Legal/Ethical Questions - PRACTICE NCLEX-RN

The spouse of a client calls the nurse at the clinic and reports that the client is not feeling well and is concerned that something is seriously wrong. How should the nurse respond initially? 1. Ask the spouse to further describe the client's symptoms 2. Indicate that privacy rules prevent discussion of concerns with the spouse 3. Offer a same day appointment to the client 4. Tell the spouse to have the client call the nurse

1 The first step in the nursing process is assessment. In this situation, additional information is needed before the nurse can determine the next course of action (Option 1). (Option 2) The United States' Health Insurance Portability and Accountability Act (HIPAA) and Canada's Personal Information Protection and Electronic Documents Act (PIPEDA) prevent release of private, privileged health care information to people who do not need to know it for a client's care. In this case, the nurse is not releasing any information and is obtaining further information to assess the client's condition. In addition, there is no privacy violation in obtaining information that the spouse would know. (Option 3) Additional information is required before knowing whether the client needs to be seen in the clinic. The client may need instruction to instead call 911 and go to the emergency department. (Option 4) The nurse can ask the client to call, but the client may be unable (eg, seizure, unconscious) or unwilling to do so. In addition, the client may not be aware of signs (eg, acute-onset confusion) that are concerning to the spouse. The situation is unclear (eg, the client may have trouble speaking [ie, stroke symptom]) but may be clarified after the nurse receives additional information from the spouse. Educational objective: The nurse should further assess the situation and gather more information when a spouse calls reporting troublesome symptoms in a client. It is not a violation to obtain information about a client from a knowledgeable source.

A male client has terminal metastatic disease. He arrives at the emergency department with respirations of 6/min and an advance directive indicating to withhold resuscitative efforts. What should the nurse's response be? 1. Apply O2 at 2L by nasal cannula 2. Ask the client if he wants to change his mind 3. Ask the spouse what she wants done 4. Determine who has medical POA

1 Advance directives are prepared by a client prior to the need to indicate the client's wishes. A living will gives instructions about future medical care and treatment if the client is unable to communicate. A medical power of attorney is the individual designated to make health care decisions should a client become unable to make an informed decision. It allows more flexibility to deal with unique situations. Because the client has indicated specific desires, these should be honored. This is especially true as the client has a terminal condition (versus, for example, an acute choking episode that could be easily reversed). Oxygen can provide comfort and is not resuscitative when given by nasal cannula. (Option 2) Advance directives are determined ahead of time to guide decision making at the time of the event. The client can indicate a desire to make a change, and the original decision should be honored. This client could be experiencing hypoxia and thus not thinking as clearly as when the advance directives were made. Asking about changes could imply that he should make a change, which is not true. The original decision should be honored; however, the client can indicate a desire to make a change. (Option 3) The client's advance directives take legal precedence over the spouse's wishes. The spouse is consulted when there are no advance directives or durable power of attorney for health care. (Option 4) Advance directives include living wills with written directives on how to handle situations. A medical power of attorney is used in situations not covered by the written directives. This client has indicated his wishes. A durable power of attorney for health care is used only when clients have not expressed wishes or cannot speak for themselves. Educational objective: Advance directives include a living will (specific situations put in writing) or a medical power of attorney (an individual appointed when the clients are unable to speak for themselves). The client's wishes should be honored.

An unaccompanied 16-year-old girl comes to the emergency department with severe abdominal pain and vomiting. The client has a temperature of 102.2 F (39 C) and a pulse of 120/min and is lethargic. The client's parents are out of town, and no guardians can be reached. How should this client's care be handled? 1. Administer care until the parents or guardians can be reached 2. Admit the client but without giving care until the parents or guardians can be reached 3. Perform a pregnancy test to see if the client qualifies as an emancipated minor 4. Provide health care and follow-up advice but do not give any direct care

1 An unaccompanied minor should be treated if the medical condition is an emergency and should be assessed and stabilized. This client clearly has a medical need and could suffer consequences if not treated. In this scenario, care should be rendered and then explained later to the parent or guardian. This approach is supported by the ethical principles of beneficence and nonmaleficence. In addition, underage clients may consent in certain circumstances without parental consent. These circumstances usually include treatment for substance abuse problems, psychiatric disorders, or sexual transmitted diseases. (Option 2) This client has signs/symptoms of systemic infection and possible dehydration or sepsis, an emergent condition. It is unknown when the parents or guardians can be reached. It would be negligent to not further assess and treat a potentially worsening condition. It is assumed that the parents or guardians would want safe, quality care for the client. (Option 3) Qualifications for the status of emancipated minor are subject to state legislation but usually include individuals age <18 who are parents or pregnant, married, living as financially independent, or in the military. This client needs care that should be rendered regardless of status. (Option 4) Providing follow-up advice will not stabilize a potentially serious medical condition. Care must be provided. Educational objective: An underage client whose parents or guardians cannot be contacted and who needs emergency care should receive all necessary medical care until a parent or guardian can be reached to provide consent.

A client with metastatic esophageal cancer says, "I don't want to be kept alive being fed by a tube." What are the most appropriate ways for the nurse to ensure that this information is available to all who may need it for future decision-making? Select all that apply. 1. Document this communication in the electronic health record 2. Encourage the client to discuss this decision with the health care proxy 3. Facilitate completion of an advance directive that reflects the client's decision 4. Obtain a signed informed consent from the client 5. Tell the HCP that the client needs a DNR order

1,2,3 Advance care planning is a process that includes: - Considering treatments that may be needed in the future - Making decisions to guide future treatments, particularly if the client is no longer able to make own decisions - Ensuring that treatment decisions are legally documented on the appropriate forms, such as the advance directive, and in the medical record (Option 1) - Ensuring that advance directive documents are in the medical record so that they are available to HCPs who care for the client in the future (Option 3) - Ensuring that the health care proxy (or durable power of attorney for health care) has information and documentation to support that role if this person needs to make decisions for the client (Option 2) The nurse's role as advocate includes discussing options with the client and ensuring that the client's wishes are communicated and documented appropriately so that the health care proxy and health care team will have the necessary information. (Option 4) An informed consent is necessary for the client or surrogate decision maker to approve certain treatments, procedures, and surgeries. The nurse's role in obtaining informed consent is to obtain and witness a signature once the HCP has explained the procedure, its risks and benefits, and answered any questions. This client is not providing consent for any procedure at this time. (Option 5) A DNR order is used to prevent resuscitation in someone with a life-limiting illness. A DNR order does not provide direction for nutrition supplementation. Educational objective: An advance directive is used to communicate a client's wishes when the client is not able to communicate them him/herself. The nurse can advocate for the client by ensuring that expressed wishes are communicated in the advance directive and medical record and by encouraging the client to share this information with the appointed health care proxy.

A nurse cares for a client on life support who has been declared brain dead. Which intervention is appropriate at this time? 1. Ask the fam members about their plans for the funeral service 2. Call the local organ procurement services representative 3. Discontinue nursing care and provide postmortem care 4. Remove life support as requested by spouse and family

2 Local organ procurement services (OPS) are notified for every client death, per hospital protocol (Option 2). If the client is deemed appropriate as a donor, then OPS collaborate with hospital staff in approaching the client's family about organ donation. Cardiac support (eg, dopamine, epinephrine) and respiratory support (eg, ventilator) continue as organ donation is discussed and/or performed. Life support is withdrawn only if the client is not a candidate for donation due to physiological reasons or the client/family does not consent. (Option 1) Organ donation is discussed before final arrangements and funeral plans are made. In most cases, the family is referred to the hospital chaplain or someone outside the hospital for assistance with final arrangements. (Option 3) Medical and nursing care would continue as organ donation is discussed due to organ and tissue perfusion being necessary for viable donation. (Option 4) Local OPS are contacted before life support is removed so that physiological support is continued in the event that the client is a viable donor. Educational objective: All client deaths are reported to local organ procurement services, per hospital protocol. Life support is continued until a decision for organ donation is reached so that organs and tissues continue to receive perfusion and oxygenation.

Which emergency department clients cannot be allowed to sign out against medical advice? Select all that apply. 1. Client in sickle cell crisis receiving O2 via face mask 2. Client who drank a 1L bottle of vodka 2h 3. Client who hears voice commands to kill a coworker 4. Client with mania who has not eaten in 5 days 5. Client with ST elevation on ECG monitoring

2,3,4 To leave against medical advice (AMA), the client must be legally competent to make an educated decision to stop treatment. Disqualifications for legal competency include altered consciousness, mental illness (ie, a danger to self or others), and being under chemical influence (eg, drugs or alcohol). The client who drank a 1 L bottle of vodka is intoxicated (Option 2). The client who hears voices has psychotic symptoms and is potentially homicidal (Option 3). The manic client who has not eaten in 5 days is a potential danger to self and cannot leave AMA (Option 4). For a competent client to leave AMA, the health care provider must explain the risks of discontinuing treatment. The nurse must witness and document the discussion on risks of leaving AMA and the client's understanding of these risks ("informed refusal"). A client leaving AMA can, and should, receive discharge instructions and the option to return at any time. (Options 1 and 5) Clients have the right to leave AMA, even if it is not in their best interests to leave (eg, even if potentially life-threatening). Not allowing a competent client to leave AMA is a form of false imprisonment, a legally liable action by the nurse. Educational objective: The client must be legally competent to leave against medical advice. Disqualifications for legal competency include impairment by drugs or alcohol, altered consciousness, and mental illness (ie, a danger to self or others).

