to deny the client's request and this honors the client's belief system. The nurse might further explain that the client cannot have anything by mouth without approval or provide any other restrictions. Hospital environments are not limited to medical treatments and are a place for providing anything that assists the client to heal physically and mentally within reasonable and safe parameters. The community healer can visit the client regardless of official status as "clergy". The visit should not be delayed. The client may not reach a stable condition and having access to the personal healer can be important to healing and progress or to peace of mind and acceptance of physical decline, should that occur. A client is in unstable condition in the intensive care unit. The client requests that the community healer be allowed to visit. How does the nurse respond to this request? Allow the visit from the community healer within the parameters of the visitation policy. The nurse cannot forbid the community healer from visiting the client. NOT: Contact the risk management team for guidance regarding the definition of clergy. "Clergy" is not left to the nurse to define. The nurse advocates for the client by supporting their spiritual needs. Explain that only conventional medical treatment is allowed in the hospital setting. This is an untrue statement. The nurse and health care provider do need to ensure that medical and complimentary therapies can be safely combined. Document that the client would like a visit from personal clergy once in stable condition. Spiritual support is often most needed when the client is not in stable condition. Waiting until the client is stable may never happen or may result in client distress related to unmet spiritual needs.

Priority interventions

The nurse should immediately assess the client to make sure they are safe. An older client has a higher risk of falling and the nurse must assess that the client is safe and not injured in any way. After assessing the client, the nurse must raise the bed rails to prevent any falls and ensure the safety of the client. After making sure the client is safe the nurse must document the situation. Reporting the incident to the nursing supervisor will help staff identify areas that need improvement and reinforcement. Hospitals are responsible for the safety of clients and policies and practices must continually be evaluated. Bed rails must always be raised on a client's bed to ensure their safety, especially older clients who are fall risks. It is important for a nurse to document any unsafe situation such as noncompliance with bed rails and report it to the nurse manager. Documentation is an important way of documenting quality. A nurse begins the shift and finds the bed rails of an older adult client are lowered. In what order does the nurse respond? (Place each option in order, from first priority to last.) Correct Answer Assess the client. Raise the bed rails. Document the situation. Report event to supervisor.

Marijuana

The nurse should strive to maintain a trusting nurse-client relationship. Confronting or making demands in a situation where the client is breaking or not following hospital policy could damage the nurse-client relationship. Security should be notified in situations that may lead to violence, which could result in client or staff injury. Security guards are specially trained for situations like this, and they should be left to approach the client about surrendering the drug. Use of marijuana, although legal in some states, still needs to be communicated to the provider due to its potential interactions with other prescribed medications or treatments. If appropriate, the provider may provide a prescription for its use. A nurse receives report on a client who is two days post-orthopedic surgery. When entering the room for initial assessment, the client exits the bathroom and gets into bed. The nurse smells a potent odor believed to be marijuana. Which actions does the nurse take? Select All That Apply Educate the client regarding effects of marijuana. It is appropriate for the nurse to educate the client regarding effects of marijuana, providing factual information. Contact security and inform them of the situation. Security personnel are trained for dealing with situations where the client may become defensive, and they should be notified of the situation. Contact the client's health care provider. The nurse should notify the primary health care provider due to the impact it could have on the client's health or interaction with other medications prescribed. NOT: Instruct the client to flush the marijuana in the toilet. This is not appropriate, as it could cause the client to become defensive and place the nurse in danger. Contact the client's family regarding use of marijuana. This would be a violation of the client's privacy.

