N5E2 L&M

Nurse must accommodate patient's constitutional rights, including the following:

- Freedom to practice religion - Woman's right to abortion - Individual's right to die

Complaints usually revolve around patient's consent for treatment

- When nurse signs consent, bearing witness that patient signed form and that patient knows he or she is signing consent form

what 3 questions should you ask after a delegated task is completed

-Was the task done PROPERLY? -Was the task done in the proper TIME frame? -Were the client's NEEDS met?

Right supervision/evaluation

the nurse must have the appropriate skills to assist, teach and guide the individual who is completing the task the nurse will determine if client needs were met the nurse can continue or withdraw the delegation problems, particularly and sentinel events, are clarified or reported to supervisors

Nurse Practice Acts Definition (3)

1. Scope of practice- Establishes guidelines by which nurses can perform skills or services. 2. Is a set of statues ( rules and regulations ) that provide guidance to professional nurses 3. Establishes Education, Examination, licensure and behavioral standards for nurses that protect public

The Nurse Practice Act is Administered by the board of nursing in each state (2)

1. The nurses must know how their state defines professional misconduct 2. For professional misconduct, the state board of nursing imposes penalties (in order of severity)

Right direction/communication: WHAT 4 THINGS SHOULD BE CLEARLY COMMUNICATED?

1. specific steps of the task 2. expectation about performance 3. reporting 4. documentation

associations have engaged in a wide range of activities over time that support the evidence-based recommendations of the IOM

ANA:

right to act or empower

Authority

is calculated by taking the total number of patients at census time, usually midnight, over a period of time-for example, weekly, monthly, or yearly- and by dividing by the number of days in the time period. many institutions budget their staffing based on ADC and then adjust for patient's census and acuity changes. aa

Average daily census (ADC):

9. The nurse assigns an unlicensed assistive personnel (UAP) to care for a client with a musculoskeletal disorder. The client ambulates with a leg splint. Which task requires supervision of the UAP? A) Report signs of redness overlying a joint B) Monitor the client's response to ambulatory activity C) Encouragement for the independence in self-care D) Assist the client to transfer from a bed to a chair

B) Monitor the client's response to ambulatory activity

The continuous measurement of a process, product, or service compared to those of the toughest competitor, to those considered industry leaders, or to similar activities in the organization in order to find and implement ways to improve it.

Benchmarking

sharing client information with a third party that result in damage to client's reputation : can occur in form of slander (spoken) or libel (in writing

Defamation of character

Patient groupings, approximately 500 Medicare groups, established for hospital reimbursement purposes; these groupings are identified by patient diagnosis or condition, surgical procedure, age, comorbidity, or complications, and are expected to use similar hospital resources and have similar needs and outcomes

Diagnosis-related group:

skillful communication

FLAT: Factual Liable Accurate Timely

Quality Improvement (QI) uses a change model referred to as:

FOCUS-PDSA- is a common quality improvement approach utilized by many healthcare organizations F = Find a problem O = Organize a team C = Clarify the problem U = Understand a problem S = Select an intervention P = Plan D = Do S = Study A = Act

is an intentional deceptive act or statement to a client for the purpose of unlawful gains.

FRAUD

Category C Biologic agents

Hantaviruses, tick-borne encephalitis virus, and yellow fever

interprets law as it rules in court cases

Judicial branch

An applicant for licensure by either examination or endorsement may have their application denied. They will not be granted a license.

LICENSE DENIED

provides the hospital with materials to meet all ongoing needs -ex:

Logistics: ex: food, medication, shelter, and other supplies

able to walk

MINOR (green triage tag color)- secondary triage

what are the 3 terms of delegations -which ones are transferable? -which ones ALWAYS remains with the delegator?

Responsibility: transferable Accountability: REMAINS Authority: transferable

Scope of Practice - determined by

STATES NURSE PRACTICE ACT

An action which is stayed will not be in effect unless the licensee violates any conditions of an order. For example, a nurse on probation with a stayed suspension is able to work under the stipulations of the probation order. If the nurse violates any condition of the order, the license is immediately suspended.

STAYED DISCIPLINARY ACTION:

The period of suspension prevents the licensee from working as a practical (LPN) or professional (RN) nurse for definite or indefinite period of time.

SUSPENSION

Which professional organizations are responsible for establishing the codes of ethics?

State Boards of Nursing, state and national organizations, and specialty organizations

Which professional organizations are responsible for establishing the codes of ethics?

State Boards of Nursing, state and national organizations, and specialty organizations (ANA)

maintain a national repository of pharmaceutical agents, vaccines, medical supplies, and equipment that will be delivered to the site of a large-scale disaster to augment local and state resources in order to decrease morbidity and mortality in the civilian population. It is organized into five tiers: 12-hour push packs, vendor managed inventory, storage and rapid deploy- ment of vaccines, buying power with surge capacity, and technical assistance.

Strategic National Stockpile (SNS):

three components of each heath care system

Structure, process, and outcome

standard method of triage in mass casualty

The Simple Triage and Rapid Treatment (START) system

the contact person for representative of other agencies, such as the fire department and police

The liaison officer

● becoming a DMAT:

The nurse must provide and pay for his or her own personal gear, including a sleeping bag./ DMAT are volunteers; however, while deployed, they are considered federal employees and are paid wages.

monitors and has authority over the safety of rescue operations and hazardous conditions.

The safety and security officer

3 Inappropriate delegation

Underdelegation Reverse delegation Overdelegation

accept a voluntary surrender of a license certificate.

VOLUNTARY SURRENDER

means that delayed care is needed, with usually one system involved. a yellow tag, indicating the delayed care needed category, the injuries can be controlled or treated for a limited time in the field.

Yellow

what 2 things MUST be communicate

a TIME frame & the PRIORTY of the task.

accepting ownership for the results or lack of results

accountability

RN's always remain __________ when delegating to a UAP -what about an RN delegating to another RN?

accountable -BOTH accountable (may also be transferred to another RN, but never to a UAP)

Defined for protection of rights of citizens this includes:

administrative law -• Administrative rules defined for payment from federal funds to health care organizations --Specify licensing requirements for health care providers

Agencies responsible for implementing law have great deal of power to draft specific rules and regulations

administrative law- federal

Agreement among states to allow nurses licensed in other states to automatically receive licensure to practice in another state

administrative law- state

treat to touch another person in an offensive manner with out that persons permission ex: treat to give meds against clients will uses fear & intimidation

assault

Ability of an individual to determine his or her own course of action... -also called: -example:

autonomy -"self determination" -signing a consent

means that the person is deceased or that death is expected, with no life-extending care to be delivered. is for individuals with no spontaneous effective respiration after the air- way is repositioned

black

Category B Biologic agents

brucellosis, glanders, ricin, staphylococcal enterotoxin B, and some food-and water-borne illnesses such as salmonella, Shigella, and Vibrio.