The nurse is participating in staff training about protecting clients' privacy and confidentiality. Which of the following incidents does the nurse recognize as a violation of client confidentiality? Select all that apply. 1. A visitor talking in the waiting room states that the client has alcoholism 2. The LPN has the client's report sheet in a pocket when going home 3. THe nursing assistant tells a client that the hospital roommate went for a gallbladder test 4. The RN tells a visitor to wear a mask bc the client is on isolation precautions 5. 2 LPNs are discussing a possible cure for AIDS on a crowded elevator

2,3 The nurse is ethically and legally obligated to protect clients' privacy and maintain confidentiality of their medical information. Clients' health information should be shared only with other health care team members directly involved in those clients' care. Report sheets used by nursing staff often include clients' private health information and must be shredded at the end of the shift (Option 2). Without the client's permission, information about the diagnosis or diagnostic tests cannot be shared with a hospital roommate (Option 3). (Option 1) Health care staff are not required to censor visitor conversation in waiting rooms. (Option 4) Nurses are obligated to help protect visitors and others by instructing visitors to wear appropriate personal protective equipment. However, the nurse should not violate the client's privacy by sharing the client's diagnosis. (Option 5) Although discussion about specific client information is not permissible, general discussion about health care topics (eg, a potential cure for AIDS) is not a violation of clients' privacy. Educational objective: The nurse must protect clients' privacy and maintain the confidentiality of their medical information. Clients' health information should be discussed only with health care team members directly involved in those clients' care. Nurses must also ensure that documents containing clients' information are shredded after use.

Which statements related to ethical nursing practices are correct? Select all that apply. 1. Accountability is documenting that the nurse administered the wrong medication 2. Autonomy is informing the client of the decision the family made for the client 3. Confidentiality is respecting a clients request to keep suicidal ideation secret 4. Justice is providing the same cardiac care to a homeless person as a businessperson 5. Nonmaleficence is reporting abuse for a client with Alzheimer disease

1,4,5 Ethical principles guide decision making and appropriate behavior. Justice is treating every client equally regardless of gender, sexual orientation, religion, ethnicity, disease, or social standing (Option 4). Accountability refers to accepting responsibility for one's actions and admitting errors (Option 1). Nonmaleficence means doing no harm. It also relates to protecting clients who are unable to protect themselves due to their physical or mental condition. Examples include infants/children, clients under the effects of anesthesia, and clients with dementia (Option 5). (Option 2) Autonomy is freedom for a competent client to make decisions for oneself, even if the nurse or family does not agree (eg, informed consent, advanced directive). The nurse can provide information and should respect the client's decisions. (Option 3) Confidentiality means that information shared with the nurse is kept in confidence unless permission is given to share or it is required by law to be shared to protect the client and/or community (eg, reportable infectious diseases). If a client discusses suicidal ideation with the nurse, it must be appropriately reported to protect the client from self-harm. Educational objective: Accountability is accepting responsibility for one's actions. Autonomy is making an informed decision about treatment for oneself. Confidentiality is not sharing information unless permission is given or required by law. Justice is treating every client equally. Nonmaleficence is doing no harm.

A client with terminal cancer arrives in the emergency department unresponsive and in respiratory distress. The client's sister is the legal medical power of attorney. Both the client's spouse and sister are present. Which action by the nurse is appropriate at this time? 1. Ask spouse about the client's wises 2. Get directions about care from the client's sister 3. Prepare from emergency intubation 4. Request that the sister provide a living will

2 Advance directives are legal documents that allow clients to make decisions about their future medical treatment in case the client later becomes medically incompetent (eg, end of life, dementia, brain injury). The most common forms are living will and medical power of attorney (POA) (ie, health care surrogate/proxy). A living will declares the client's wishes related to specific situations (eg, do not intubate). A medical POA allows the client to designate a specific decision-making individual who can advocate for the client as needed and can be flexible in changing circumstances (Option 2). (Option 1) A client's spouse is typically the primary decision maker. However, clients have the right to declare any specific individual who they trust as their agent with medical POA, and the agent becomes the final decision maker. (Option 3) The client should receive treatment immediately if there are no advance directives or family members present, but in this case, the agent authorized with medical POA is present and should approve the treatment plan before interventions are initiated. (Option 4) If the client's medical POA agent is present, treatment should not be delayed by requesting a living will as the agent will advocate for the client's wishes and has final decision-making authority. Educational objective: Medical power of attorney (POA) is an advance directive that allows clients to designate a specific decision-making individual who advocates on their behalf if they become medically incompetent. Clients have the right to declare any individual they trust as their agent with medical POA, and that individual becomes the final decision maker.

The nurse is eating lunch in the hospital cafeteria, which is crowded with visitors and other staff. A health care provider approaches the nurse and asks, "How is my client Mrs. Jones in Room 312 doing?" Which response by the nurse is appropriate? 1. I dont know because I am off duty right now 2. Let's step away from the crowd to discuss it 3. Mrs. Jones was fine when I last checked on her during rounds 4. You will have to talk with the nurse caring for her while I am on break

2 The nurse is ethically and legally obligated to protect clients' privacy and maintain confidentiality of their medical information. If another staff member asks a question about a client's medical information in an open area with visitors, the nurse should first move the conversation to a secure area. Answering the question will promote further conversation, making it likely that the client's privileged health care information will be discussed and overheard by others. The best response is to suggest changing the location of the conversation so that the information can be discussed privately (Option 2). (Option 1) This response is neither accurate nor helpful because the nurse knows how the client was earlier in the day. It is best to make the conversation private so that the nurse can respond to the question appropriately. (Option 3) Although vague, this response in a public area (ie, cafeteria) violates the client's privacy by acknowledging the client's presence in the hospital, where the response may be overheard by others. In addition, it does not provide accurate information. (Option 4) It is appropriate to direct questions about the client to the currently assigned nurse; however, this response violates the client's privacy by confirming the client's presence in the hospital. It is best to make the conversation private before sharing any information. Educational objective: The nurse must protect clients' privacy and ensure that their medical information remains confidential. Conversations about the client with other staff, even those regarding the client's presence in the hospital, should occur in a private area.

The nurse finds a client on the floor in the client's room. Based on the documentation shown in the exhibit, the nurse made an incorrect entry in the client's medical record at what time? Click on the exhibit button for additional information. 1700 Found client lying on floor next to bed. Client states, "I fell out of bed while reaching for my eyeglasses and hit my head on the bedside table." Client is alert and oriented to time, place, person, and situation. Denies pain, dizziness, or nausea. No visible injuries. Assisted back to bed. Neurological vital signs within normal limits (see assessment flow sheet). Client instructed to use call bell for assistance. Will continue to monitor. __________RN 1710 Health care provider (HCP) notified of fall. Prescribed CT of head STAT. ___________RN 1740 No change in neurologic status. Client to CT via gurney. Report filed per policy. __________RN 1810 Client returned from CT. No change in neurologic status. Reinforced use of call bell, and client demonstrated understanding. Will continue to monitor. __________RN 1. 1700 2. 1710 3. 1740 4. 1810

3 All incidents, accidents, or occurrences that cause actual or potential harm to a client, employee, or visitor must be reported. The person who witnesses an unusual occurrence or event must file an incident report in the institution's computer documentation system using an electronic form. Alternately, a paper form may be completed and filed. The purposes of the report are to inform risk management of the occurrence, allowing them to consider changes that might prevent similar incidents, and to notify administration of a potential litigation claim. The nurse should not document that an incident report was filed, or refer to the incident report in the medical record. (Options 1, 2, and 4) Because the incident report is not a part of the medical record, an objective note should be placed in the client's medical record documenting the facts and events of the incident, HCP notification and findings, prescriptions, treatment, follow-up care, and monitoring. Educational objective: The person who witnesses an unusual occurrence or event must file an incident report in the institution's computer documentation system, using an electronic form. The nurse should not document that an incident report was filed or refer to the incident report in the medical record.

While reviewing prenatal records with a client and her partner, the nurse notes documentation in the medical record indicating that the client is a G2P0. However, the client denies a previous pregnancy. Which action by the nurse is appropriate? 1. Adjust documentation to indicate that the client is a G1P0 2. Ask the client and partner about a previous miscarriage or abortion 3. Confirm the obstetric hx when the client is alone 4. Explain the importance of accurate info to the client and partner

3 When reviewing obstetric history, the GTPAL notation system gives the health care provider information about a client's past pregnancies. This notation may be shortened to gravida (ie, number of previous pregnancies) and para (ie, number of births after 20 weeks). For example, a G2P0 indicates 1 prior pregnancy ending before 20 weeks and 1 current pregnancy. The nurse should be cautious of discussing obstetric history with a client in front of the partner or family and not assume that others have knowledge of the client's past pregnancies. If there is a discrepancy between what the client discloses in the interview and the medical record, the information should be clarified when the client is alone to maintain confidentiality (Option 3). (Option 1) The nurse should not change information in the medical record until the information is clarified appropriately with the client. (Option 2) Although the client's medical record indicates a previous pregnancy, it is not appropriate to ask if the pregnancy was an abortion or a miscarriage in front of the client's partner. (Option 4) Explaining the need for accurate information is not appropriate at this time and does not assist with clarifying the client's obstetric history in a private manner. Educational objective: The nurse should be cautious of discussing a client's obstetric history in front of the client's partner or family to avoid breaching confidentiality. Clarification or further questioning about the client's history should take place when the client is alone.

