Fundamental of Nursing Ch7: Legal Dimensions of Nursing Practice

What statent made by the nurse providing care to a group of clients indicates that the nurse requires further education regarding negligence?

"I don't need to assess distal pulses on a client after a femoral arteriography."

A nurse hired to work in an ambulatory setting attends new employee orientation. The nurse never worked in ambulatory before and is concerned about the Scope and Standards of Practice for Professional Ambulatory Care Nursing. Which response, given by the nurse educator, would further explain the Scope and Standards of Practice for Professional Care Nursing to the new nurse?

"The Scope and Standards of Practice for Professional Ambulatory Care Nursing deal with the professional obligations of a nurse working in the ambulatory setting."

Explanation: To prevent invasion of privacy, all client information is considered confidential and private; this includes name and all identifiers (e.g., social security number, address, date of birth). With the client's permission, information can be shared with a spouse.

A client should be taken to a private soundproof area to collect data. Unnecessary exposure of a client's body, taking pictures of a client, and questioning a client's social life when it does not affect care planning are examples of invasion of privacy.

A nurse fails to communicate a change in the client's condition to the physician. Which element related to proving malpractice has been met?

Breach of duty

Explanation: The nurse has committed the tort of invasion of privacy. Personal names and identities are concealed or obliterated in case studies or research work. Invasion of privacy is a type of intentional tort.

Defamation is an act in which untrue information harms a person's reputation, and is therefore not applicable here. Negligence is the harm that results because a person did not act reasonably.

common categories of malpractice (cont)

Failure to act as a patient advocate or to follow the chain of command: for example, you are in the operating room and watch a surgeon break the sterile field twice. No one else seems to notice. You are intimidated by this surgeon and fail to bring this to anyone's attention. You learn that the patient developed a serious infection postoperatively.

common categories of malpractice (cont)

Failure to document: for example, you work up the chain of command when your repeated calls to a physician to see a patient that you believe is in danger of arresting are ignored. Before any physician sees the patient, he arrests and, despite a code, dies. You document the arrest, code, and death but fail to document all the steps you took to get the patient the medical attention he needed. Sixteen months later, the family sues and you try to remember what action you took that evening—most of which was never recorded.

Causation

Failure to use appropriate safety measures; this failure causes the patient to fall while attempting to get out of bed, resulting in a fractured left hip

Damages

Fractured left hip, pain and suffering, lengthened hospital stay, and need for rehabilitation

Explanation: Distal pulses should be checked immediately after a femoral arteriography; therefore, the nurse is negligent for checking three hours after the procedure. Fresh fruit may contain bacteria and further compromise a client with neutropenia.

The Allen's test confirms that there is proper circulation to the hand before drawing an ABG. The nurse checks breath sounds at least every 8 hours for adventitious sounds that may indicate aspiration.

A nurse witnesses a traffic accident and dresses the open wounds sustained by a child. Later, in the hospital, the child develops complications from an infection in the wound. The family holds the nurse responsible for the complications and attempts to file a lawsuit. Which of the following statements is true regarding the Good Samaritan law?

The Good Samaritan law will provide legal immunity to the nurse.

When making client rounds, the charge nurse observes which action by a staff nurse that would constitute battery?

The elderly client refuses the intramuscular injection, but the staff nurse administered it.

Explanation: Failing to communicate a change in the client's condition reflects a breach of duty. Duty describes the relationship between the person and the person being sued. Nurses have a duty to care for their clients.

The existence of a duty is rarely an issue in a malpractice suit. The action or lack of action must be proven as the cause of the injury. Damages refer to the injury suffered by the client.

A client is being prepared for an elective surgical procedure and the consent form has not been signed. Who should the nurse have obtain consent for the procedure?

The health care provider performing the surgical procedure

The health care facility is involved in litigation by four clients. When reviewing the cases, which legal case would the nurse attorney identify to best describe malpractice?

The nurse administers amoxicillin (Amicar) to a client with known allergies to penicillin. The client has a seizure with resulting respiratory arrest.

Explanation: All elements of liability are in place for administering amoxicillin to a client with documented allergies to penicillin: the nurse had a duty, but breached it when giving the medication. There also was causation (amoxicillin) and harm (seizures and respiratory arrest).

The nurse is negligent when applying an ice pack without an order. The nurse used proper mechanics, so the client fall is an accident even though harm occurred. Giving the wrong medication could be cause for malpractice, but there was no harm.

Explanation: If a client wishes to go before his medical treatment is finished, he should sign a document indicating personal responsibility for leaving against medical advice. The nurse should not restrain the client, as it would make the nurse liable for legal action.