Governs how individuals relate to others in everyday matters

civil law

Category A Biologic agents

smallpox, anthrax, plague, botulism, tularemia, and viral hemorrhagic fever

Five rights of delegation

Right task Right circumstances Right person Right direction/communication Right supervision

Right person

determine if staff members have the necessary knowledge, skills, and abilities (KSA) to perform the delegated tasks and if this information is documented determine if the client's condition is stable with predictable outcomes prior to delegating care

Right task

determine if the task is within the scope of practice for the delegatee determine agency policies, procedures, and standards understand standards of practice, e.g., the American Nurses Association (ANA) Standards of Practice remember - nursing tasks that be delegated to unlicensed assistive personnel (UAP) are intended to assist, but not replace, the nurse

Right circumstances

determine if there is anything about the client's condition or the environment which would preclude this delegatee from performing the task as delegated determine if staff members have the resources, equipment, and supervision needed to work safely

Focus of Quality Improvement (QI) or Performance Improvement (PI) is (5)

"DOING THE RIGHT THING": 1. Meeting the needs of the customer 2. Building quality performance into the work process 3. Assessing the work process to identify opportunities for improved performance 4. Employing a scientific approach to assessment and problem solving (Nursing Process) 5. Improving performance continuously as a management strategy not just when standards are not met

method of triage in PEDIATRIC POPULATION

"Jump START"

LVN/LPN scope of practice

-ASSIST IN IMPLEMENTING -assessment skills (normal vs abnormal) -care to clients that are stable or predictable -taking ROUTINE VS -providing BASIC life support -hygiene, digital fecal removal, changing linens, turning & positioning -admin: enteral/tube feedings, resp treatments, enemas, instilllation of eyes, ears, nose, buccal muscosa & rectum, meds that are suppositories, PO, NG, PEG, IM, ZTRACK, intradernal, SQ topical, SL (NOT INTRAURETHERAL ROUTE) -monitoring glucose -oral suctioning & feeding clients w/out oral or swallowing issues -inserting or removing foley caths -ostomie care -simple dressing changes (dry gauze) - providing postmortem care -inserting rectal tubes -removing sutures & staples -newborn care (cord, VS, feeding) -noncomplex sterile tech procedures -doc care and response & updating an initial assessment (validated by RN) -reinforced teaching from an RN or noncomplex teaching (simple diabetic teaching, simple dressing changes)

civil law encompases ...

-contract -tort

essential elements of the good samaritan law

-emergency situation -without pay -care that is NOT reckless or intentionally caused harm/injury

how do you effectively delegate? (6)

-giving written instructions for assignments -make frequent walking rounds to assess clients -delegate task based on the experience -take frequent mini reports -have them repeat instructions -explain unexpected outcomes of delegated tasks

delegating task to a FLOATING nurse -all nurses know how to: (3)

-interprete VS -give blood -give meds

Proving malpractice

1. Duty of care was owed to the injured party 2. Breach 3. Foreseeability 4. Causation 5. Injury 6. Damages DUTY BREACH OF DUTY-omission or commission HARM PROOF OF HARM

the 3 major categories of The Sentinel Event Database

1. Sentinel event data 2. Root cause data 3. Risk reduction data

6. The nurse in a same-day surgery unit assigns the unlicensed assistive personnel (UAP) to provide a hernia patient with a lunch tray. Which statement by the nurse is most appropriate? A) "Tell the family they can bring in a pizza if the patient would prefer that." B) "Make sure the patient gets at least 2 cartons of milk." C) "Stop the IV if the patient is able to eat solid food." D) "Encourage the patient to eat slowly to prevent gas."

D) "Encourage the patient to eat slowly to prevent gas."

3. A nurse from the pediatric unit is assigned to work in a critical care unit. Which client assignment would be appropriate? A) A client admitted with multiple trauma with a history of a newly implanted pacemaker B) A new admission with left-sided weakness from a stroke and mild confusion C) A 53 year-old client diagnosed with cardiac arrest from a suspected myocardial infarction D) A 35 year-old client in balanced traction admitted 6 days ago after a motor vehicle accident

D) A 35 year-old client in balanced traction admitted 6 days ago after a motor vehicle accident

This disciplinary action is a public reprimand by the Board of Nursing for a violation of the Nurse Practice Act. It is in the form of a written document and does not impose any conditions on the practical or professional license.

DECREE OF CENSURE:

integrate best research with clinical expertise and patient values for optimum care, and participate in learning and research activities to the extent feasible

EBP

unable to walk + no spontaneous breathing + spontaneous breathing after positioning airway=

IMMEDIATE (red triage tag color)

unable to walk + spontaneous breathing +RR <30 + perfusion (present radial pulse & <2 sec cap refill) + doesnt obey command

IMMEDIATE (red triage tag color)

unable to walk + spontaneous breathing +RR <30 + poor perfusion (absent radial pulse & >2 sec cap refill)

IMMEDIATE (red triage tag color)

unable to walk + spontaneous breathing +RR >30

IMMEDIATE (red triage tag color)

is violating the privacy of the client by sharing their patient information other personal information.

Invasion of privacy

can a UAP delegate to a UAP

NO

EACH BOARD OF NURSING HAS ITS OWN _________ passed by each states _________ to regulate the practice of nursing in that state

NURSE PRACTICE ACT legislature

legally, a breach of the duty to provide nursing care to the client and failure of an individual to perform or not perform an act that a reasonable person would or would not perform in a similar set of circumstances

Negligence

What is the Difference between Negligence and Malpractice

Negligence is the failure to act as a reasonably prudent (careful) person would have acted in a specific situation and harm occurs to the patient. Malpractice is negligence by a professional person during the performance of professional duties. Malpractice refers to a professional.

negligence vs malpractice

Negligence occurs when one fails to exercise the care that a reasonable person would exercise. Injury does not have to occur for negligence to occur. Malpractice is usually described as having multiple elements that all must be satisfied for malpractice to occur. There must be a duty, a breach of the duty, and a subsequent injury due to the breach.

is the amount of nursing care required per patient in a 24 hour period and is usually based on midnight census and past unit needs, expected unit practice trends, national benchmarks, professional staffing standards, and budget negotiations, the NHPPD reflects only productive nursing time needed.