Which of the following are examples of medical battery? Select all that apply. 1. A child is placed in a papoose restraint for suturing of a facial laceration with the parent present 2. Application of soft wrist restraints to the arms of a confused, adult client with a NG tube 3. The nurse administers 2mg of morphine PRN to a difficult, alert client but tells the client it is saline 4. The nurse inserts a needed urinary catheter even though a competent client refuses it 5. The nurse threatens to put a client in restraints if the client does not stay in bed

3,4 Battery is the intentional touching of a person that is legally defined as unacceptable or occurs without the person's consent. Many routine actions that are permissible when proper consent is obtained would otherwise be considered medical battery. Furthermore, actions can be considered battery even if no physical injury results. Any health care provider (HCP) who performs a medical or surgical procedure without receiving the required informed consent from a competent client (or parent/legal guardian in the case of a child) is committing battery and could be legally charged (Option 3). A competent client has the right to refuse any treatment, even if it is for the client's benefit. The nurse should help the client understand the need (eg, informed refusal), but the client's decision should be upheld. Proceeding to administer treatment to a competent client who has refused that treatment is medical battery (Option 4). (Option 1) The temporary restraint for this minor child is needed for a therapeutic intervention, and it is implied that the parent consents to its use. (Option 2) Using a restraint to prevent a client from inadvertently removing essential medical interventions is an acceptable medical precaution. A prescription from the HCP is required, and the nurse is responsible for performing appropriate, timely assessments related to the restraint. This is not an example of battery as there is a medical reason for the restraint and a prescription/order was obtained. (Option 5) This is an example of assault. Assault is a deliberate threat with the power to carry out the threat. Educational objective: Battery is touching that is legally defined as unacceptable or occurs without consent. Examples include performing a procedure despite a competent client's refusal or without obtaining proper consent from a competent client (or parent/legal guardian when the client is a child). Assault is the threat of battery.

Which pediatric presentation in the emergency department should the nurse follow up for possible abuse and mandatory reporting? 1. A 2mo who rolled off the changing table and is now lethargic 2. A 3 mo with flat bluish discoloration on the buttock that the mother says has been present since birth 3. A 3 yo with forehead bruises that the mother says come from running into a table 4. A 4 yo who pulled boiling water off the stove and has splattered burns on the arms

1 Infants do not start rolling until age 4 months and normally roll front to back at 5 months. This explanation for the injury does not fit the growth capacity of the child. Because lethargy is present, head injury must be ruled out. (Option 2) Congenital dermal melanocytosis (Mongolian spots) are an expected finding. These are seen on the lower back and/or buttock more often in African American, Asian, Hispanic, and Native American infants. Although they can be mistaken for bruising and the size and location should be documented, they are not a concerning finding and usually disappear by school age. (Option 3) A toddler's forehead is the height of many tables. Due to toddlers' lack of coordination, this explanation is plausible in the absence of other concerning findings (eg, child is afraid of caregiver, multiple bruises of various ages over other parts of the body, malnourished). (Option 4) Due to the child's short height, this is a credible explanation. A child can pull water down from a higher-level stove top. Burns that are suspicious for abuse include scalds without splash marks; scalds with a clear line of demarcation/immersion ("dunking"); scalds involving the perineum, genitalia, and buttocks; burns on the back (versus the front) of the child; mirror-image burn injury of the extremities; and cigarette burns. Educational objective: Infants begin to roll at age 4-5 months. History that does not match growth and development is a concern for abuse. Burns with splash, bruises from areas typically hit when falling, and Mongolian spots are expected findings.

A newly reassigned nurse enters a hospital room at the beginning of the shift and finds the client unconscious and unresponsive. Resuscitation is initiated and then continued by the rapid response team. The nurse realizes that there is a do not resuscitate (DNR) prescription posted in the client's chart. Which action is correct? 1. Stop all resuscitation activity immediately 2. Continue resuscitation until DNR status is verified with HCP 3. If client shows any signs of life, follow advanced cardiovascular support protocol until stable 4. Once resuscitation has begun, complete it regardless of client code status

1 Many health care professionals react to an emergency situation automatically. However, some states and provinces will further penalize health care workers with loss of their professional license if they fail to render cardiopulmonary resuscitation in an emergency situation. Health care professionals will not be penalized for an honest mistake. However, resuscitation must end immediately after they are notified of the error (Option 1). (Option 2) Continuing treatment until the code status is verified with the health care provider (HCP) constitutes malpractice. Before a do not resuscitate prescription can be posted in a client's medical record/chart, the HCP must provide documentation that the client's code status has been established through consultation with the client or family. (Options 3 and 4) Gross negligence of a client's advance directive can result in legal action. Educational objective: Failure to stop an erroneous code on a client with an advance directive in a timely fashion may result in legal action.

During change-of-shift report, the nurse going off duty notes that the nurse coming on has an alcohol smell on the breath and slurred speech. What actions are most important for the nurse to take? Select all that apply. 1. Don't continue the handoff report with the oncoming nurse 2. Document the incident according to facility policy 3. Notify the charge nurse 4. Say nothing but watch for impaired behaviour 5. Tell the oncoming nurse that he/she is not fit for duty

1,2,3 An impaired nurse cannot safely give care regardless of the reason for impairment. If impairment is suspected, the nurse has a duty to take action that will both protect the client and ensure that the impaired individual receives assistance. The charge nurse/nurse supervisor should be notified (so the nurse can be replaced and sent home safely), the incident documented, and the nurse not allowed to give care while impaired (Options 1, 2, and 3). (Option 4) The off-going nurse will not stay on the new shift to watch for impairment. The impaired nurse may not behave in an obvious manner while the off-going nurse is watching. Regardless of these factors, the nurse has alcohol on the breath and slurred speech; by definition there is evidence of impairment. (Option 5) Confronting the impaired nurse in a hostile manner does nothing to protect the client and offers no support to the nurse. Confrontation may be necessary if the client is in immediate danger (eg, the impaired nurse draws up a medication for administration). The off-going nurse should notify the charge nurse so that facility authorities can collaborate with the governing state board of nursing to carry out appropriate investigation, discipline, and supportive interventions. Most state nurse practice acts allow rehabilitation for a cooperative professional rather than automatic loss of license. Educational objective: A nurse who is impaired by alcohol cannot be given client responsibility. The recognizing nurse should notify the supervisor, document the incident, and not give client responsibility to the impaired nurse.

The medical-surgical nurse cares for a group of clients. Which client situations would prompt the nurse to notify the health care provider during the middle of the night? Select all that apply. 1. Client develops R sided upper and lower extremity drift 2. Client found lying unconscious on the floor 3. Client has order for heparin with sx planned for the morning 4. Client has serum Na of 124 mmol/L 5. Client refuses a prescribed, routine pain medication

1,2,3,4 The nurse contacts the health care provider (HCP) for certain circumstances, regardless of the time of day. An emergent call is warranted if a client: Falls Deteriorates significantly or dies Has critical laboratory results Needs a prescription that requires clarification Leaves against medical advice or runs away Refuses key treatments in a relevant period The HCP should be called after the initiation of hospital protocols (eg, stroke, code blue) and after a concerning assessment finding (eg, significant change in vital signs, unilateral drift, change in level of consciousness, signs of trauma after a fall ) (Options 1 and 2). Administration of heparin is normally discontinued prior to surgery due to the increased risk of bleeding and should be clarified with the HCP (Option 3). A serum sodium of 124 mEq/L (124 mmol/L) (normal: 135-145 [135-145]) represents a critical value that can lead to altered mental status and seizures (Option 4). (Option 5) Clients have the right to refuse treatment; there is no indication that the client needs pain medication. With additional explanation, the client might reconsider if and when symptoms occur. Educational objective: The nurse should notify the health care provider, regardless of the time, for acute client deterioration (eg, neurological changes), critical laboratory values, falls, or death. Other reasons include prescription clarification and the client leaving against medical advice or refusing a key treatment.

The charge nurse supervising a graduate nurse would need to intervene when the nurse violates health information privacy laws with which action? Select all that apply. 1. Accesses the medical record of a client not currently assigned, but previously cared for, to assess client improvement 2. Advise a client's transport technician, "this client has metastatic breast cancer and must be moved very carefully due to fragile bones" 3. Asks a client quietly "when were you diagnosed with diabetes?" during admission assessment in a semiprivate room with the privacy curtain in place between beds 4. Explains the results of a client's diagnostic testing to the unit clerk who is organizing paperwork to be included in the client's medical record 5. Writes a client's last name on a whiteboard hanging in the nurses' station on which scheduled procedures are logged

1,2,4 Nurses need to maintain privacy and confidentiality when caring for clients. Health care workers (HCWs) need to use the minimum necessary standard (reasonable precautions) to protect a client's health information. Confidentiality is violated when information about a client's personal health (eg, diagnosis, test results) is accessed by or given to those without permission or without a "need to know." For example, a transport technician may require pertinent client information (eg, fragility) to transport a client safely but never needs to know the client's exact diagnosis (Option 2). Other violations include when HCWs access medical records of clients not currently assigned or discuss client diagnoses with nonessential personnel (Options 1 and 4). Certain incidental disclosures are allowed if reasonable precautions are taken. Common precautions include: Allowing medical record access to a HCW only when necessary to perform job duties Employing room dividers/curtains in semiprivate spaces (Option 3) Avoiding discussions about clients and their conditions in public areas Listing only last names on whiteboards at nurses' stations (Option 5) Placing communication whiteboards where they are least visible to the public Communicating with lowered voices in semiprivate spaces (eg, nurses' stations, client rooms) Educational objective: Only health care personnel requiring client health information to carry out their job duties should have access to or be advised of this information. Nurses, health care providers, and hospitals should take reasonable precautions at all times to safeguard client information.

