RNSG 1125 Exam 2
Incident Reporting
-Tools used to document anything out of the ordinary that has the potential to cause harm to a patient, employee, or visitor. -Not used for disciplinary purposes but for quality control to see if the event could be prevented from occurring again. To identify risk. -Should NEVER be noted in the official patient chart
Incident Report Includes
-Names of all involved -Names of witnesses -Complete facts of the incident -Date, time, and place of incident -Characteristics of the person involved (alert, ambulatory, asleep, etc.) -Any equipment involved -Any resources used
Nursing Competencies: Personal Attributes
-Open minded -A profound sense of the value of the person -Self-awareness and knowledge of own beliefs -Sense of personal responsibility for your actions -Motivation to do what you need to do to the best of your ability because you care about the well-being of those entrusted to your care -Leadership skills -Bravery to "question the system"
Advocacy
-Protection and support of another's rights. Promoting dignity and well-being. -Make sure your loyalty to your employer does not compromise your primary commitment to your patient.
HIPPA rights of patients
-To see a copy of health record -To update their health record -To request correction of any mistakes -To get list of disclosures a health care institution has made independent of disclosures made for treatment, payment, and health care operations -To request a restriction on specific uses or disclosures -To choose how to receive health information
Charting by exception
-Use of predetermined standards and norms to record only significant assessment data -Charting only abnormalities is not always sufficient for negligence claims. -Make sure you are also documenting narratives for patient -Do end of shift report
Ethics Committee: Focus
-clinical ethics -organizational ethics -provide different views
The role of the nurse in discharge planning process?
-educate the patient and family members during ADMISSION -communicate with the patient and family throughout the patients hospitalization -document and complete patients final discharge per HCP
Ethics Committee: Chief function
-education -policy making -case review -consultation -research
Developing a Plan of Care
-Establish priorities -Identify and write expected outcomes -Select evidence-based-nursing interventions -Communicate the nursing care plan -Apply standards of care
Medical Errors: Common types
-Inappropriate prescribing of drug -Incorrect dose, quantity, route, or inadequate instructions -Extra, omitted, or wrong dose -Give medication not ordered -Wrong time -Incorrect preparations -Improper technique -Giving deteriorated drug
What steps do you want to follow prior to calling the physician?
- have I assessed the patient myself? - has the situation been discussed with the nursing coordinator or RRT? - review chart for appropriate physician to call - know the admitting diagnosis and date of admission have I read the most recent MD progress notes and notes from nurses who worked the shift ahead of me?
What should you have available when speaking with the physician?
- patient's chart - list of current meds, allergies, IV fluids, & labs - most recent vital signs - reporting lab results: provide the date and time test was done and results of previous tests for comparison - code status
Background
- pertinent information r/t the situation - admitting diagnosis, date of admission - current meds, allergies, IV fluids, labs - most recent vital signs - lab results: provide last results for comparison - other clinical info - code status
Situation
- what is situation? - identify self, unit, patient, room number - briefly state problem, what is it, when it happened or started, and how severe
Proper Documentation: Medication Errors
-Make good habits -Technology does not replace critical thinking, purposeful actions, and repeated checking for accuracy -Must be prompt -Check patient condition immediately looking for adverse effects -Notify charge nurse and MD -Describe error in medical record of the patient -Describe remedial steps that are taken -Complete incident report
Proper Documentation: Format
-Make sure you are in the correct chart -Proper form/screen -Paper charts print legibly and in black ink using correct grammar, terminology, and spelling -Draw a single line for errors -Do not leave spaces between lines
Proper Documentation: Accountability
-Must have your first name, last name, and title on each entry -Each page should have the patient's name and DOB -Recognize that this is a legal document and is permanent -DO NOT chart something you did not do -DO NOT use dittos, erasures, or correction fluids
It is an ethical dilemma when:
-A review of scientific data is not enough to solve it -It involves a conflict between two moral imperatives -The answer will have a profound effect on the situation and the client
Proper Documentation: Timing
-Agency policy to be done in timely manner -Date and time with pertinent information -Use military time -Chart as close to time as the intervention (try to avoid back charting) -Never chart before doing intervention
Nursing Roles and Responsibilities
-Caregiver -Advocate -Teacher/Educator -Communicator -Leader -Counselor -Researcher -Collaborator
Nursing Competencies: Evidence-based Practice
-Cognitive -Technical -Interpersonal -Ethical/Legal The ability to use these creatively and critically when working with the patient to restore health. We must develop critical thinking skills meaning being able to make a judgement about a particular patient or situation or how best to intervene.