Nursing hours per patient day (NHPPD):

Doing it right vs doing the right thing

QA=Doing it right QI=doing the right thing

what 3 things might you want to determine when delegating to a right person

SAK! -knowledge -skills -abilities

NERVE AGENTS S/S: (mnemonic)

SLUDGEM: salivation, lacrimation, urination, defecation, gastric upset, emesis, and miosis (pupil contraction) Often there is a complaint of dim vision. The nerve agents also cause cardiac dysrhythmias, confusion, fasciculations (muscle twitches), and convulsions, along with unconsciousness. all ppl usually have: SOB, Miosis, Rhinorrhea

institutional policy and procedure documents

STANDARD OF CARE

EACH STATE HAS ITS OWN _________ that oversees _________ law

STATE BOARD OF NURSING statutory law

Touching without consent

battery

examples of federal administrative law

-Safeguards patients' private medical information.. HIPPA -Includes laws that prohibit discrimination -OSHA & its sharps container.. COME BACK

examples of intentional tort

-assault -battery -false imprisonment -invasion of privacy -defamation (libel=written/slander=verbal) -fraud

what can an UAP do? (cant say scope cuz unlicensed=NO SCOPE OF PRACTICE)

-basic care: housekeeping, changing linens, stocking supplies, bathing, transferring, turning & positioning, ambulating, feeing, toileting, oral hygiene (no swallowing issues) -obtaining measurements: ROUTINE VS, height, weight, I&Os, blood glucose -assisting with elimination & general ADL -obtaining specimens -documenting & reporting -utilizing proper communication -prioritizing task -handling complaints

examples of unintentional torts

-malpractice -negligence

right supervision/evaluation involve appropriate: - - - -

-monitoring -intervention -evaluation -ongoing feedback

a UAP can NOT... (2)

-perform any invasive or sterile procedures -assist in client teaching

sentile events include -who responds to sentinel events?

-the joint commission

Expectations Under the Standards for a Hospital's Response to a Sentinel Event

Accredited hospitals are expected to identify and respond appropriately to all sentinel events (as defined by the hospital in accordance with the preceding paragraph) occurring in the hospital or associated with services that the hospital provides, or provides for. Appropriate response includes conducting a timely, thorough, and credible root cause analysis; developing an action plan designed to implement improvements to reduce risk; implementing the improvements; and monitoring the effectiveness of those improvements.

A pediatric nurse receives a subpoena in a court case involving a child. Before appearing in court, what should the nurse review in addition to the State Nurse Practice Act and the ANA Code for Nurses? A. Nursing's Social Policy Statement B. State law regarding protection of minors C.ANA Standards of Clinical Nursing Practice D. References regarding a child's right to consent

Answer C. These guidelines govern safe nursing practice; nurses are legally responsible to perform according to these guidelines.

11. When walking past a client's room, the nurse hears 1 unlicensed assistive personnel (UAP) talking to another UAP. Which statement requires follow-up intervention? A) "If we work together we can get all of the client care completed." B) "Since I am late for lunch, would you do this one client's glucose test?" C) "This client seems confused, we need to watch monitor closely." D) "I'll come back and make the bed after I go to the lab."

B) "Since I am late for lunch, would you do this one client's glucose test?"

8.The home care nurse has been managing a client for 6 weeks. What is the best method to determine the quality of care provided by a home health care aide assigned to assist with the care of this client? A) Ask the client and family if they are satisfied with the care given B) Determine if the home health aide's care is consistent with the plan of care C) Investigate if the home health aide is prompt and stays an appropriate length of time for care D) Check the documentation of the aide for appropriateness and comprehensiveness

B) Determine if the home health aide's care is consistent with the plan of care

5.Two people call in sick on the medical-surgical unit and no additional help is available. The team consists of an RN, an LPN and an unlicensed assistive personnel (UAP). Which of these activities should the nurse assign to the UAP? A) Assist with plans for any clients discharged B) Provide basic hygiene care to all clients on the unit C) Assess a client after an acute myocardial infarction D) Gather the vital signs of all clients on the unit

B) Provide basic hygiene care to all clients on the unit

12. Which task for a client with anemia and confusion could the nurse delegate to the unlicensed assistive personnel (UAP)? A) Assess and document skin turgor and color changes B) Test stool for occult blood and urine for glucose and report results C) Suggest foods high in iron and those easily consumed D) Report mental status changes and the degree of mental clarity

B) Test stool for occult blood and urine for glucose and report results

4. An unlicensed assistive personnel (UAP), who usually works in pediatrics is assigned to work on a medical-surgical unit. Which one of the questions by the charge nurse would be most appropriate prior to making delegation decisions? A) "How long have you been a UAP?" B) "What type of care did you give in pediatrics?" C) "Do you have your competency checklist that we can review?" D) "How comfortable are you to care for adult clients?"

C) "Do you have your competency checklist that we can review?"

7. A staff nurse complains to the nurse manager that an unlicensed assistive personnel (UAP) consistently leaves the work area untidy and does not restock supplies. The best initial response by the nurse manager is which of these statements? A) "I will arrange for a conference with you and the UAP within the next week" B) "I can assure you that I will look into the matter" C) "I would like for you to approach the UAP about the problem the next time it occurs" D) I will add this concern to the agenda for the next unit meeting

C) "I would like for you to approach the UAP about the problem the next time it occurs"

2. Which client data should the nurse act upon when a home health aide calls the nurse from the client's home to report these items? A) "The client has complaints of not sleeping well for the past week" B) "The family wants to discontinue the home meal service, meals on wheels" C) "The urine in the urinary catheter bag is of a deeper amber, almost brown color" D) "The partner says the client has slower days every other day"

C) "The urine in the urinary catheter bag is of a deeper amber, almost brown color"

1. The measurement and documentation of vital signs is expected for clients in a long term facility. Which staff type would it be a priority to delegate these tasks to? A) Practical nurse (PN) B) Registered Nurse (RN) C) Unlicensed assistive personnel (UAP) D) Volunteer

C) Unlicensed assistive personnel (UAP)

• most reliable information by conducting ______ or _____

CINAHL or MEDLINE

A monetary penalty for each violation of the Nurse Practice Act.

