Exam 2 Blueprint

Question 1

Ethics (Nurse Ethics)

Answer 1

🔸 Definition:
➢ System of principles that govern the actions of the nurse in relation to patients, families, other health care providers, policymakers, and society

🔸 Codes of ethics
➢ Implicit standards and values for the profession
➢ American Nurses Association Code of Ethics
➢ International Council of Nurses Code for Nurses

Question 2

Bioethics

Answer 2

🔸 Description
➢ Interdisciplinary field within healthcare that has evolved with modern medicine to address questions that arise as science and technology produce new ways of knowing

➢ Physicians, nurses, social workers, psychiatrists,
clergy, philosophers, and theologians are joining to address ethical questions in health care

🔸 Dilemmas for health professionals
➢ Life and death
➢ Right to decide
➢ Informed consent
➢ Alternative treatment issues
➢ Stem cell research
➢ Sexual reassignment
➢ Therapeutic and reproductive cloning
➢ In vitro fertilization; donor insemination
➢ Surrogate motherhood
➢ Organ transplantation

🔸 Dilemmas created by technology
➢ Illnesses that once led to mortality are now manageable and are classified as chronic illnesses
➢ Cost is a consequence of prolonging life with
technology
➢ Manipulation of DNA

Question 3

Ethical principles

Answer 3

🔶 Purpose of ethical principles
➢ Establish common ground among nurse, patient, family, other health care professionals, and society for discussion of ethical questions and ethical decision making
➢ Permit people to take a consistent position on specific or related issues
➢ Provide an analytical framework by which moral problems can be evaluated

🔸 Autonomy
- Right to make own decision
- Principle of respect for the person
- Primary moral principle
- Concepts of freedom and informed consent are grounded in this principle

🔸 Beneficence
- Do good
- To promote goodness, kindness, and charity

🔸 Non-maleficence
- Do no Harm
- Implies a duty not to inflict harm
- To abstain from injuring others
- To help others further their own well-being by removing harm

🔸 Veracity
- Being Truthful, Honesty
- Principle of truth-telling
- Belief that truth could at times could be harmful held for many years

Question 4

Malpractice insurance

Answer 4

🔸 Malpractice:
- Special type of negligence; that is, the failure of a professional, a person with specialized education and training, to act in a reasonable and prudent manner

🔸 Reasons for Malpractice Insurance
- More states recognize nurse malpractice as a legitimate claim in a civil suit
- Functions for RNs and advanced practice nurses are expanding
- Increasing floating and cross-training mandates
- Nurses have increasing responsibility for supervising subordinate staff
- Some employers may fail to initiate an adequate defense for nurses

Question 5

Statutory laws

Answer 5

➢ Statutory law are governed by the law/Judicial system)

➢ Violations are criminal offenses and are punishable by fines or imprisonment.

➢ Violations of the nurse practice act or rules and regulations
* Licensing boards have the authority to hear and decide cases against nurses
* Penalties
* Issuing a formal reprimand
* Establishing a period of probation
* Levying fines
* Limiting, suspending, or revoking the nurse’s license

Question 6

Tort

Answer 6

➢ Its a direct violation of a person’s legal rights
➢ Plaintiff does not have to prove that the nurse breached a special duty or was negligent
➢ Consequences include fines and punitive damages, but may rise to the level of criminal acts

🔸 Assault and battery
🔸 Defamation of character; libel/slander
🔸 False Imprisonment; restraints
🔸 Intentional infliction of emotional distress
🔸 Invasion of privacy

Question 7

Incident reporting (unusual occurrence reports)

Answer 7

➢ Nurses legally bound to report critical incidents to the manager
➢ Critical incidents that result in patient injury or death may lead to a malpractice claim
➢ Know appropriate procedures for completing and filing the incident report
➢ Describe events objectively; avoid subjective comments or personal opinions
➢ Never note in the medical record that an incident report was completed or filed
➢ Never photocopy the incident report
➢ Physician’s order for an incident report should not be written in the chart
➢ Report every unusual occurrence or incident

Question 8

Mandated reporting

Answer 8

➢ Laws mandating reporting of specific health problems and suspected or confirmed abuse
➢ Health professionals must report the following under penalty of fine or imprisonment for failing to do so:
🔸 Infant and child abuse
🔸 Dependent elder abuse
🔸 Specified communicable diseases

➢ Most laws grant immunity from suit within the context of the mandatory reporting statute

Question 9

Ethical decision making

Answer 9

• Answering difficult questions
• What is safe care?
• When staffing is inadequate, what care should be accepted or refused?
• What does it mean to be ill or well?
• What is the proper balance between science/technology and the good of humans?
• Where do we find balance when science will allow us to experiment with the basic origins of life?
• What happens when tension exists between personal beliefs and values and institutional policy or patient desires?