Proper Documentation: Content
-Complete, accurate, concise, and factual -No interpretations, actual findings only -No generalizations like "good" -Problems in order of sequence -Any precautions or preventions -MD response to questionable orders (time, date, facts)
Which element of transition management emphasizes acting as the "voice" for patients?
Advocacy
Health Information and Privacy
All information regarding a patient is considered confidential, this includes: -Patient Name -Address -Telephone number -Email address -Social Security Number -Treatments patient receives -Past health history
Patient Confidentiality
All patients have a right to privacy and all information should remain privileged. Discuss patient information only with the patient's physician or office personnel that need certain information to do their job. Obtain a signed consent form to release medical information to the insurance company or other individual.
The Nursing Process ADPIE
Assess-Diagnose-Plan-Implement-Evaluate -Individualize care that maximizes outcome achievement -Set priorities -Facilitate communication amongst nursing personal -Promote continuity of high-quality, cost-effective care -Coordinate care -Evaluate the patient's response to care -Create a record that can be used for evaluation, research, reimbursement, and legal purposes -Promote nurse's professional development
What info do you provide during A or SBAR?
Assessment: - What I think the problem is... - seems to be - not sure - unstable, may get worse
What info do you provide during B or SBAR? (8)
Background: - allergies - pertinent health history - meds - labs - transportation needs: stretcher, wheelchair... - communication: hearing, vision, language - patient's mental status - O2
Ethics committee
Committee made up of individuals who are involved in a patient's care, including health care practitioners, family members, clergy, and others, with the purpose of reviewing ethical issues in difficult cases
Interpersonal communication
Communication between two people. A sender and a receiver and a message in between.
What should a nurse do following an SBAR conversation with a physician?
Document! - changes in pt condition & physician notification
What is the goal of care coordination and transition management?
Enhance patient's quality of life
HIPPA Authorization Rule
Items allowed to be disclosed without prior authorization from the patient. Otherwise, if health facility wants to release PHI for treatment, payment, or routine health care purposes, the patient must sign an authorization.
Admission
Nurse responsible for ensuring patient safety, comfort, and wellbeing upon arrival. We set up the room for patient needs. We welcome that patient to the room as they arrive. Introduce ourselves and explain what is about to happen: -Medication reconciliation (last dose taken) -Valuables & belongings -Admission questionnaire (smoke, alcohol, flu shot) -Ask about advanced directive -Head to toe assessment -Confirm ID bands -Allergies -Code status REMEMBER WE ARE ASSESSING FOR DISCHARGE NEEDS
Patient leaving AMA
Patient has the right to leave at any time. They must be education on the complications and consequences of leraving AMA and if they still want to go they must first sign papers and get IV removed before leaving. This released the hospital and MD of any liability. If they have insurance, the insurance company WILL NOT pay for readmission.
What info do you provide during R or SBAR?
Recommendation: - special treatments/tests? - special needs when off unit? - need nurse for procedure or transport? - get orders from physician - get specific info regarding orders: - how often check vitals? - how long do you expect this to last? - if pt does not improve when would you want me to call again?
Examples of client advocacy include:
Representing the client's needs and wishes to other healthcare professionals. Helping clients exercise their rights.
When calling the physician, what process do you want to follow?
SBAR process
Intrapersonal communication
Self-talk. Analyze, be thinking what I can do better for this patient. What could I have done?
Proper Documentation: Progress notes (narrative)
Should be written for: -Admission, transfer, discharge -When a procedure is performed -Upon receiving a patient post-op/post-procedural -Change in patient status
SBAR stands for?
Situation Background Assessment Recommendation
What info do you provide during S or SBAR? (7)
Situation: - name - age - diagnosis - surgical treatment / interventions - code status - vitals - concerned about...
Discharge planning
Starts at admission! We as care coordinators start this process. Begins with first assessment of patient. Finding out health history and home environment. Their strengths and weaknesses. We education patients and families using teach back method for home care for their diagnosis.
Care transition
The movement patients make between health care practitioners and settings as their condition and care need to change during the course of an illness. The goal is to avoid complications and readmissions.
When does discharge planning begin?
Upon admission
Focused charting
Used for narratives. It can include patients' strength, problem, or need. Focus on the patient's needs, what we did for that need, and the response: -patient concerns, behaviors, therapies, changes in condition -significant events such as teaching, consultations, monitoring, ADLs management, assessment of functional health problems Narrative Format Examples: DAR= Data-Action-Response PIE= Problem-Intervention-Evaluation SOAP=Subjective data-Objective data-Assessment-Plan
Care coordination
Using the nursing process to develop a plan of care for the patient using interdisciplinary care teams working together to achieve optimal health for the patient.