Paternalism

The nurse's provision of care is guided by ethical principles. It is important to understand these principles and to evaluate one's own beliefs related to maintaining them. The major principles nurses should be familiar with are accountability, advocacy, autonomy, beneficence, nonmaleficence, responsibility, and veracity. Other ethical issues to consider are paternalism, being a "good samaritan," justice, fidelity, and confidentiality. Paternalism can be viewed in contrast to autonomy. It is appropriate under certain circumstances, such as the client's sudden loss of consciousness in an emergency. A graduate nurse reviews ethical principles with the preceptor assigned to assist with orientation. The nurse uses which scenario to explain the principle of paternalism to the graduate nurse? The nurse is working in the emergency department and makes decisions for care in the best interest of a client who is admitted with traumatic injuries from a motor vehicle accident. This is a description of the principle of paternalism. Paternalism occurs when a nurse or physician takes it upon themselves to make a decision on behalf of their patient, whereas autonomy respects the patient's right to make their own decisions. NOT: The nurse is traveling by car to work and witnesses a motor vehicle accident and stops to provide assistance to the victims while waiting for emergency personnel to arrive. This is a description of the nurse adhering to the Good Samaritan Rule. Nurses acting as a Good Samaritan are protected when providing emergency care at the scene of a disaster, emergency, or accident. The nurse stops at a convenience store on the way to work and witnesses a shooting from a robbery. The nurse calls 911 and waits for emergency personnel to arrive. This is a description of the principle of beneficence. Beneficence is acting in the best interest of the client. Veracity is the responsibility of the nurse to be truthful. The nurse speaks with the family regarding the nature of the client's injury and informs them that the provider will establish prognosis after the client is stabilized. This is a description of the principle of veracity. Veracity is adhering to the truth or facts.

Acetaminophen (Tylenol)

The nurse's responsibility is to always question a medication order if it does not look correct. There should always be a route included in a medication order in addition to the name of medication, dose, and frequency of administration. Acetaminophen has a maximum daily dose of 4,000 mg, and 6 doses of 1,200 mg is well over this liver-safe limit. Even electronic prescribing systems can allow errors such as typing in an incorrect dose but choosing the intended frequency from a drop-down menu. A nurse checks the prescriptions in the computer for a newly admitted client. The nurse notices that PRN acetaminophen 1,200 mg every 4 hours is prescribed. What is the nurse's best action? Contact the prescribing health care provider. The order for 1,200 mg of acetaminophen is a large dose and should be questioned by the nurse. There is also no route indicated in the order and the nurse needs further clarification on the order before administering. NOT: Change the prescription to an acceptable dose. A nurse is legally not able to change a medication dose. If a nurse suspects a medication order is incorrect, then it is their responsibility to contact the prescribing health care povider for further clarification. Contact the nursing supervisor for instructions. It would not be appropriate to contact the nursing supervisor in this situation. The best response from the nurse is to contact the prescribing health care provider and question the order. Administer the medication as prescribed. The order is for a large dose of acetaminophen. While it may be the correct order for the medication, it is a dose that it is not commonly administered, and it is the responsibility of the nurse to question the dose before administering it.

Near miss

The precepting nurse has the responsibility to ensure client safety by bringing this situation to the new nurse's attention, the charge nurse's attention, as well as documenting the near miss in an incident report. Incident reporting is not intended to assign blame but to allow nursing leadership to identify and resolve processes that lead to errors and near misses. The risk manager will need the first nurse's objective account when investigating the cause of this incident. A nurse precepting a newly hired nurse enters a client room to observe medication administration. The precepting nurse notes the newly hired nurse has prepared a medication prescribed for the client in the room next door. After discreetly alerting the nurse to hold the medication, the newly hired nurse quickly exits the room. Which additional actions does the precepting nurse take? Select All That Apply Alert the charge nurse to the potential risk for client injury related to the new nurse's behavior. The charge nurse should be aware of potential errors in client care and is responsible for providing continued follow-up for safe client care. Assist the new nurse in completing an incident report in the facility's incident reporting system. This is a near miss. There required to be reported utilizing the facility's incident reporting system. Take the new nurse to a private location and discuss the incident and ways to prevent future error. The nurse should have the incident brought to her attention in private in order to determine potential causes of the error and plans to prevent future occurrence. NOT: Inform the client that the nurse was about to administer an incorrect medication. There is no need to notify the client of the near miss since there was no harm and will diminish the new nurse's credibility with the client. Discuss the new nurse's incompetence during the next scheduled staff meeting. Discussing the new nurse's error diminishes credibility and harms the nurse's reputation.