CIVIL PENALTY

A person who files a lawsuit must prove four essential elements

COME BACK

Conduct a hazard risk analysis.

COME BACK

example of false imprisonment

Can occur when nurse misinterprets patient rights granted to others by legal documents • E.g., power of attorney -and of course using restraints w/ out permission

5. The LPN delegates the task of taking vital signs of all the clients on the medical- surgical unit to an unlicensed assistive personnel (UAP). Specific written and verbal instructions are given to not take a post-mastectomy client's blood pressure on the left arm. Later as the RN is making rounds, the nurse finds the blood pressure cuff on that client's left arm. Which of these statements is most immediately accurate? A) The RN has no accountability for this situation B) The RN did not delegate appropriately C) The UAP is covered by the RN's license D) The UAP is responsible for following instructions

D) The UAP is responsible for following instructions

unable to walk + spontaneous breathing +RR <30 + perfusion (present radial pulse & <2 sec cap refill) + obeys commands

DELAYED (yellow triage tag color)

has remains of several victims of a disaster to be identified and collected

DMAT

-responsible for morgue-related operations, remains identification, and family notification.

DMORT

is a contractual agreement that is entered into voluntarily

Delegation

Negligence involves four legal concepts:

Duty Breach of duty Proximate cause Damages Duty: nurses have a legal obligation to provide nursing care to clients must meet a reasonable and prudent standard of care under the circumstances must deliver care as any other reasonable and prudent nurse of similar education and experience would, under similar circumstances Breach of duty: failure to provide expected, reasonable standard of care under the circumstances (includes errors of omission or commission) Proximate cause: relationship between the breach of duty and the resulting injury the injured party must prove that the nurse's action or omission led to the injury Damages: the injury and the monetary award to the plaintiff

• hospital integrated informatics into patient care:

EHR

unable to walk + no spontaneous breathing + apnea after positioning airway=

EXPECTANT (black triage tag color)

order of triage categories by importance

EXPECTANT (black triage tag color) IMMEDIATE (red triage tag color) DELAYED (yellow triage tag color) MINOR (green triage tag color)

means treason; murder; manslaughter; sexual battery; carjacking; home-invasion robbery; robbery; burglary; arson; kidnapping; aggravated assault; aggravated battery; aggravated stalking; aircraft piracy; unlawful throwing, placing, or discharging of a destructive device or bomb; and any other felony which involves the use or threat of physical force or violence against any individual

Forcible felony

________ amount of radiation affects the GI ______ amount of radiation affects the CNS

GI: 600 rad/ CNS: 1000 rad

means that minor care is needed. for green tags includes individuals who are ambulatory, with or without minor injuries that do not require immediate or significant treatment.

Green

Invasion of Privacy: laws are mandated by _________ & standards set by _____________

HIPPA ANA's code of ethics for nurses

National Evidence-Based Strategies: 6 interventions targeted at harm(IHI):

High alert meds; Reduce surg complications; Prevent pressure ulcers; Reduce MRSA infections; Deliver reliable EB care for CHF; Get boards on board

who can an LPN delegate to? who can an UAP delegate to?

LPNs: delegate to UAP's UAPs: NO ONE (unlicensed = no scope)

3 branches of constitution

Legislative, Executive, Judicial

personal equipment levels

Level A Level B Level C Level D

NEVER DELEGATE

PACET: -Planning -Assessment -Collaboration/consult (wound/therapy) -Evaluations (requires nursing Judgement) -teaching (primary)

All licensed nurses (LPN or RN) on probation have work conditions and may have other mandated requirements. EMPLOYERS must be presented with a complete copy of the licensee's Probated Order, including findings of fact, conclusions of law, and terms of the order.

PROBATION

Responsibilities of a RN (summary)

Performing head-to-toe assessment including complex and/or routine vital signs. Administering basic and advanced life support. nursing process: -Assessing—data collection and analysis. Diagnosing—identifying and prioritizing client problems. -Planning—stating expected outcomes and methods for achievement. -Implementing—interventions to achieve expected outcomes. -Evaluating—analysis of plan of care and client outcomes. Caring for invasive lines (examples: peripherally inserted central line PICC], Swan Ganz catheter, arterial lines). Feeding clients with oral or swallowing problems. Administering blood and blood product transfusions. Titrating medications based on specific client needs and physician orders. Performing extensive or complex dressing changes or wound care. Teaching of clients and families (Example: discharge teaching to parents caring for a child with a ventriculoperitoneal shunt).

YOU CANNOT DELEGATE

Planning (care plan) Assessment (initial assessment)( Secondary assessment can be delegated not primary) First assessment cannot be delegated. Collaboration - If a patient needs a consult Wound consult Therapy consult Evaluation - evaluation goals, pain levels, trending vitals signs, outcomes. This is the role of the RN. The LPN and UAP can collect data vitals signs but they cannot evaluate Teaching - You cannot delegate primary education. This primary role of an RN is teaching. LVN can reinforce *PAY ATTENTION TO WORD LIKE CHRONIC- A PATIENT WITH CHRONIC DISEASE CAN BE DELEGATED UNLESS THEY ARE NON COMPLIANT- EXAMPLE - A diabetic patient can be delegated unless they are noncompliant because if they are non-compliant it means they health becomes unpredictable NEW ADMISSION: INITIAL assessment. the nursing process: key words- assess, observe, teach, monitor problem-solving skills. a task that has the slightest chance of causing harm. Feeding a client who has dysphagia Ambulating a client who recently has had hip surgery. Taking vital signs on client who is unstable. PATIENT WHO HAS JUST RECEIVED A SURGICAL PROCEDURE PATIENTS WHO NEED ADVANCED INFECTION CONTROL MEASURES Do not delegate establishing a plan of care. Do not delegate teaching.(lpn's can reinforce teaching, note the words reinforce) Do not delegate telephone advice. Do not delegate the handling of any invasive lines. This includes central lines, arterial lines, Swan-Ganz catheters, and PICC lines Never delegate discharge planning or any skill that requires judgment skills ***however if a patient is being discharged they a usually considered stable thus can usually delegated unless there is a mention of planning the discharge. Don't assume someone is competent to do something just because of their JOB DESCRIPTION. It is the RN's REPONSIBILITY to figure out the staffs strength and WEAKNESSES ***When you(RN) identify a weakness you are supposed to TEACH. Teach, teach.*** When staff members are pulled to a new floor, you should pretend they are a brand NEW nurse all over again.