Therapeutic communication
Verbal and nonverbal communication techniques that encourage patients to express their feelings and to achieve a positive relationship.
Veracity
a commitment to tell the truth
A client with diabetes also has hypertension. The nurse would expect that the blood pressure goal for the client would be which of the following? a. 130/80 mm Hg b. 140/90 mm Hg c. 150/100 mm Hg d. 100/70 mm Hg
a.
A current trend in health education that significantly influences nursing practice is: a. Increased emphasis on patient involvement in their own care. b. Improved distribution of health information materials. c. Increased numbers of health care providers. d. Increased emphasis on the diversity of patient needs.
a.
A nurse is discussing a lumbar puncture with a nursing student who observed the procedure. The student noticed that the cerebrospinal fluid was blood tinged and asked what that meant. The correct reply is which of the following? a. "It can mean a traumatic puncture or a subarachnoid bleed." b. "It can mean a bleed around the hypothalamus or damage from the needle." c. "It can mean the spinal cord was damaged or a traumatic puncture." d. "It can mean a subarachnoid bleed or damage to the spinal cord."
a.
A pregnant client has received results of genetic testing that show the fetus has trisomy 13. The health care provider has discussed options for care, including termination of the pregnancy. How does the nurse best respond to support this family's decision-making? a. "Can you tell me about your beliefs and values related to this decision?" b. "Would you like to meet other families who have a child with trisomy 13?" c. "I can refer you to pastoral care for help in making this decision." d. "How do you feel about your ability to care for a child with an impairment?"
a.
Priority setting is based on the information obtained during reassessment and is used to rank nursing diagnoses. Each factor contributes to priority setting except which? a. Finances of the client b. The client's condition c. Time and resources d. Feedback from the family
a.
The nurse hears an unlicensed assistive personnel (UAP) discussing a client's allergic reaction to a medication with another UAP in the cafeteria. What is the priority nursing action? a. Remind the UAP about the client's right to privacy. b. Report the UAP to the nurse manager. c. Notify the client relations department about the breach of privacy. d. Document the UAP's conversation.
a.
The nurse is assessing a 35-year-old woman at 22 weeks' gestation who has had recent laboratory work. The nurse notes fasting blood glucose 146 mg/dl (8.10 mmol/L), hemoglobin 13 g/dl (130 g/L), and hematocrit 37% (0.37). Based on these results, which instruction should the nurse prioritize? a. Check blood sugar levels daily. b. the signs and symptoms of urinary tract infection c. Include iron-enriched foods in the diet. d. Take daily iron supplements.
a.
The nurse is providing care to a woman who has just given birth to a healthy term neonate. The woman's partner arrives and asks about the neonate's status. Which action by the nurse would be appropriate? a. Check the medical record for written client approval with whom to share information. b. Ask the partner for identification first before sharing any information. c. Answer the partner's questions honestly and without hesitation. d. Tell the partner that no information can be shared with him or her at this time.
a.
The nurse is providing care to several clients. In which situation would the nurse be able to accept a verbal order from the healthcare provider? a. The client is hemorrhaging from a surgical wound. b. The client has just been admitted to the unit from the emergency department. c. The client reports new onset headache and has a blood pressure of 90/50 mm Hg. d. The client is being transported to the cardiac catheterization department.
a.
The nurse managers of a home healthcare office wish to maximize nurses' freedom to characterize and record client conditions and situations in the nurses' own terms. Which documentation format is most likely to promote this goal? a. narrative notes b. SOAP notes c. focus charting d. charting by exception
a.
Which are the benefits of care coordination?
a. Improved quality of care b. Improved clinical outcomes c. Reductions in number of emergency department visits
The nurse is writing a medication order that a health care provider provided by telephone. Which should be included when writing the order? Select all that apply a. date the order is written b. code status c. medication dosage d. client allergies e. route of administration f. medication ordered
a. c. e. f.
The client refuses to wear a name band on the arm during the hospital stay. The client is scheduled for surgery. What actions will the nurse take to ensure safe client identification? Select all that apply a. Explain the need to have an identification name band. b. Alert the operative suite about the client's refusal to wear a name band. c. Attach the name band to the client's gown with tape. d. Apply the name band to the client's leg. e. Send the name band to the operative suite with the medical record.
a. d.