Following a motor vehicle crash, the nurse stops to help a victim who has a laceration with spurting blood. The nurse giving reasonable assistance could be held liable despite Good Samaritan laws in which situations? Select all that apply. 1. The nurse accepts money from the victim 2. The nurse does not accompany the victim on the ambulance 3. The nurse does not apply direct pressure to the artery 4. The nurse knows the victim from college 5. The victim dies after reaching the hospital

1,3 Good Samaritan laws prevent civil action against nurses who stop of their own accord (eg, not part of their job duties) to help injured individuals after an accident. The nurse cannot receive payment for any care given (Option 1). It is essential for the nurse to perform in the same manner as any reasonable and prudent medical professional would in the same or similar circumstances. A reasonable, prudent nurse would apply pressure to help control an arterial bleed (Option 3). (Option 2) Although this nurse is not legally obligated to offer assistance, it can be argued that there is an ethical responsibility. Once the nurse starts to render care, the nurse is responsible to continue until the care can be handed off to an appropriate caregiver, such as a paramedic. The nurse is not obligated to accompany the client to the hospital. (Option 4) Knowing the client does not affect the application of Good Samaritan laws. (Option 5) This nurse is not liable for the victim's outcome as long as the nurse performs in a competent manner. Educational objective: Good Samaritan laws prevent civil action if a nurse stops to assist after an accident, as long as the nurse acts competently, continues care until another appropriate caregiver takes over, and does not accept money.

Which concepts are regarded both legally and morally as patient/client rights? Select all that apply. 1. Access to the client's test results in the medical record 2. Choosing who will be the client's nurse for the shift 3. Having the client's pain assessed and addressed appropriately 4. Knowing the name and position of the client's HCP 5. Receiving any health care procedures the client wants

1,3,4 The Patient Care Partnership (formerly known as the Patient's Bill of Rights) is a set of standards developed by the American Hospital Association. It informs patients/clients about what they should expect during their hospital stay with regard to their rights and responsibilities. Client rights originate in laws or desirable ethical principles but have limitations. Clients have the right to know the names and positions of their health care providers (HCPs). These individuals should introduce themselves by name and discipline (Option 4). Clients have the right to access information within their own medical record. A release form may need to be signed, or the HCP can review information (eg, biopsy results) with the client. In 2014, the Department of Health and Human Services further strengthened the rights of clients to access their test results (Option 1). Pain management is also addressed by the Joint Commission and is considered a basic client right. Although success in pain relief is not guaranteed, the issue is to at least be addressed with the goal of successful management (Option 3). (Option 2) Clients do not have an open-ended right to choose their nurse for every shift. If the client has a special request (eg, does not want a male nurse based on religious beliefs), the facility will usually try to accommodate these wishes. (Option 5) There is no basic right for clients to have whatever procedures they want. Clients sometimes want things that are not essential to their health or that they do not need (eg, those with body dysmorphic syndrome who desire plastic surgery, those with Munchausen syndrome who act ill and request unnecessary treatment). A client is offered treatment that the HCP feels is needed and has the right to choose or refuse the treatment. Educational objective: Basic client rights include knowing the identity of their health care providers, access to the information in their medical records, and having pain assessed and addressed appropriately.

Which actions by a registered nurse are reportable to the state board of nursing? Select all that apply. 1. Administering hydromorphone without a prescription 2. Being habitually tardy to work 3. Documenting an intervention that was not performed 4. Stealing narcotics 5. Walking off duty in the middle of a shift

1,3,4,5 The National Council of State Boards of Nursing advises any individual who has knowledge of a potential violation of a nursing law or rule to file a complaint with the appropriate state board of nursing. A nurse should be knowledgeable concerning the presiding board's stance on mandatory reporting and which actions are considered reportable. In general, reportable actions may include any behavior by a licensed nurse that is unsafe, unethical, incompetent, impaired (eg, by substances or a mental or physical condition), or in violation of nursing law. - Practicing outside of the scope of the license is reportable even if the practice meets quality standards - Documenting an intervention that was not performed is considered falsification of records regarding client care and is a reportable action (Option 3). - Stealing narcotics is a criminal offense (a violation punishable by the state that can result in prison or a fine) and is reportable in all states. Many states offer an alternate rehabilitation program to nurses who diverted or abused drugs (Option 4). - Abandonment (eg, leaving without proper replacement of personnel and transfer of responsibility for client care) is reportable in all states (Option 5). (Option 2) Work habits are handled under the facility's management policies and are often part of the criteria for discipline and/or termination. If the facility has 24-hour care, the off-going nurse cannot leave without someone assuming responsibility for the clients or waiting for the tardy nurse. Educational objective: Nurse offenses reportable to the state board of nursing include criminal acts (such as theft), practicing outside of the scope, falsification of records, and client abandonment. Any individual may file a complaint regarding an action that is potentially unethical, incompetent, impaired, or in violation of nursing law.

The nurse prepares to teach an in-service on legal issues related to nursing. Which legal terms are followed by an appropriate example? Select all that apply. 1. Assault: Threatening to admin a benzo if the client does not comply 2. Battery: misinforming a client that a painful injection will not create discomfort 3. False imprisonment: storing a competent client's clothes to prevent the client from leaving prior to a prescribed treatment 4. Informed consent: calling the parent of an emancipated minor for approval prior to providing care 5. Invasion of privacy: posting a medical update on the social media page of a client who is a friend

1,3,5 Assault is an act that threatens the client and causes the client to fear harm, but without the client being touched (Option 1). False imprisonment is the confinement of a client against the client's will or without legal justification (eg, client is not a threat to self or others) (Option 3). Invasion of privacy includes disclosing medical information to others without client consent. Under the Health Insurance Portability and Accountability Act (HIPAA), a client's information regarding medical treatment is private and cannot be released without the client's permission (Option 5). (Option 2) Battery involves making physical contact with the client without permission. This includes harmful acts or acts that the client refuses (eg, performing a procedure). When interacting with the client, it is important to practice veracity, the ethical principle of being truthful. (Option 4) An emancipated minor is an individual under the age of legal responsibility who has been legally freed from parental control through a court order (eg, due to enlistment in the military, marriage, pregnancy). The parent in this situation would not need to be called. Clients have the right to be informed of risks and benefits of procedures prior to care and to give informed consent. Educational objective: Clients have the right to privacy and to give informed consent prior to medical care. Assault is an act that threatens the client, causing the client to fear harm without the client being touched. Battery is physical contact against a client's will or without legal justification. False imprisonment includes restraining a competent client without the client's permission.

The home health nurse is providing long-term care to several clients. Which are examples of inappropriately crossing professional boundaries? Select all that apply. 1. Accepting a birthday gift of a gold bracelet from a client 2. Making a visit to the hospital after a client has sx 3. Offering to pray together if a client so wishes 4. Sending a sympathy card to fam after a client dies 5. Soliciting a wealthy to invest in a company 6. Staying after work hrs and drinking wine with a client

1,5,6 Professional boundaries set limits to maintain a therapeutic professional relationship between the nurse and client. However, the line between professional and personal interactions is sometimes blurred in extended relationships or when care is given in the client's home. The nurse should always put the client's needs first and never seek personal gain (eg, accepting gift worth >$20, asking for financial investment/loan) (Options 1 & 5). The nurse should follow a facility's policy on professional standards of behavior. In the absence of a formal policy, the nurse should consider if the action would be appropriate to include in the medical record. If the nurse is unsure, it may be indicative of a violation of professional boundaries (eg, flirting with client, consuming alcoholic beverages with client) (Option 6). (Option 2) An occasional visit to a previous client in a different circumstance (hospital, nursing home) is considered appropriate and caring. (Option 3) It is appropriate for the nurse to offer assistance in meeting a client's spiritual needs if the client desires it. The nurse should not force their own beliefs, religion, or practices on the client. (Option 4) Sending a sympathy card to acknowledge a family's loss is a holistic and therapeutic measure. Educational objective: Professional boundaries involve maintaining a relationship that benefits the client, not the nurse, and to which the nurse would not be reluctant to admit. It is generally not appropriate to socialize with a current client after hours, ask for a financial investment/loan, or accept a valuable gift.