AMERICAN NURSING CODE OF ETHICS

Provision 1 The nurse, in all professional relationships, practices with compassion and respect for the inherent dignity, worth, and uniqueness of every individual, unrestricted by considerations of social or economic status, personal attributes, or the nature of health problems. Provision 2 The nurse's primary commitment is to the patient, whether an individual, family, group, or community. Provision 3 The nurse promotes, advocates for, and strives to protect the health, safety, and rights of the patient. Provision 4 The nurse is responsible and accountable for individual nursing practice and determines the appropriate delegation of tasks consistent with the nurse's obligation to provide optimum patient care. Provision 5 The nurse owes the same duties to self as to others, including the responsibility to preserve integrity and safety, to maintain competence, and to continue personal and professional growth. Provision 6 The nurse participates in establishing, maintaining, and improving health care environments and conditions of employment conducive to the provision of quality health care and consistent with the values of the profession through individual and collective action. Provision 7 The nurse participates in the advancement of the profession through contributions to practice, education, administration, and knowledge development. Provision 8 The nurse collaborates with other health professionals and the public in promoting community, national and international efforts to meet health needs. Provision 9 The profession of nursing value, for maintaining the integrity of the profession and its practice, and for shaping social policy. COME BACK

goal to prepare nurses to continuously improve quality of care in their work environments. states that nurses must have to improve quality and safety in...

Quality & Safety Education for Nurses (QSEN): • SAK! Skills Attitudes Knowledge... (he has some QUALITY SAKs)

- also known as Performance Improvement (PI)

Quality Improvement (QI)

Inspection approach to ensure that minimum standards of patient care quality are maintained in health care institutions

Quality assurance (QA):

Systematic process of organization-wide participation and partnership in planning and implementing continuous improvement methods to understand and meet or exceed customer needs and expectations

Quality improvement (QI):

means that immediate care is needed, with usually two or more systems affected. Those with a red tag, indicating the immediate care needed category, classic assessment findings include that respirations are present only after repositioning the airway, respiratory rate is less than 8 or greater than 30, capillary refill is delayed more than 2 seconds, and there may be a significant decrease in level of consciousness.

RED

The START triage system uses four categories:

RED YELLOW GREEN BLACK

Licensee's privilege to practice either as a practical (LPN) or professional (RN) is revoked for a period. This person may not practice for the stipulated time frame.

REVOCATION

Summary of rules of Delegation

Rule #1: Do not delegate the functions of assessment, evaluation and nursing judgement. During your nursing education, you learned that assessment, evaluation and nursing judgement are the responsibility of the registered professional nurse. You cannot give this responsibility to someone else. Rule #2: This is not the real world. Do not make decisions regarding management of care issues based on decisions you may have observed during your clinical experience in the hospital or clinic setting. Remember, the NCLEX is ivory tower nursing. The answers to the questions are found in nursing testbooks or journals. Always ask yourself, "Is this textbook nursing care?" Rule #3: Delegate activities for stable patients with predictable outcomes. If the patient is unstable, or the outcome of an activity not assured, it should not be delegated. Rule #4: Delegate activities that involve standard, unchanged procedures. Activities that frequently reoccur in daily patient care can be delegated. Bathing, feeding, dressing and transferring patients are examples. Activities that are complex or complicated should not be delegated. Rule #5: Remember Priorities! Remember Maslow, the ABC's, and stable versus unstable when determining which patient the RN should attend to fist. Keep in mind that you can see only one patient or perform one activity when answering questions that require you to establish priorities.

is a not-for-profit organization whose purpose is to provide an organization through which boards of nursing act and counsel together on matters of common interest and concern affecting the public health, safety and welfare, including the development of licensing examinations in nursing.

The National Council of State Boards of Nursing (NCSBN)

16.A newly admitted older adult client is diagnosed with severe dehydration. When planning care for this client, the nurse should assign which task to an unlicensed assistive personnel (UAP)? a. Converse with the client to determine if the mucous membranes are impaired b. Report hourly outputs of less than 30 mL/hr within 15 minutes of the check c. Monitor client's ability for movement in the bed from side to side d. Check skin turgor every four hours along with the need to change the adult diaper

b. Report hourly outputs of less than 30 mL/hr within 15 minutes of the check

what is the difference b/w a baccalaureate vs an associates degree

baccalaureate: prepared nurses are equipped to care for individuals, FAMILIES, GROUPS, and COMMUNITIES in BOTH a structured and UNSTRUCTURED health setting associates degree: ONLY INDIVIDUALS and only in a STRUCTURED health care environment

ethics specific to health care service as a framework to guide behavior in ethical dilemmas

bioethics

The Registered Nurse working in the emergency room observes that his co-worker is not performing well in providing care to the client. He suspects that his /her co-worker is substance impaired and notes signs of alcohol intoxication. The Nurse Practice Act requires that the Registered Nurse do which of the following ask the colleague to go to the nurse's lounge to sleep for a while talk with the colleague report the information to a nursing supervisor call the impaired nurse organization

c

IMMEDIATE (red triage tag color)

can be helped by immediate interventions & transport requires medical attention w/in minutes to survive (up to 60 mins) includes compromise to patients airway, breathing, circulation

DELAYED (yellow triage tag color)

can delay transport serious or life threatening injury but status not expected to deteriorate significantly over hours

individuals relate to each other in ever day matters in encompasses contract and tort laws

civil law

Malpractice is usually filed as a

civil tort, a court finding or guilty usually results in restitutiON

● the nurse is assessing victims of a building collapse. Ambulances are nearby and there is a shelter set up with carts, chairs, tables, and refreshments for the victims, name zone:

cold zone

which zone are you not allowed in until the decontamination process is completed -also called the

cold zone -green zone or support zone ● The cold zone, or green zone, is also known as the support zone. The hospital is in the cold zone. In situations in which decontamination is necessary, no one is allowed into the cold zone without being decontaminated

made when judicial decisions used by other courts and develop force of law

common law

grants authority to make, implement, and interpret laws

constitution

public law include

constitution criminal administrative

Focuses on actions of individuals that can potentially do harm to others -often focused on _______ --2 examples that affects nurses:

criminal law -Often focuses on abuse and neglect of young and elderly --• Nurses must have criminal background checks for hiring purposes --Affects nursing practice in prohibition against substance abuse