Beneficence
action that promotes good for others, without any self-interest
what is SBAR utilized as?
an off unit hand off / report tool
A client asks to be discharged from the healthcare facility against medical advice (AMA). What should the nurse do first? a. Prevent the client from leaving. b. Notify the physician. c. Have the client sign an AMA form. d. Call a security guard to help detain the client.
b.
A client is 2 days post small bowel resection with a placement of an ostomy in the right lower quadrant. The nurse is teaching the client to apply an ostomy appliance to the client's abdomen. Which client action would indicate to the nurse that the teaching was successful? a. The client trims the faceplate opening giving the stoma a 1-inch (2.5 cm) border around the stoma. b. The client assesses the stoma and the surrounding skin before placing the new appliance. c. The client chooses an antibacterial soap to scrub the fecal material around the stoma. d. The client states that the faceplate should be changed every other day.
b.
A client is diagnosed with scabies in a long-term care facility. Which type of client care precautions would the nurse institute? a. Strict b. Contact c. Respiratory d. Enteric
b.
A nurse is assisting in developing a teaching plan for a client who is about to enter the third trimester of pregnancy. The teaching plan should note which symptom should be reported immediately? a. hemorrhoids b. blurred vision c. dyspnea on exertion d. increased vaginal mucus
b.
A nurse records a client's fingerstick blood glucose level and gives 2 units of regular insulin as ordered. At the next scheduled blood glucose assessment, the nurse realizes that the wrong client was tested and given insulin. What is the nurse's priority action related to this incident? a. Explain the error to the client, and document it in the client's chart. b. Assess both clients, and call the appropriate healthcare providers to notify them of the errors. c. Recheck blood glucose levels, and then determine whether the healthcare providers need to be notified. d. Notify the charge nurse of the error, and document it in the client's chart.
b.
Before administering an immunization to their child, the nurse asks parents to take which priority action? a. Reassure the child. b. Sign a consent form. c. Provide the child's immunization record. d. Assist in restraining the child.
b.
Besides being an instrument of continuous client care, the client's health care record also serves as a(an): a. assessment tool. b. legal document. c. Kardex. d. incident report.
b.
The nurse is updating the records of a 10-year-old girl who had her appendix removed. Which action could jeopardize the privacy of the child's medical records? a. Changing identification and passwords monthly. b. Letting another nurse use the nurse's log-in session. c. Closing files before stepping away from computer. d. Printing out confidential information for transmittal.
b.
Which of the following would a nurse least likely assess in a client experiencing anxiety? a. Sleeping difficulties b. Positive self-talk c. Irritability d. Muscle tension
b.
A client believes that restoring optimal health takes more than treating the body; the client believes that the mind and spirit must be addressed as well. What is this perspective of health? a. Wellness b. Equilibrium c. Holism d. Balance of body
c.
A client living alone has a degenerative joint disease, hypertension, and neuropathy. It is difficult for the client to bathe, and the client's blood pressure is unstable. Which type of care would this client benefit from most? a. Acute care b. Ambulatory care c. Home care d. Respite care
c.
A client taking furosemide and digoxin for exacerbation of heart failure reports weakness and heart fluttering. What would be the priority action by the nurse? a. Tell the client to rest more often to decrease symptoms. b. Tell the client to stop taking the digoxin and to stop all physical activity. c. Investigate the symptoms further with the client and suggest contacting the physician. d. Offer the client clear instructions about avoiding foods that contain caffeine.
c.
A nurse assessing a client who underwent cardiac catheterization finds the client lying flat on the bed. The client's temperature is 99.8° F (37.7° C). Their blood pressure is 104/68 mm Hg. Their pulse rate is 76 beats/minute. The nurse assesses the limb and detects weak pulses in the leg distal to the puncture site. Skin on the leg is cool to the touch. The puncture site is dry, but swollen. What is the most appropriate action for the nurse to take? a. Document the findings and recheck the client in 1 hour. b. Slow the I.V. fluid to prevent any more swelling at the puncture site. c. Contact the physician and report the findings. d. Encourage the client to perform isometric leg exercise to improve circulation in the legs.
c.
A nurse is caring for a client with end-stage heart failure. Which statement by the client best demonstrates a good understanding of an advance directive? a. "An advance directive gives my family members permission to make decisions about my care needs." b. "An advance directive identifies the people I want to receive items from my estate once I pass away." c. "An advance directive allows my decisions for health care to be known if I cannot speak for myself." d. "An advance directive will allow my daughter to use my funds to pay for my health care costs if I cannot do so."
c.