The nurse witnessed a signed informed consent for an inguinal hernia repair surgery. During the procedure, the surgeon discovers a secondary ventral hernia that also requires repair. Which action should the nurse perform? 1. Add the secondary hernia to the consent form that the client signed before the procedure 2. Call the client's medical POA to provide consent for the additional proceudre 3. Document that an additional hernia was found and that it will require sx at a later time 4. Witness an additional consent after both procedures are complete and the client is awake

2 Informed consent is required before any nonemergency procedure. The 3 principles of informed consent include: - The surgeon explains the diagnosis, planned procedure with risks and benefits, expected outcome, alternate treatments, and prognosis without surgery. - The client indicates understanding of the information. - The client is competent and gives voluntary consent. The nurse is responsible for witnessing the client's signature and ensuring that the client is competent and understands information provided by the surgeon. Clients unconscious or under the influence of mind-altering drugs (eg, opioids) cannot provide consent. If the sedated client requires procedures not listed on the consent form, the client's medical power of attorney, legal guardian, or next of kin should be contacted so that the surgeon can explain the situation and obtain consent (Option 2). (Option 1) Modifying a consent form after it has been signed is an illegal falsification of documentation. (Option 3) Unless family members deny consent or cannot be reached, it is in the client's best interest to have the hernia repaired now rather than go through the physical and financial strain of a second surgery. (Option 4) Procedures can be performed without prior consent only when lifesaving measures are necessary. Obtaining consent after a procedure is illegal and considered assault and battery. Educational objective: Informed consent is required before any nonemergency procedure. If the need for an additional procedure is discovered during surgery, the client's medical power of attorney, legal guardian, or next of kin should be contacted to provide consent.

The clinic nurse is teaching a client about the advance directive form that needs to be completed. Which statement indicates that the client understands the information? 1. I will get this notarized as soon as I can 2. I will give a copy of this to my daughter, who is listed as my health care proxy 3. I'll put this on my refrigerator, so no one will give me cardiopulmonary resuscitation 4. You and my daughter can witness this for me

2 When the advance directive is completed, a copy should be placed in the client's medical record and copies should be given to everyone listed as health care proxies. The client should also keep a copy in a safe place. (Option 1) The advance directive form does not need to be notarized, and so it can be completed in the health care setting if there are 2 witnesses. (Option 3) The advance directive is used to document a client's wishes, but it is not a medical order. It will not prevent from performing CPR on a client when necessary. If this client does not want CPR, a portable "do not resuscitate" (DNR) order should be used to ensure that the DNR order is followed outside the hospital setting. Types of portable orders include a POLST (Portable Orders for Life Sustaining Treatment) form, an out-of-hospital DNR, and a DNR bracelet. (Option 4) Two witnesses are required for completion of the advance directive form. The witnesses cannot be health care providers involved in the care of the client or individuals named as health care proxies in the document. Educational objective: An advance directive is placed in the client's medical record and copies are given to health care proxies. Two witnesses are required for completion of the advance directive, but they should not be the health care proxies listed in the document.

A visiting family member of a hospitalized client reports sudden onset of a headache and numbness in half of the body. The visitor asks the nurse to take a blood pressure reading. What is the most appropriate response by the nurse? 1. Encourage the visitor to lie down to see if symptoms change 2. Initiate protocol to assist the visitor to the emergency depertment 3. Proced to take the visitor's BP 4. Suggest that the visitor call the HCP

2 Providing care establishes a legal caregiver obligation/relationship between the nurse and the visitor. If a relationship is started, the nurse has a duty to continue care until the visitor is stable or other health care personnel can take over. If proper care is not continued, the nurse could be accused of negligence (ie, failure to act in a prudent manner as would a nurse with similar education/experience). This visitor's symptoms are potentially serious as sudden onset of headache and numbness in half of the body may indicate stroke. In the event of a visitor emergency, the nurse should not establish a caregiver relationship but rather implement facility protocol to help the visitor get to the emergency department promptly to receive immediate assessment and further evaluation (Option 2). (Options 1 and 4) Asking the visitor to call the health care provider (HCP) or giving advice to lie down delays the essential assessment and treatment that this visitor with potentially serious symptoms requires. (Option 3) When a nurse provides care (eg, takes blood pressure), a client-caregiver relationship is established. The nurse caring for a visitor is ill-equipped to provide care without any HCP prescriptions in place and risks being negligent. Educational objective: Providing care establishes a legal caregiver obligation/relationship between the nurse and a visitor. In the event of a visitor emergency, the nurse should refrain from actions that establish this relationship and instead implement facility protocol to help get the visitor promptly to the emergency department.

The acute care clinic nurse administers a prescribed narcotic for a client with renal colic and then discharges the client without ensuring that the client has a designated driver. The client is subsequently involved in a motor vehicle accident causing injury to self and others. Which ethical principle did the nurse violate? 1. Autonomy 2. Nonmaleficence 3. Paternalism 4. Veracity

2 The nurse violated the ethical principle "nonmaleficence" (ie, do no harm). It is rare to see a nurse inflict intentional harm. However, problems do occur due to unintentional harm, which is usually a result of poor clinical judgment. Beneficence is a nurse's duty to promote good and do what is best for the client. (Option 1) Autonomy is allowing the clients to choose the direction of their care. This is accomplished with advanced directives along with informed consent and choices regarding proposed treatments. (Option 3) Paternalism is a type of beneficence whereby clients are treated as children. The nurse claims to know what is best for the client and coerces the client to act as the nurse wishes without considering the client's autonomy. (Option 4) Veracity refers to the duty to tell the truth. This principle should always be applied to client care and documentation. Educational objective: Nonmaleficence is the ethical principle of doing no harm. All nurses must exercise sound clinical judgment to prevent harm, even if it is unintentional, to their clients.

The charge nurse is reviewing events that staff nurses experienced during the shift. Which events require an incident/occurrence report to be completed? Select all that apply. 1. Client determined brain dead was taken off life support 2. Client with alcohol intoxication physically assaulted a nurse 3. Serum troponin level was prescribed but never obtained 4. Staff nurse did not present for work and did not notify management 5. Visitor fell and refused care in the ED

2,3,5 Incident/occurrence reports are used in a health facility to document events that pose unanticipated actual or potential risk to the health or safety of a client, visitor, or employee. Incident/occurrence reporting is a method of quality improvement and should not be considered punitive in nature or be documented in the health record. Examples of events requiring reporting include: Assault and injury Physical, verbal, or sexual assault occurring in a health facility (Option 2) Client falls, with or without injury Staff and visitor falls, regardless of acceptance or refusal of treatment (Option 5) Treatment and intervention Failure to obtain or intervene upon the results of diagnostic procedures (Option 3) Inadequate or delayed diagnosis and monitoring Delay, omission, or incorrect performance or administration of prescribed therapies and medications Hospital equipment failure (Option 1) Withdrawal of life support in clients deemed brain dead is an expected and clinically justified course of care, and should be documented in the health record. (Option 4) Incident/occurrence reports are used to document clinical health and safety issues; managerial issues (eg, tardy or absent staff) should be documented in the employee's record. Educational objective: Incident/occurrence reports are used to document events that pose actual or potential risk to the health or safety of clients, visitors, or employees. Examples of reportable events include assault and injury; delay, omission, or incorrect provision of treatment; and equipment failure.

The emergency department nurse is obligated to make a report for which situations? Select all that apply. 1. To a client's employer that the client had a car crash while intoxicated 2. To the authorities that an elderly client has suspicious bruising but denies caregiver abuse 3. To the medical examiner of a death following trauma, even if the family refuses autopsy 4. To the spouse of a client that the client has a reportable sexually transmitted disease 5. To the supervisor that an oncoming HCP has the smell of alcohol on the breath

2,3,5 There are several circumstances in which the nurse is legally required to report to appropriate civil authorities: - Suspected elder abuse must be reported to the appropriate authorities for investigation. The nurse has a legal obligation to report signs of abuse regardless of clients' ability or willingness to advocate for themselves - The nurse should report deaths that meet medical examiner reporting guidelines (eg, suspected to be the result of a crime, trauma, or suicide) to the authorities for investigation. The local medical examiner has the legal authority and obligation to perform an autopsy independent of the family's wishes - For the sake of client safety, nurses should immediately report impaired or intoxicated health care workers, regardless of their position - Under the Health Insurance Portability and Accountability Act, a client's reason for an emergency department visit cannot be communicated to employers without the client's permission - Health authorities must be notified of a reportable sexually transmitted disease regardless of client wishes. Depending on the condition, authorities may report findings to sexual contacts, but it is a violation of client privacy for the nurse to share this information with the client's family or spouse (Option 4). Educational objective: The nurse is required to report an impaired coworker, a suspicious death, and elder abuse to appropriate authorities. The nurse is legally prohibited from sharing health information with employers or family members without the client's permission.

An elderly client visits the clinic for an annual examination, which includes updating the client's advance care plan. When assessing the client's advance care planning needs, which topics should the nurse discuss? Select all that apply. 1. Financial POA 2. Health care proxy 3. Life insurance beneficiary 4. Living will 5. Safe deposit box

2,4 Advance care planning is an ongoing process that should be revisited yearly and after changes in condition. Legal documentation is needed to ensure that the client's advance care plan is carried out correctly. Advance care planning documents may include the following: A health care proxy (durable power of attorney for health care or medical power of attorney) is a person appointed by the client to make decisions on behalf of the client. The proxy document only goes into effect when the health care team determines that the client lacks the capacity to make decisions. This should be deactivated if the client regains decision-making capacity. A living will is an advanced directive describing the type of life-sustaining treatments (eg, cardiopulmonary resuscitation, intubation, mechanical ventilation, feeding tube) that the client wants initiated if unable to make decisions. (Option 1) The financial power of attorney form can help clients having difficulty managing financial affairs and needing someone to help; however, it is not part of the advance care planning process. (Option 3) The client must choose a beneficiary for life insurance policies; however, life insurance is not part of the advance care plan. (Option 5) A safe deposit box can be a good place to ensure that legal documents are stored safely. It is not part of the advance care planning process. Educational objective: Advance care planning allows the client to determine desired treatments (eg, cardiopulmonary resuscitation, intubation, mechanical ventilation) and decision makers in the event the client is unable to do so. Advanced directives are legal documents outlining these wishes and include living wills and health care proxies (durable powers of attorney for health care or medical power or attorney).