A nurse observes that a client received pain medication 1 hour ago from another nurse but the client still has severe pain. The nurse has previously observed this same occurrence. On the basis of the nurse practice act, the observing nurse plans to do which of the following? a. Report the information to the police. b. Call the impaired nurse organization. c. Talk with the nurse who gave the medication. d. Report the information to a nursing supervisor.

d

invoked when the client is no longer able to make decisions on his or her own behalf.

durable power of attorney

DIFF B/T EMERGENCIES & DISASTERS:

emergencies can be handled in available emergency services

example of mitigation

ex: a building, located in a high risk for earthquake area, is constructed to withhold earthquakes

Nurse can face charges of battery for

failing to honor advanced directive, durable power of attorney, or living will -side note: Do Not Attempt Resuscitation (DNAR) order may be written by practitioner without evidence of living will on medical record

restraining an individual or restricting an individual's freedom

false imprisonment

The principle of promise keeping; the duty to keep one's promise or word.

fidelity

provides the funding for the operation and assists with recovery of costs

finance

waiting to be decontaminated

hot zone ● The hot zone, also called the exclusion zone or red zone, is the area of highest contamination. This is where people who are waiting to be decontaminated are staged.

Decontamination Zones:

hot zone warm zone cold zone

Zones of Decontamination

hot zone: warm zone: cold zone:

where all involved can interact and communicate in all phases of disaster management

incident command system (ICS)/ HICS

The principle of fairness that is served when an individual is given that which he or she is due, owed, deserves, or can legitimately claim

justice

Enact laws on both federal and state

legislative

is making false statement in print or in writing.

libel

is invoked only when the client has a terminal condition or is in a persistent vegetative state

living will

● running out of blood, who you gunna call (HICS):

logistics

a form of prevention that involves reducing or eliminating the consequences of a hazard or incident so that it has limited impact on society.

mitigation

the 4 phases of emergency disaster

mitigation, preparedness, response, recovery

Behavior in accordance with custom or tradition; usually reflects personal or religious beliefs.

morality

DISASTERS: human-generated VS natural

natural disasters: include hurricanes, floods, tornadoes, wildfires, and earthquakes. human-generated disasters: include motor vehicle crashes with multiple victims, release of chemical agents into the environment, release of biologic agents, exposure to radiation, and explosions

s when a resident is harmed due to care giver not acting in reasonable and caring manner towards the resident.

negligence

delegating task to a FLOATING nurse: -all nurses know how to: (3)

no specialized assignments -interprete VS -give blood -give meds

the integration of nursing, its information, and information management with information processing and communication technology to support the health of the people worldwide

nursing informatics

Standards of Practice - established by

nursing profession, i.e., the ANA

• Three integral pieces of federal legislation that states use to regulate health insurance through the development of national standards are:

o COBRA (Consolidated Omnibus Budget Reconciliation Act), o HIPAA (Health Insurance Portability and Accountability Act) o ERISA (Employee Retirement Income Security Act).

what are the 5 stages of disaster cycle

o The Non-Disaster Stage o The Pre-Disaster Stage o The Impact Stage o The Emergency Stage o The Reconstruction and Recovery Stage o The Non-Disaster Stage → planning, preparing, and mitigation. o The Pre-Disaster Stage → there is evidence of impending disaster is known of and action include warning, pre-impact mobilization, and evacuation. o The Impact Stage → when the disaster has occurred and the community experiences immediate effects; rapid assessment of damages, injuries, and population needs is completed. o The Emergency Stage → when there is immediate and long-term need for assistance including first aid, search and rescue, emergency medical assistance, establishment and restoration of transportation and communication, assessment of infectious diseases and mental health problems, and evacuation of residents as needed . o The Reconstruction and Recovery Stage → includes restoration of property with rebuilding, replacing lost or damaged property, returning to school and work, and continuing without those lost in the disaster; reconstitution, where the life of the community returns to normal; and mitigation- future-oriented activities to prevent or minimize the effects of future disasters take place.

IOM sets recommendations for the curriculum for the nursing program

o ability to provide pt- centered care o Ability to effectively worth in interprofessional teams o Understanding evidence-based practice o ability to measure quality care o Ability to use health information technology

EHR must incorporate the following functionalities

o computerized physician order entry (CPOE) o e-prescribing o clinical decision support (CDS) o clinical e-doc system

Omission vs. Commission

omission is when you don't provide service that's necessary- making assumption someone can't afford diagnostic test so don't recommend- would be that a physician is unaware of patient's cultural background - did not know patient had to pray about it before going through with treatment so didn't go through with it. Commission providing wrong treatment- beta blockers don't work well in blacks- recommend to someone without knowing they're black, over diagnosing kids into special education

who can a RN delegate to?

other RN's LVN/LPN UAPs CNAs PCT (patient care tech) or other ancillary staff

when nurses are able to identify personal values and then accurately identify the values of the client and articulate the client's point of view.

patient advocate

Statement of beliefs based on core values and rational investigations of the truths and principles of knowledge, reality, and human conduct.

philosophy

planning section is responsible for providing a situation status report to hospital workers every 4 to 6 hours and interacts with operations to establish plans for medical staff rotation

planning

requires that those who may be affected by the disaster have the equipment and resources needed to increase the chances of survival and decrease losses related to the disaster. accomplished via development & rehearsal of an emergency plan.

preparedness

requires that those who may be affected by the disaster have the equipment and resources needed to increase the chances of survival and reduce losses related to the disaster example:

preparedness ex: stalking food and water

functions of the nurse practice act (2)

protect the public define the scope of nursing practice

getting financial assistance to help pay for the repairs

recovery

Hospital-Specific Definition of Sentinel Event

requires each accredited hospital to define sentinel event for its own purposes and to communicate this definition throughout the organization. While this definition must be consistent with the general definition of sentinel event as published by The Joint Commission, accredited hospitals have some latitude in setting more specific parameters to define unexpected, serious, and the risk thereof. At a minimum, a hospital's definition must include those applicable events that are subject to review under the Sentinel Event Policy as defined in Section IV of this chapter

: Acknowledgement of the right of people to make their own decisions

respect for others

involves returning the lives and the environment of those example

response ex: seeking shelter from a tornado

an obligation to accomplish a task

responsibility

Designed to identify and correct problems that contribute to errors in patient care or employee injury

risk management Can assist in identifying and correcting underlying problems of incident - Can investigate and record information surrounding patient or employee incident that may result in lawsuit COME BACK