The nurse may call the physician and get the discharge paper signed, but this is not appropriate. The nurse cannot warn the client that he will be denied health care in future, because it is his right to access the health care facility whenever he needs.

The Joint Commission

can also accredit health care agencies.

The Occupational Safety and Health Act

helps to reduce injuries and illness in the workplace.

Licensure

is granted by the state to a graduate of a nursing education program who passes NCLEX-RN.

Breach of duty

-Failure to note and report that an older adult patient assessed as alert on admission is exhibiting periods of confusion -Failure to execute and document use of appropriate safety measures (e.g., upper and lower bedside rails, use of restraints if necessary, assisted ambulation)

Explanation: The Scope and Standards of Practice for Professional Ambulatory Care Nursing are the standards of care for nurses working in the ambulatory arena.

It does not take precedent over the facility's policies and procedures, but must be worked in conjunction with the policies and procedures. It is not used for assessing nurses. NCLEX determines if a nurse is minimally competent to practice as a nurse.

A client informs the nurse that he wants to discontinue his treatment and go home. Later, the nurse finds the client dressed to leave. Which action should the nurse take in this situation?

Let the client go after signing a document stating he is going against medical advice.

Explanation: The health care institution determines the unit and institutional policies. These policies may vary from institution to institution.

Such policies may include clinical procedures, policies specific to the institution, and personnel and employment policies.

A client is in a persistent vegetative state. The client has no immediate family and is a ward of the state. Under these circumstances, who will speak on this client's behalf?

Surrogate decision maker

A physician is called to see a client with angina. During the visit the physician advises the nurse to decrease the atenolol to 12.5 mg. However, since the physician is late for another visit, she requests that the nurse write down the order for her. What should be the appropriate nursing action in this situation?

The nurse should ask the physician to come back and write the order.

Explanation: The nurse should ask the physician to come back and write down the order. Nurses are discouraged from following any verbal orders, except in an emergency.

The nurse should never write an order on a physician's behalf because this is a wrong practice. The client should be informed about the change of medications, but this is not an appropriate action. The nurse should not leave the work for a later time, because the nurse may forget it.

After reporting to work for a night shift, the nurse learns that the unit will be understaffed because two RNs called out sick. As a result, each nurse on the unit will need to provide care for an additional four acute clients, in addition to her regular client assignment. Which statement is true for this nurse when working in understaffed circumstances?

The nurse will be legally held to the same standards of care as when staffing levels are normal.

Explanation: The claim of being overworked does not constitute a legal defense, and both the potential for liability and standards of care remain unchanged despite an increased client assignment.

While it is prudent to make all realistic attempts to fill the gaps in staffing, documenting these efforts does not change the nurse's legal position. A nurse has the right to refuse an unsafe client assignment but the nurse is not legally obliged to withhold care.

The National Practitioner Data Bank

is a clearinghouse for health care practitioners who engage in unprofessional conduct and restrict them from moving from state to state.

Accreditation

is a voluntary process by which a nursing education program is recognized as having met certain standards by the National League for Nursing Accrediting Commission and/or the American Association of Colleges of Nursing.

Explanation: Certification

is a voluntary process whereby a person who has met criteria established by a nongovernmental association is granted special recognition in a specified practice area.

Malpractice

negligence by professional personne

common categories of malpractice (cont)

• Failure to assess and monitor: for example, you fail to follow your hospital's standards for postoperative assessments after receiving a patient from the operating room and response to a ruptured suture line is delayed • Failure to communicate: for example, you fail to communicate your concerns about an elderly patient being discharged home; she lives alone and is soon rehospitalized because no provisions were made to secure the nursing care she needed after discharge

common categories of malpractice

• Failure to follow standards of care: for example, you fail to follow the standards for administering insulin or other injectable medications • Failure to use equipment in a responsible manner: for example, you attempt to use a bariatric patient lift for the first time without getting help and the patient falls

A living will

is an instructive form of advance directive; that is, it is a written document that identifies a person's preferences regarding medical interventions to use in a terminal condition, irreversible coma, or persistent vegetative state with no hope of recovery.

During the orientation to the hospital, the staff development educator discusses unit and institutional-based policies. What is the source of the practice rules that result in unit and institutional-based policies?

Health care institution

Duty (Liability element)

Hospital staff nurses are responsible for: -Accurate assessment of patients assigned to their care -Alerting responsible health care professionals to changes in a patient's condition -Competent execution of safety measures for patients

An HIV-positive client discovers that his name is published in a research report on HIV care prepared by his nurse. He is hurt and files a lawsuit against her. Which offense has the nurse committed?