Which situations would prompt the health care team to use the client's advance directive to make a decision regarding care? Select all that apply. 1. Client diagnosed with lumbar spinal cord compression has paraplegia 2. Client's GCS score is 3 3. Client is refusing a life saving treatment due to religious beliefs 4. Client with a intracerebral hemorrhage has aphasia 5. Oriented client has cancer and is on a ventilator

2,4 Advance directives give people the chance to make decisions about their medical treatment ahead of time in case they are unable to personally make their wishes known. The 2 most common forms are living wills and durable power of attorney for health care (health care surrogate/proxy). A client who is alert and oriented can directly address a health care decision. Clients in a coma (GCS score ≤7) or with expressive aphasia would need an advance directive to make treatment decisions because they cannot directly express their wishes. Aphasia involves the inability to express thoughts and comprehend language due to brain dysfunction and includes both verbalizing and writing (Options 2 and 4). (Option 1) Mental capacity is not affected in spinal cord compression. The client is able to speak. (Option 3) An adult who is mentally capable of making decisions has the right to refuse treatment for any reason at any time whether the health care provider believes it is in the client's best interest or not. (Option 5) A client who is oriented can make and communicate decisions for him/herself although unable to verbalize. The client could nod or write out wishes. Educational objective: Advance directives take effect when the client is unable to speak for him/herself due to such conditions as mental incapacity. Aphasia involves the inability to express thoughts and comprehend language due to brain dysfunction and includes both verbalizing and writing.

The parent of a child treated for injuries consistent with suspected child abuse has been told that a report will be made to Child Protective Services (CPS). The parent says angrily to the nurse, "I don't know why this is being reported. I told the health care provider (HCP) that it was an accident." What is the best response by the nurse? 1. A case worker for CPS will be visiting you in a few days. The case worker can explain it to you then 2. Did you ask the HCP why it to you then 3. Reporting your child's injuries is required by law. It is for your child's safety and protection 4. Your explanation of your child's injuries does not seem plausible

3 In discussing the reporting aspect of suspected child abuse with a caregiver, the nurse needs to convey an attitude that is not judgmental, punitive, or threatening. Whether or not the parent has actually harmed or abused the child, the parent needs to know that a report will be made, why it is being filed, and an investigation will be conducted by a CPS worker and/or by the police. The nurse should emphasize that the primary concerns are for the safety and well-being of the child and that reporting is mandatory for the types of injuries sustained by the child. It is not unusual for a parent to react to this information with denial and/or anger. The nurse needs to anticipate that such a reaction may occur and maintain a supportive, empathetic, and nonaccusatory approach. (Option 1) This response also diverts the need for the nurse to provide a response or explanation to the parent. The child's caregiver should be told why the report is being filed. (Option 2) This response is nontherapeutic. It diverts the need for the nurse to respond to the parent's question, and it does not provide information or education. (Option 4) This response is confrontational and could give the parent the impression that the nurse and health care team do not believe the story of how the child sustained the injuries. The parent could react with a heightened sense of anger. Educational objective: When discussing suspected child abuse with a caregiver, the nurse needs to be supportive and empathetic and maintain a neutral, nonpunitive and nonaccusatory manner. The parent needs to be told that the safety and well-being of the child are the primary concerns and that certain types of injuries and/or situations must be reported to the appropriate CPS agencies.

A nurse is documenting notes in the client's electronic record after making rounds on assigned clients. Which entry is an appropriate documentation? 1. Client appears to be sleeping. Eyes closed 2. Client reports, "im in pain". Medication provided 3. Inspiratory wheezes heard in bilateral lower lung fields 4. Voided x1

3 The electronic record is a legal document and should contain factual, descriptive, objective information that the nurse sees, feels, hears, and smells. It should be the result of direct observation and measurement. "Inspiratory wheezes heard in bilateral lung fields" best fits these criteria. The nurse should avoid vague terms such as "appears," "seems," and "normal." These words suggest that the nurse is stating an opinion and do not accurately communicate facts or provide information on behaviors exhibited by the client. The nurse should provide exact measurements, establish accuracy, and not provide opinions or assumptions. (Option 1) The nurse should not use the word "appears" as it is too vague. "Eyes closed" is a factual observation. A more accurate entry would be, "Client lying in bed with eyes closed. Respirations even and unlabored." (Option 2) It is a good practice to document client quotes. However, in this case, the nurse should have elicited more information from the client, such as a pain scale, and then documented the analgesic the client was given. (Option 4) This documentation would be more descriptive if it listed how much urine, its color and clarity, and if an odor was present. Educational objective: Nursing documentation should be factual, descriptive, and contain objective information that the nurse sees, hears, feels, or smells. It must include direct observation and measurement.

The nurse is caring for a 4-year-old child in the emergency department who has a 104 F (40 C) temperature, is obtunded, and has a positive Kernig's sign. The parents are refusing antibiotics and any treatment. The parents state that their religious belief is to trust in just prayer and believe the child will receive divine healing. What action does the nurse anticipate? 1. Assisting the parents in signing AMA papers 2. Discharging the child if parents have POA papers 3. Notifying the hospital administration about the situation 4. Reassuring the parents that their decision will be respected under the principle of autonomy

3 A competent adult has the right to make any decision regarding the client's health care even if the provider does not believe it is in the client's best interest. However, parents do not have the right to place their minor child in a life-threatening position. Parents have legal authority to make choices about their child's health care, but not when they do not permit life-saving treatment or when there is a potential conflict of interest, such as child abuse or neglect. The hospital will seek court-appointed custody to treat this child who is seriously ill with dangerously high temperature and signs of severe neurologic deficit. Bacterial meningitis presents with high fever, change in level of consciousness, nuchal rigidity, and meningeal signs (positive Kernig's and Brudzinski's signs). Antibiotic treatment is essential. (Option 1) The parents will not be allowed to take this child out of the hospital against medical advice as it will endanger the child's life. It does not matter that it is a religious reason for the desired AMA. (Option 2) Durable power of attorney for health care (health care proxy) is something a competent adult establishes when that adult can no longer self-advocate. Parents are automatically the legal guardians and decision makers for their minor children as long as the decisions do not put any of their children in danger. (Option 4) The ethical principle of autonomy is deciding for oneself. In this case, the child's best interest is priority and the legal authority takes precedent. Educational objective: Hospital administration will obtain legal protective custody of a minor child if the parents are deciding against life-saving measures for their child or when there is child abuse/neglect.

A nurse discontinues patient-controlled analgesia per the health care provider's prescription, and notes that there is 10 mL of morphine sulfate left in the cartridge. All other nurses on the unit appear busy. What is the most appropriate action by the nurse? 1. Ask UAP to witness the wasting of the med 2. Document that another nurse was not available to waste the med 3. Wait until another nurse is available and then witness the waste together 4. Waste the morphine alone and then show the empty cartridge to the charge nurse

3 Opioids (eg, morphine, hydromorphone, fentanyl) are controlled medications, regulated in the United States by the Controlled Substances Act and in Canada by the Controlled Drugs and Substances Act. These laws contain regulations (eg, methods of disposal) for various controlled substances. To properly dispose of leftover opioid medication in a patient-controlled analgesia pump, the nurse must have a second licensed nurse witness the waste of the medication (Option 3). Hospital policy should be followed to properly waste the medication and discard the empty cartridge. When a controlled substance is discontinued, the nurse documents the date, time, amount used, reason for the waste, and amount wasted. (Option 1) Unlicensed assistive personnel (UAP) cannot witness the waste of medication as it is outside their scope of practice. Two licensed nurses must document this process. (Option 2) Simply documenting that another nurse is not available does not follow government regulations for wasting controlled substances. Disposal should occur only when a second licensed nurse is available as a witness. (Option 4) It is never appropriate to waste a controlled substance without the witness of another nurse. In addition, nurses should never document or sign off on anything that was not personally witnessed or completed as this constitutes falsified documentation. Educational objective: Waste of controlled substances (eg, opioids) must be witnessed by two licensed nurses to comply with facility policy and government regulations.

A client with end-stage renal disease, oxygen-dependent chronic obstructive pulmonary disease (COPD), and a Do Not Resuscitate (DNR) code status is admitted to the medical floor for COPD exacerbation. The nurse walks into the room and finds that the client is not breathing. What should the nurse do first? 1. Activate the code system 2. Call the HCP stat 3. Check the apical pulse 4. Check the BP

3 The nurse has a medical order stating that the client should not be resuscitated. Therefore, the appropriate first action is to assess the apical pulse. Then the nurse should call the HCP. If the client's family members are present, the nurse should explain what is happening and make sure that they have support. (Option 1) Activating the code system is not appropriate as this client has an order to withhold resuscitation. (Option 2) The nurse should assess the client and then call the HCP. A stat page is not needed when the client is DNR. (Option 4) Measuring the blood pressure is not appropriate if this client has stopped breathing. Checking an apical or central pulse would be appropriate after noticing that the client is not breathing. Educational objective: A DNR order requires the nurse to withhold resuscitation in the event of a cardiac or respiratory arrest. If an event occurs, the nurse should assess for breathing and check the central or apical pulse. After performing these actions, the nurse should call the HCP to confirm the death.