A nurse is educating a client who is at risk for coronary artery disease (CAD). The nurse knows that the teaching has been successful when the client states that the risk factors that can be controlled or modified include: a. gender, family history, and older age. b. inactivity, stress, gender, and smoking. c. obesity, inactivity, diet, and smoking. d. stress, family history, and obesity.
c.
A registered nurse is providing community-based health care for a client diagnosed with early-onset dementia. Which strategy is best for the nurse to use to facilitate the family's participation in the client's care? a. Reinforce the care plan to the family if it is determined that the client is not properly cared for. b. Provide referrals for health care professionals to perform the client's activities of daily living (ADLs). c. Encourage active participation of the client and family in health care decisions. d. Create a care plan based on the client's requests and inform the family of the client's wishes.
c.
For individuals known to be dying by virtue of age and/or diagnosis, which sign indicates approaching death? a. Increased wakefulness b. Increased eating c. Increased restlessness d. Increased urinary output
c.
On admission to the hospital, each client is asked whether the client has a living will or a durable power of attorney. If not, the admitting staff person provides a sample form to the client if wanted. The purpose of this inquiry is to determine: a. what the client wants to have to happen during the hospitalization. b. how the client feels about being resuscitated and maintained on life support if this is necessary. c. whether the client has a document describing wishes for care when the client is no longer able to make decisions. d. previous decisions made regarding whom to contact should the client die in the hospital.
c.
The depressed client is deciding which type of treatment would be beneficial. The nurse would document that the client is utilizing which ethical principle in this situation? a. Justice b. Beneficence c. Autonomy d. Veracity
c.
The nurse is discussing life management with the client with rheumatoid arthritis in a health clinic. What assessment finding indicates the client is having difficulty implementing self-care? a. ability to perform activities of daily living (ADL) b. decreased joint pain c. increased fatigue d. a weight gain of 2 pounds
c.
The nurse working in the recovery room is caring for a client who had a radical neck dissection. The nurse notices that the client makes a coarse, high-pitched sound upon inspiration. Which intervention by the nurse is appropriate? a. Document the presence of stridor b. Administer a breathing treatment c. Notify the physician d. Lower the head of the bed
c.
Which is a factor that contributes to urinary incontinence in older female adults? a. Decreased urinary residual b. Increased bladder capacity c. Relaxed perineal muscle d. Detrusor stability
c.
Advocacy
can be defined as protecting by expressing and defending the cause of another. Thes ANA key concept. Client advocacy is a primary role of the nurse.
Nonverbal communication
communication using body movements, gestures, and facial expressions rather than speech
A client is receiving home health services after having a stroke and being hospitalized. After a thorough assessment of the home environment and the client, what would indicate to the nurse that there is an impairment in the client's home management? a. The client reports having slipped in the restroom the first night in the hospital. b. The client refuses to allow the caregiver to help the client sit up in bed. c. The home care nurse has to reschedule an appointment with the client. d. The client's caregiver is absent whenever the nurse visits and the client is alone.
d.
A mentally incapacitated client is scheduled for surgery. Considering the principle of autonomy, who should give consent for surgery? a. client b. operating surgeon c. attending nurse d. surrogate decision maker
d.
A nurse administers pain medication to clients on a med-surg ward. The client that would benefit from a PRN drug regimen as an effective method of pain control would be the client: a. experiencing acute pain. b. in the early postoperative period. c. experiencing chronic pain. d. in the postoperative stage with occasional pain.
d.
A nurse is caring for a client with bruises on her face and arms. Her partner refuses to leave the client's bedside and answers all of the questions for the client. Which intervention by the nurse would be most appropriate? a. Tell the partner that to leave because the partner is intimidating the client. b. Question the woman in front of her partner. c. Contact hospital security to escort the partner from the hospital. d. Collaborate with the physician to make a referral to social services.
d.
Older adults, who are more subject to falls, may fracture one or more ribs and be more susceptible to which condition after a rib fracture? a. Confusion b. Asthma attacks c. Bronchospasm d. Pneumonia
d.
Which action would cause a charge nurse to have concerns about a nurse's moral agency? a. The nurse often must stay after shift change to complete documentation. b. A family member complained that the nurse was slow answering call lights. c. The nurse was unable to pass a required dosage calculation examination. d. The nurse was seen at a grocery store after calling in sick.
d.
Non-maleficence
duty to do no harm
What is discharge planning based on?
individual patient needs
Autonomy
right to make one's own decisions.
Assessment
what is the nurse's assessment of the situation?
Recommendations
what is the nurse's recommendation or what does he/she want? - notification that patient has been admitted - patient needs to be seen now - order change