Invasion of privacy

A nurse is caring for a client following endotracheal intubation. Before applying soft wrist restraints to prevent the client from pulling out the endotracheal tube, what is the most appropriate action of the nurse?

Obtain a medical order.

The health care provider prescribes orders for a client with newly diagnosed uncontrolled seizure activity. When reviewing the prescriptions, the nurse correctly identifies which prescription, if followed, puts him at risk for negligence charges?

Restrain all four extremities

Explanation: Infants, young children, people who are severely mentally handicapped or incapacitated, and people in a persistent vegetative state or coma do not have the capacity to participate in decision making about their health care. For such people,

a surrogate decision maker must be identified to act on their behalf.

Advance directives

are written statements identifying a competent person's wishes concerning terminal care (and are not applicable here. )

Explanation: The nurse is obligated to carry out health care provider's orders unless it is unclear or incorrect. The client with seizures must be protected from harm. Restraints

restricts the client's movement and can cause harm. Diazepam, oxygen, and frequent neurologic assessments are correct interventions for a client with uncontrolled seizure activity.

A client is brought to the emergency department in an unconscious state with a head injury. The client requires surgery to remove a blood clot. What would be the appropriate nursing intervention in keeping with the policy of informed consent prior to a surgical procedure?

The nurse ensures that the client's family signs the consent form.

Explanation: Obtaining informed consent is the responsibility of the person who will be performing the diagnostic or treatment procedure or the research study.

The nurse's roles are to confirm that a signed consent form is present in the client's chart and to answer any client questions about the consent.

The nurse educator provides an educational session to the nursing staff on protection of a client's privacy. Which circumstances, identified by the staff, would indicate to the educator that the teaching was effective? Select all that apply.

- With the client's permission, the nurse explained the client's diagnosis to the client's spouse. -The nurse removed the client from the emergency department waiting room into a private area to collect assessment data.

Which of the following is an example of certification?

A nurse who demonstrates advanced expertise in a content area of nursing through special testing.

A nurse enters a client's room and finds that the client is lying on the floor. The nurse makes the client comfortable on the bed and completes an examination. She informs the physician and the nursing supervisor about this incident and also completes an incident report. Which action by the nurse indicates correct knowledge of handling an incident report?

The nurse documents a complete description of the happenings in the client's records.

The evening nurse received a change-of-shift report from the day nurse. The day nurses' report states, "The client required intubation for respiratory distress this morning, but has been stable all day." The evening nurse collects the following information during the first assessment: Skin flushed. Client lethargic. Temperature 103.0°F. A review of the client's chart reveals that the client's last assessment was done 7 hours earlier. A review of the findings by the nurse attorney determines which facts might be in place regarding liability? Select all that apply.

Breach of duty has occurred. Explanation: The nurses had a duty to care for the client and breached duty by not assessing the client in 7 hours. No determination of the nurse or facility's response is made until a complete investigation is done.

Explanation: If the client refuses a procedure or medication and the nurse proceeds with it, it is battery. Threatening a client is assault.

Discussing another client within earshot of others is an invasion of privacy. Keeping a client against her wishes, regardless of her health status, is false imprisonment.

Explanation: The Good Samaritan laws provide legal immunity to passersby who provide emergency first aid to victims of accidents. Therefore, the law is applicable to the nurse as well; moreover, the nurse did not accept any compensation for the service provided. The law is equally applicable to everyone, but does not provide absolute exemption from prosecution in cases of negligence.

Paramedics, ambulance personnel, physicians, and nurses who stop to provide assistance are still held to a higher standard of care because they have training above and beyond that of average laypeople. In cases of gross negligence, health care workers may be charged with a criminal offense.

Explanation: The nurse should ensure that the client's family signs the consent form. However, in some states and health care facilities, it is the physician who ensures that the client's family signs the consent form.

The client cannot sign the consent form if he is not in an alert state or is unable to communicate. If the client is not in a condition to the sign the consent, a family member can sign the consent on his behalf.

Explanation: An incident report is a written account of an unusual, potentially injurious event involving a client, employee, or visitor. It is kept separate from the medical record.

The incident report is a legal document and making a copy of it is not advisable. It should not be placed in the client's records; however, the nurse can mention the incident in the client's records without mentioning the incident report.

The American with Disabilities Act

protects people with communicable diseases and those recovering from drug or alcohol addiction.

Explanation: Nurses must obtain a medical order before each and every instance in which they use restraints. Due to the severity of the client illness requiring endotracheal intubation,

the client may not be able to provide a written consent. The client does not need to be sedated unless medically necessary, and although it is appropriate to notify the family, this is not the priority.