The hospital nurse coming on duty notifies the unit of a delay due to a motor vehicle accident. The off-going nurse has an important appointment and must leave on time. How should the off-going nurse handle the situation? 1. Ask another nurse to watch the current assigned clients until the incoming nurse arrives 2. Tape record a report and leave a cell phone number to call if there are any questions 3. Tell the charge nurse of the impending need to leave and that client coverage is required 4. Write out a report about the clients for the incoming nurse prior to leaving

3 The off-going nurse must ensure that there is another registered nurse responsible for the care of the clients, if this is not done then abandonment has occurred. A deliberate report must be given using standardized format for continuity of care. During the hand-off, objective data should be provided about the clients' current status and response to treatment to enable planning care. The off-going nurse should let the charge nurse know as this individual is responsible for the staffing of the unit and would have the authority to try different options, such as asking another nurse on the unit to stay or notifying the main nursing office to obtain a nurse from another unit. In addition, there is no established time frame for the incoming nurse's actual arrival; a significant amount of time could pass before this inadequate staffing issue is resolved. (Option 1) This general vague oversight is an inadequate report and transfer of responsibility to the other nurse. (Option 2) Tape recording a report is a legitimate method of communication as long as there is an opportunity to ask questions. However, this does not resolve the issue of procuring a nurse to take over responsibility for the clients' care. (Option 4) Although this would help transmit essential information, it does not accomplish procurement of another nurse to be responsible for the clients' current care. Educational objective: In a facility with 24-hour care, prior to leaving, an off-going nurse must have another nurse take over the responsibility for the clients' care and give an appropriate report for these clients. Leaving clients without these elements can be deemed to be an act of abandonment.

During shift change, the night nurse notices that the graduate nurse administered IV dopamine instead of the prescribed norepinephrine for a client with sepsis. What should the night nurse do first? 1. Administer the correct medication and obtain current vital signs 2. Alert the grad nurse and complete an incident report 3. Assess the client and notify the HCP 4. Discontinue the dopamine and inform the nursing supervisor

3 When a medication error occurs, client safety is the nurse's first priority. The nurse should assess the client immediately for any adverse effects and inform the healthcare provider (HCP) (Option 3). Before taking any other actions, the nurse must ensure that the client is stable. Following client stabilization, the error should be reported to the appropriate nursing authority (eg, supervisor, manager), and an incident or occurrence report should be filed within 24 hours. (Option 1) Prior to administering the correct medication, the HCP should be informed to ensure that the original medication is appropriate in light of the medication error. Additional medications or therapies may be necessary to reverse the effects of the medication given in error. (Option 2) Although it is important that the graduate nurse has a chance to learn from the mistake, ensuring client safety is the first priority. An incident report can be filed after the client is stable. (Option 4) Discontinuing dopamine without providing another medication for hemodynamic stabilization may harm the client. The nursing supervisor should be informed after client stabilization. Educational objective: Client safety is the first priority when a medication error occurs. The nurse should assess the client and inform the HCP about the error before reporting to nursing management and completing an incident report.

Which of the following are violations of protected client health information? Select all that apply. 1. Client overhears the nurse give report on the client's roommate through the room curtain 2. Nurse calls a client by the first and last names in the public waiting room 3. Nurse givs a pregnancy result to the client's partner without the client's permission 4. Nurse tells the transporting tech that the client has breast cancer 5. UAP tells a discharged client, "You take care now"

3,4 Under the Health Insurance Portability and Accountability Act (HIPAA) and the Personal Information Protection and Electronic Documents Act (PIPEDA), a client's information regarding medical treatment is private and cannot be released without the client's permission. There must be a reasonable effort to limit the use of, disclosure of, and requests for protected health information (PHI) to the minimum necessary to accomplish the intended purpose. The client's PHI should not be shared with a partner or spouse without the client's permission (Option 3). PHI is shared with an employee on a "need-to-know" basis. A transporting employee does not need to know the client's diagnosis, only information related to positioning/transferring or personal protective equipment (for infection precautions), if applicable (Option 4). (Option 1) A client overhearing report through a privacy curtain is inadvertent communication and is not considered a violation. (Option 2) Calling a client by the first and last names in the waiting room is not a violation as long as no other pertinent information is given. (Option 5) Any employee can provide socially acceptable well wishes to a client. This does not involve PHI. Educational objective: The Health Insurance Portability and Accountability Act and the Personal Information Protection and Electronic Documents Act requirements related to protected health information include not giving results to a spouse without permission or telling a client diagnosis to an employee who does not need to know it. It is not a violation to call clients by their names, have information overheard inadvertently, or indicate well wishes.

The nurse is caring for a hospitalized client. Which are the best examples of narrative documentation to provide legal malpractice protection for the nurse after an adverse event? Select all that apply. 1. Client found on floor this morning at 6:50AM. No verbalized symptoms. I think client tripped over a cord. Client instructed on safety during ambulation 2. Client reports that IV pole hit head at 0730. Denies pain. IV pole removed for client safety. Will continue to monitor. HCP notified 3. Heparin infusion running at 15units/kg/h at 0715; infusion rate adjusted to prescription of 12units/hg/hr. Labs drawn at 0720, aPTT 65 sec. HCP notified; will draw labs again at 1320 4. IV site in R hand is red and swollen at 0930. IV removed, bleeding controlled, and warm compress administered at 0940. Will reassess for swelling and pain every hour 5. Package of green leaves found in client drawer at 1300. Client acting suspicious at 1400. HCP notified. Will call security. Client has multiple tattoos and piercings

3,4 Documentation should be clear, concise, and accurate to be credible, which includes being timely, truthful, and appropriate. When charting a symptom or situation, the nurse should chart the interventions taken and the client response. An adverse event is an unusual occurrence, accident, or injury unrelated to the client's underlying condition. Adverse events must be acknowledged and documented in the chart. It is essential for the nurse to note the actions taken in response to the event (eg, client teaching, safety precautions) and the time frame in which they were performed. Documenting the key, pertinent negatives indicating that no client harm resulted and the appropriate interventions implemented to rectify or reduce harm will minimize nursing liability. If an incident report is also required, it is separate from the medical record and should never be mentioned in the client's chart. (Option 1) Lack of a verbalized symptom does not ensure that no injury was sustained. In addition, documentation should be objective and not contain opinions. (Option 2) A generic notation of "continue to monitor" is meaningless; the nurse should monitor all clients regardless of the situation. (Option 5) "Suspicious" is subjective wording; the nurse should document exactly which actions appeared suspicious (eg, rapidly hides package every time nurse enters room; will not let nurse see package). Educational objective: After an adverse event, the nurse should document objective, specific assessments and interventions. These include signs/symptoms indicating a lack of client harm and any corrective actions taken.

Which are correct understandings of applying nursing ethical principles? Select all that apply. 1. Autonomy is requiring the client to have an advance directive 2. Beneficence is withholding prognosis from a client due to family wishes 3. Fidelity is administering meds as prescribed to the client 4. Justice is telling the client the truth that the biopsy is positive 5. Nonmaleficence is refusing to give report to a nurse who is impaired

3,5 Ethical principles guide the nurse in making appropriate decisions and acting accordingly. They speak to the essence but not to the specifics of the law. Fidelity is exhibiting loyalty and fulfilling commitments made to oneself and others. It includes meeting the expected responsibilities of professional nursing practice and provides the basis of accountability (taking responsibility for one's actions) (Option 3). Nonmaleficence means to do no harm and relates to protecting clients from danger when they are unable to do so themselves due to a mental/physical condition (eg, children, client with Alzheimer disease) and from a nurse who is impaired (Option 5). (Option 1) Autonomy is the right to make decisions for oneself (eg, informed consent). Although having an advance directive is an example of autonomy, requiring one violates this principle. The client has a right to refuse even if the nurse believes it is in the client's best interest. (Option 2) When a diagnosis is withheld, even if due to the nurse's or family's good intentions, it violates the principle of autonomy. Beneficence means to do good (eg, implementing interventions to promote the client's well-being). (Option 4) The principle of justice refers to treating all clients fairly (ie, without bias). Veracity is telling the truth as a fundamental part of building a trusting relationship. Educational objective: Nonmaleficence is doing no harm, fidelity is loyalty and commitment, justice is equal treatment for all, beneficence is doing good for the client's best interest, and autonomy is making decisions for oneself.