• informatics in an informal manner

seminars and scholarly journals.

is an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. -why are they called this?

sentinel event -because they signal the need for immediate investigation and response.

example of Sentinel event:

surgery on wrong limb

organizes and directs the emergency operations center and gives overall direction for the hospital operations

the incident commander:

who & what operations are involved in the HICS (chart)

the incident commander: The liaison officer the public info officer The safety and security officer medical or technical specialist the operations: Logistics Operations planning finance

What group primarily is protected under the regulations of the practice of nursing?

the public

provides information to the media, releases other information as indicated, and assists with communication.

the public info officer:

Which of the following phrases describes one of the purposes of the ANA's nursing's social policy statement?

to describe nursing's values and social responsibility -The nursing's social policy statement describes the values and social responsibility of nursing. The American Nurses Association (ANA) publishes its Standards of Nursing Practice, which defines the responsibilities of the RN to all clients for quality of care. ANA also publishes a code of ethics for nurses

Negligent or intentional civil wrong not arising out of contract

tort law

EXPECTANT (black triage tag color)

unlikely to survive provide palliative care & pain relief

Personal beliefs about the truth of ideals, standards, principles, objects, and behaviors that give meaning and direction to life.

values

A smallpox outbreak has been identified, and supplies have been requested from

vendor-managed inventory. (hospital's internal inventory)

● arrives to hospital after being exposed to chemicals. name the decon. zone:

warm

This area is where decontamination of victims or triage and emergency treatment take place.

warm zone ● The warm zone, or yellow zone, is also referred to as the contamination reduction corridor. The warm zone, or control zone, is adjacent to the hot zone. This area is where decontamination of victims or triage and emergency treatment take place.

the delegator validates with the delegatee that an understanding exists regarding _______________________ & the ______________, ____________ & ____________ are discussed

what is to be done expected outcomes potential problems solutions

Negligence and Nursing Advocacy

• ANA Code of Ethics and many state Nurse Practice Acts require nurses to serve as patient advocates • Most hospitals have policies and procedures to assist nurse in carrying out advocacy function • Nurses serve as advocates by safeguarding patient legal interests and helping patients make end-of-life decisions

consumer empowerment, better access to health information, and complete and accurate health information.

• Benefits of the EHR:

Malpractice/Professional Liability Insurance

• Nurses may need to carry own malpractice insurance - May not be covered under employer's liability insurance • Professional liability insurance provides assurance and pays for attorney to defend nurse in malpractice lawsuit

Documentation

• Occurs because of professional responsibility and accountability • Provides written evidence of nurse's accountability to patient, organization, profession, and society - Legal document to protect patient, organization, and nursing and medical practitioners COME BACK

HIPAA

•This legislation, better known by most as HIPAA, describes how personal health information, or PHI, may be used and how the client can access the information. •HIPAA requires every healthcare agency to keep PHI private, provides information to the client about the agency's legal responsibilities regarding privacy, and explains the client's rights with respect to PHI. •The client has various rights as a consumer of health care under HIPAA. •The client who feels that his or her privacy rights have been violated may file a complaint with the

phases of Acute radiation syndrome (ARS)

● prodromal phase: GI symptoms- N/V/D for 2 days & onset w/in 30 min. At higher levels, fever, hypotension, and diarrhea can also be present. but fatigue and malaise will last longer ● latent phase: individual is relatively symptom free. 2 weeks ● illness phase: individual is relatively symptom free.

reaction phase: reentry phase fact phase: teaaching phse:

● reaction phase, the participants identify their own emotional reactions to the most traumatic aspects of the event. ● reentry the session is summarized and questions are answered. ● fact phase each participant describes the event from his or her own point of view. ● teaching phase of the critical incident stress debriefing session, the facilitators of the session provide education regarding adaptive coping mechanisms.

● priority for a pt whos been exposed to over 1,000 rads of radiation:

: Administer sedatives and analgesics. (CNS symptoms)

covers the work of medical care.

Operations

• The PHR is maintained by the:

PATIENT

A systematic process to improve outcomes based on customers' needs

QI

An inspection approach to insure that health care institutions maintain minimum standards of care

Quality Assurance (QA)

various educational content or exercises

Remediation

is making false statements (spoken) which may injure the reputation of a client.

Slander

publishes its Standards of Nursing Practice, which defines the responsibilities of the RN to all clients for quality of care

The American Nurses Association (ANA)

Nurse Practice Act of each state - Defines practice of nursing - Mandates requisite preparation for practice of nursing - Disciplines members of profession

administrative law- state

set of basic laws that specifies the powers of various segments of the government and how these segments relate to each other

constitution

• QSEN is an initiative focused on:

reform in nursing education in the areas of quality and safety

The obligation to tell the truth

veracity

6 Pitfalls for Nursing

• Misunderstanding of verbal orders • Illegible writing • Poor use of professional judgment • Not following institution's policy and procedures • Failure to adhere to institutional protocol • Not adhering to standards of practice

Nurse/Attorney Relationship

• Retain specialist • Be attentive • Notify insurance carrier as soon as aware of any real or potential liability issue • Keep costs sensible • Keep informed • Weed through writing • Set own course

was created to develop and implement a national strategy for health care quality measurement and reporting.

• The National Quality Forum

UAP(SUMMARY)

assist in a variety of direct client care activities or tasks, e.g., bathing, transferring, ambulating, feeding, toileting, and obtaining measurements (vital signs, height, weight, intake and output, blood glucose levels) perform indirect activities such as housekeeping, transporting people and stocking supplies Obtaining routine vital signs. Did you catch the word "ROUTINE"? Bathing, providing oral hygiene, changing bed linens. Turning and positioning. Feeding clients without any oral or swallowing problems. Providing basic life support. Ambulating. (Stable/noncomplex clients only) Obtaining height and weight measurements. Assisting with elimination. Monitoring input and output (I & O). Administering soapsuds enemas. PAY ATTENTION TO THIS ONE Assisting with general activities of daily living Obtaining specimens (such as a clean catch or midstream urine specimen. Or stool specimen). Transferring clients with the use of proper body mechanics. Documenting and reporting information related to client care to the RN. Reporting unusual observations and symptoms reported by the client or observed to the RN. Utilizing proper communication techniques (introducing self; listening to the nurse/client; resolving conflicts or initiating resolution giving/receiving feedback). Prioritizing tasks (per the direction of the RN or LPN/LVN), Handling complaints. ***The UAP cannot perform any invasive or sterile procedures or assist in client teaching***