A 16-year-old walks in unaccompanied by a parent and approaches the clinic nurse. The adolescent asks to be tested for a sexually transmitted infection (STI). How should the clinic nurse respond? 1. Determine if the client wore protection 2. Inform that parental consent if required 3. Inform that the request is honored if the client has symptoms 4. Provide requested service

4 "Mature minors" are adolescents who are age 14-18 and are deemed able to understand treatment risks. They are legally allowed to give independent consent to receive/refuse treatment for some limited conditions. Classically, these conditions include testing and treatment for STIs, family planning, drug and alcohol abuse, blood donation, and mental health care. A minor who is a parent, pregnant, or an emancipated minor can also give consent. An emancipated minor is a self-supporting adolescent under age 18 who is married, on active duty in the military, granted emancipation by the court, or not living at home. (Option 1) This information could be requested if a professional relationship with assessment is established. It would be beneficial to reinforce the concept of safer sex regardless. However, that is not the essential need as STIs can be transmitted even when protection is used. (Option 2) Minor children ordinarily need parental consent unless specific conditions are met. In this case, the nature of the request allows the care to be given. (Option 3) STIs do not always have obvious signs/symptoms that would allow the client's needs to be determined accurately. Educational objective: Mature minors are adolescents between age 14-18 who can give independent consent for limited conditions such as STIs, family planning, drug and alcohol abuse, blood donation, and/or mental health care.

The client has metastatic cancer, and a living will on record indicates that the client does not want cardiopulmonary or pharmacologic resuscitation. The client is brought to the emergency department with respirations of 4/min and a heart rate of 20/min. How should the nurse handle the situation at this time? 1. Ambu bag the client with a bag valve mask apparatus 2. Ask the client if the client has had a change of mind 3. Find out who is designated as the client's durable POA for health care 4. Provide comfort measures

4 The 2 most common forms of advance directives are living wills and durable power of attorney for health care (health care surrogate/proxy). These take effect when the client cannot self-advocate. A living will represents the client's wishes regarding actions to be taken in specific situations. A durable power of attorney is an individual who decides actions to fluid situations according to an understanding of the client's wishes. The client was lucid when indicating wishes. Ordinary care is usually considered fluids, oxygenation, analgesics, and antibiotics. The client has a terminal illness, and aggressive interventions would probably be futile over the long term. The client's wishes should be honored. (Option 1) Artificially ventilating a client is part of cardiopulmonary resuscitation. The client has indicated not to be resuscitated. However, nasal cannula oxygen can be given for comfort. (Option 2) If the client indicates a change of mind, it should be honored. However, a client with respirations of only 4/min and a heart rate of 20/min probably does not have adequate perfusion and oxygenation to the brain to make the best decisions (if alert and oriented). The client's wishes were indicated when the client was able to think clearly, and these wishes should be honored at this time. (Option 3) A durable power of attorney takes effect when there is no living will indicating what actions to take on the client's behalf. Educational objective: Two common advance directives are a living will (dealing with specific events/issues) and a durable power of attorney for health care (eg, an individual who can make decisions on the circumstances in light of the client's wishes). A client's specific wishes as indicated should be honored.

The nurse caring for a terminally ill client asks if the client has an advance directive. The client states, "I already have a power of attorney." What is the best response by the nurse? 1. A power of attorney (POA) is good to have in place. It sounds like you are on the right attack 2. Great. Your POA can start to make decisions for you when you are no longer able to do so 3. Many people find a lawyer at this stage of life. A lawyer can help you get your affairs in order 4. There are many types of POAs. Let's clarify if your POA can make health care decisions for you

4 A power of attorney (POA) designates a representative to act on a person's behalf in the event that the individual becomes incapacitated. There are different types of POAs, including medical and financial. An advance directive or living will describes the client's health care decisions (eg, do not resuscitate). As part of an advance directive, the client may designate a representative to make health care decisions for the client - a durable POA for health care or POA for health care (Canada). This client's statement requires further clarification regarding what type of POA is in place (Option 4). (Option 1) The nurse should not assume that the client's affairs are in order based on this statement. Further clarification is needed to determine whether the client has made the appropriate arrangements regarding health care decisions. (Option 2) Although it is correct that the POA makes decisions for a client only when the client is no longer able to make them, the nurse first needs to determine what type of POA is in place. (Option 3) Lawyers can help with end-of-life paperwork, but the priority is to clarify whether the client has the appropriate POA in place. Educational objective: An advance directive makes clear a client's health care wishes (eg, do not resuscitate). A power of attorney (POA) designates a representative to act on a person's behalf. It is important to clarify that the client has the type of POA who can make health care decisions (durable POA for health care, POA for health care [Canada]).

A housekeeping employee tells the staff nurse of having a headache and asks for acetaminophen. How should the nurse respond? 1. Ask about liver disease and give acetaminophen from the nurse's personal supply 2. Assess the employee's BP 3. Check for allergies to drugs before giving acetaminophen from hospital stock 4. Refer employee to the employee health provider

4 Although acetaminophen is an over-the-counter drug, the nurse should not give it without a prescription. By doing so, the nurse would be functioning outside the job description. There has not been a proper assessment (eg, allergies, liver disease), and a legal caregiving relationship will be established by administering the medication. If the employee does not want to go to the employee health provider, the nurse can suggest that the employee purchase acetaminophen in the gift shop. (Option 1) It is advisable for the nurse to ask about liver issues prior to administering acetaminophen, but this nurse has no prescription to administer it. Taking the medication from a personal supply, rather than hospital stock, does not change the fact that the nurse is functioning outside the job description while on duty. (Option 2) The nurse could technically perform the assessment, but it is not within the nurse's current role and job description. The employee health provider (or the emergency department) should be used for this assessment. (Option 3) The nurse should check for allergies before administering a drug, but this nurse has no prescription to administer acetaminophen. Acetaminophen being an over-the-counter medication does not change this fact. Educational objective: The nurse should not give medication to an employee without a prescription even if it is an over-the-counter drug.

A client was treated in the emergency department 2 days ago. The nurse makes a follow-up call to say that a culture shows that the client needs an antibiotic. The client's spouse answers the phone, says that the client is at work and doing fine, and that the client does not need the antibiotic. Which is a priority action for the nurse? 1. Call the prescription into the client's pharmacy 2. Document the spouse's statement in the client's chart 3. Notify the ED physician 4. Request that the spouse tell the client to call back

4 The spouse does not have the authority to refuse the required medication for the client as the client is competent and has decision-making capacity. An informed refusal includes knowing the risks and benefits of the decision, including the potential of latent infection/damage in this case. If the client does not call back, the typical facility policy is to try to reach the client by phone 3 times, then by certified letter, and (depending on the seriousness of the result) then sending the police to contact the client. (Option 1) The prescription can be called into the pharmacy, but there is no guarantee that the client will pick it up and take it in light of the spouse's response. Speaking to the client is the priority. (Option 2) The statement and attempts for contact should be documented, but the first priority is client care. (Option 3) The emergency department physician should be notified of the conversation, but the priority is to speak to the client and explain the importance of the new follow-up treatment. If the client has a primary care provider, the nurse could also communicate with that office to aid follow-up. Educational objective: A competent adult with decision-making capacity can refuse essential treatment; the client's spouse does not have that legal authority. Treatment refusal must include awareness of the risks and benefits.

Which emergency department client would be allowed to leave against medical advice after the risks are discussed with the primary health care provider? 1. 5yo client meningitis whose parent refuses antibiotics 2. Client who tried to commit suicide by taking a handful of acetaminophen an hour ago 3. Client with a UTI who is disoriented to time and place 4. Client with coffee-ground emesis from chronic use of high-dose aspirin

4 To leave against medical advice (AMA), a client must have the risks explained and be able to understand them (ie, competent). Issues that can make a client ineligible to leave AMA include danger to self or others, lack of consciousness, altered consciousness, mental illness, being under chemical influence, or a court decision. Despite it not being in the client's best health interest, the client with gastrointestinal bleeding can leave AMA (Option 4). (Option 1) Parents may not refuse life-, limb-, or organ-saving treatment on behalf of their minor child for religious or personal reasons; they can make that decision only for themselves. If the parents deny critical treatments to the child, the hospital may seek protective custody. (Option 2) Suicidal ideation (ie, danger to self) is a criterion that prevents a client from being allowed to leave AMA. (Option 3) The client is not oriented x3 and is therefore not competent. There are 3 orientation categories (time, place, and person); orientation to time is lost first. To be oriented, the client must answer all questions in each category correctly. Educational objective: After an explanation of the risks is given, a client must be considered competent in order to leave against medical advice. A client with suicidal ideation or altered consciousness is not competent. Parents may not refuse limb-, life-, or organ-saving treatment for a minor child based on their own personal beliefs.

The nurse is working with a client admitted with delirium and reduced level of consciousness due to pneumonia and respiratory failure. The nurse anticipates that the client may need to be intubated soon. The client is not able to make decisions. Who will make decisions for the client? 1. The client's sibling 2. The client's spouse 3. The HCP 4. The health care proxy

4 When a client is unable to make decisions, the health care proxy is legally able to make decisions for the client. In the event that the health care proxy is unable to fulfill this role, the responsibility goes to the alternate proxies identified on the advance directive. If the client does not have a health care proxy, the family members would make decisions for the client. Occasionally, there is no family and no proxy. If this happens, a proxy may be appointed, an ethics board may make the decision, or the HCP may be responsible for making the decision. (Options 1, 2, and 3) The health care proxy would be the legally appointed primary decision maker. Educational objective: The role of the health care proxy is to make decisions for a client who is unable to do so. Ideally, the proxy will have a good understanding of the client's wishes and will be emotionally capable of fulfilling this important role.