LVN/LPN scope of practice (SUMMARY)

assist in implementing a defined plan of care and to perform procedures according to protocol assessment skills are directed at differentiating normal from abnormal competence to care for physiologically stable clients with predictable conditions Taking routine vital signs. Did you catch the word "routine? Providing basic life support. Bathing, giving oral hygiene, and changing bed linens. Turning and positioning. Administering enemas, digital fecal removal. Administering medications via PO, NG, PEG, IM, Z-track, intradermal, SQ, suppository, topical, and sublingual routes. Medication administration via the intrauretheral route is not within the LPN/LVN's scope of practice. Administering instillations in the eyes, ears, nose, buccal muscosa, and rectum. Administering enteral or tube feedings. Monitoring blood glucose Oral suctioning. Feeding clients without any oral or swallowing problems. Performing simple dressing changes (example: dry gauze dressing). Inserting and removing Foley catheters. Caring for ostomies. Administering respiratory treatments. Providing postmortem care. Inserting rectal tubes. Removing sutures and staples. Caring for newborns including cord care, vital signs, and feeding. Performing noncomplex procedures requiring sterile technique. Documenting the care given to the client and the client's response to that care. Updating an initial assessment; the data that is collected by the LVN must be validated by the RN Reinforcing the teaching performed by the RN. Teaching from a standard care plan, noncomplex teaching Examples: simple diabetic teaching, simple dressing changes).'' *****Be aware that prior to any discharge teaching, an assessment must be done by the RN to determine what needs teaching. In an NCLEX question, however, you may have to select appropriate discharge teaching for a LPN/LVN to complete. The key in this situation is to make sure that what is taught is noncomplex, simple, and fairly the same tor each client****

Right direction/communication:

potential problems and solutions are discussed the nurse intervenes if necessary staff members must be able to decline without jeopardizing their jobs

Focus of Quality Assurance (QA) is (3)

"DOING IT RIGHT": 1. Assessing or measuring performance 2. Determining whether performance conforms to standards 3. Improving performance when standards are not met

Responsibilities of a RN

-ADPIE -teaching -head to toe assessments -complex &/or routine VS -admin life support (basic or advanced) -admin blood products -titrating meds -invasive line care (PICC, swan ganz, arterial) -feeding clients with swallowing diff -complex/extensive wound care/ dressing changes

● core competencies of emergency and disaster preparedness for nurses

-Creative problem -solving skills -Emergency communication skills -Understanding of personal limitations -Identification of emergency situations

medical vs sentinel events

-side note: The terms "sentinel event" and "error" are not synonymous; not all sentinel events occur because of an error, and not all errors result in sentinel events.

MAJOR ROLES OF NURSE IN DISASTERS

1. Determine magnitude of the event 2. Define health needs of the affected groups 3. Establish priorities and objectives 4. Identify actual and potential public health problems 5. Determine resources needed to respond to the needs identified 6. Collaborate with other professional disciplines, governmental and non-governmental agencies 7. Maintain a unified chain of command 8. Communication

Possible reasons for disciplinary action or sanction include the following

1. Professional misconduct 2. Negligence- conduct that could negatively affect public health and welfare (by commission or omission) 3. Accepting and carrying out assignments incorrectly or with insufficient preparation. 4. Physical or verbal abuse 5. Breach of confidentiality 6. Improper delegation 7. Failure to maintain accurate records 8. The impaired nurse 9. The nurse who violates boundaries ( Sex with patient, taking money etc)

the four goals of Sentinel Event Policy

1. To have a positive impact in improving patient care, treatment, and services and preventing sentinel events 2. To focus the attention of a hospital that has experienced a sentinel event on understanding the factors that contributed to the event (such as underlying causes, latent conditions and active failures in defense systems, or organizational culture), and on changing the hospital's culture, systems, and processes to reduce the probability of such an event in the future 3. To increase the general knowledge about sentinel events, their contributing factors, and strategies for prevention 4. To maintain the confidence of the public and accredited hospitals in the accreditation process

14. Which statement by the nurse is appropriate when giving an assignment to an unlicensed assistive personnel (UAP) to help a client ambulate for the first time after a colon resection? A) "Have the client sit on the side of the bed before helping the client to walk." B) "If the client is dizzy ask the client to take some slow, deep breaths." C) "Help the client to walk in the room as often as the client wishes." D) "When you help the client to walk, ask if any pain occurs."

A) "Have the client sit on the side of the bed before helping the client to walk."

10. The care of which of the following clients can the nurse safely delegate to an unlicensed assistive personnel (UAP)? A) A client with peripheral vascular disease and an ulceration of the lower leg. B) A pre-operative client awaiting adrenalectomy with a history of asthma C) An elderly client with hypertension and self-reported non-compliance D) A new admission with a history of transient ischemic attacks and dizziness

A) A client with peripheral vascular disease and an ulceration of the lower leg.

2. A nurse is attending an In-service training class on delegation. The nurse learns that proper delegation can involve which of the following? Select all that apply a) giving authority b) delegating nursing process c) delegating tasks d) delegating accountability e) delegating responsibility f) giving orders

A, C, E - proper delegation involves giving authority, delegating tasks, and delegating responsibility. Nursing process, accountability and giving orders are to be done by the RN, and not to be delegated.

1.A nurse recently started working in a hospital that employs unlicensed assistant personnel (UAP). Which of the following are essential to effective delegation? SATA a) give the UAP written instructions for assignments b) make frequent walking rounds to assess clients c) delegate tasks based on the experience of the UAP d) take frequent mini-reports from the UAP e) have the UAP repeat instructions f) explain unexpected outcomes of delegated tasks to the UAP

ALL

1. During an interview of a prospective employee who just completed the agency application, which approach should a nurse manager use to assess skills' competence of this potential employee? A. "Let's review your skills check-list for type and level of skill for tasks." B. "Let's talk about your comfort zones for working independently." C. "What degree of supervision for basic care do you think you need?" D. "What types of complex client care tasks or assignments do you prefer?"

ANS: A The nurse needs to know that the potential employee has competence in certain tasks that are common on the unit. One way to do this is to do mutual review of the agency list of skills. The other questions might be asked during the skills checklist review.