Question 10

Ethical decision making Model

Answer 10

🔸 Situation assessment procedure
➢ Identify the ethical issues and problems
➢ Identify and analyze available alternatives for action
➢ Select one alternative
➢ Justify the selection

🔸 Bioethical Dilemmas
➢ Abortion; Reproduction issues: genetic screening, and cloning; Human Genome Project
➢ Euthanasia and assisted suicide
➢ Right to healthcare; Allocation of scarce resources

Question 11

Moral development for a professional nurse

Answer 11

🔸 Moral development:
- Forming a worldview and value system through an evolving, continuous, dynamic process that moves along a continuum of development

Question 12

Negligence/malpractice

Answer 12

🔸 Negligence:
- Failure to act in a reasonable and prudent manner

🔸 Malpractice:
- Special type of negligence; that is, the failure of a professional, a person with specialized education and training, to act in a reasonable and prudent manner

Question 13

The law and patient rights

Answer 13

🔸 Advance directives
➢ Statutes grant adults the right to refuse extraordinary medical treatment when no hope of recovery
➢ Patient’s wishes are made known through execution of a formal document known as the living will
➢ Medical and physician directives
* Document that lists desire of patient in a particular scenario
* If properly executed, provides physician with immunity from claims of negligence in the patient’s death

🔸 “Do not resuscitate”orders
* Written by physician on the basis of directives by the patient
* Nurses have absolute duty to respect patient’s DNR orders
* A lawfully executed DRN order must be followed

🔸 Durable power of attorney for healthcare:
- Document that authorizes patient to name the person who will make the day-to-day and end-of-life decisions when he or she becomes decisionally incompetent

Question 14

Informed consent

Answer 14

🔸 Informed consent
➢ Physician or advanced practice nurse has duty to disclose information so patient can make choices
➢ Mandated by federal statute and state law
➢ Information that must be disclosed:
* Nature of the therapy or procedure
* Expected benefits and outcomes
* Potential risks
* Alternative therapies
* Risks of not having the procedure

Question 15

Values Formation and Moral Development

Question 16

RN, LPN, UAP tasks and responsibilities

Answer 16

🔸 Registered Nurse (RN)
➢ Unstable client, outcome unpredictable
➢ Assessment
➢ Initiate teaching
➢ Initiate plan of care
➢ Administer high-risk meds
➢ Initiate IVs and Blood products

🔸 Licensed Practicing Nurse (LPN)
➢ Cannot be assigned to initially assess, initially teach, or evaluate any client.
➢ Can reinforce client teaching.
➢ Cannot delegate the care of an unstable client.
➢ Can give some but not all medications (they can give PO meds but not IV Meds).
➢ Trach care, suctioning, insert urinary catheters, and administration of enteral feedings.
➢ Sterile procedures

🔸 Unlicensed Assistive Personnel (UAP)
➢ Cannot be given any activity that requires nursing judgment. These include assessing, teaching, evaluation, or administering meds to any client.
➢ The collecting, reporting, and documentation of simple data.
➢ ADL’s & hygiene
➢ Feeding (if no swallowing precautions)
➢ Ambulation & positioning
➢ I/Os, specimen collection
➢ Vital Signs (stable patients).
➢ Weight

Question 17

ANA Delegation standards

Answer 17

• ANA’s standard states that in delegation, the RN will consider the following:
  ➢ Assessment of the patient’s condition
  ➢ Capabilities of the nursing and assistive staff
  ➢ Complexity of the task to be delegated
  ➢ Amount of clinical oversight (supervision) the RN will be able to provide
  ➢ Staff workload

Question 18

Delegation Criteria

Answer 18

1. Low potential for harm
2. The activity has minimal complexity
3. Problem solving/innovation involved is minimal
4. Outcome is highly predictable
5. Patient has ample opportunity to interact with RN
6. RN is available to supervise activity and its outcome

Question 19

Safe delegation practices

Answer 19

• Develop a foundation of knowledge (i.e., nurse practice act, policies, standards of care, competencies, etc…)
• Know the patient
• Know the staff member and his/her skills & competencies
• Know the task
• Explain tasks and expected outcomes
• Expect responsible action
• Assess and supervise
• Evaluate and follow-up

Question 20

Five rights of delegation

Answer 20

🔸 Right task
- Delegated tasks must conform to established guidelines

🔸 Right circumstances
- Delegated tasks do not require independent nursing judgment

🔸 Right person
- One who is qualified and competent

🔸 Right direction & communication
- Clear explanation about the task and outcomes and when the delegatee should report back to the RN

🔸 Right supervision and evaluation
- Feedback to assess and improve the process; evaluate patient outcomes

Question 21

Assignment considerations

Answer 21

• RN responsible for assignments made to nursing personnel and should consider:

➢ Patient’s physiologic status and complexity of care ➢ Infection control or cross-contamination issues
➢ Level of supervision required
➢ Staff development opportunities such as assigning a less experienced nurse to a more complex patient with an increased level of supervision

Question 22

Nurse Practice Act

Answer 22

• RN should understand the legal scope of practice for an LPN/LVN

Question 23

Activities an RN cannot Delegate

Answer 23

• Initial and any subsequent assessment that requires nursing knowledge, judgment, and skill
• Determination of nursing diagnoses
• Establishment of nursing care goals
• Development of nursing plan of care
• Evaluation of patient’s progress
• Health counseling or teaching
• Activities that require specialized nursing knowledge, skill, or judgment

Question 24

Levels of Supervision

Answer 24

🔸 Unsupervised
➢ One RN works with another RN in a collegial relationship
➢ Neither RN is in the position of supervising the other

🔸 Initial direction/periodic inspection
➢ RN is supervising a licensed or unlicensed caregiver
➢ Knows the individual’s training and competencies
➢ Has developed a working relationship with the individual

🔸 Continuous supervision
➢ RN has determined that the delegatee will need very frequent to continual support and assistance

Question 25

Prioritization

Answer 25

➢ Acute vs Chronic
➢ ABCs
➢ Maslow’s Hierarchy of Needs
➢ Urgent vs Non-urgent
➢ Survival Potential

Question 26

Federal policies that shaped nursing practice

Answer 26

➢ Nurse practice acts and registration of nurses (implemented in most states by 1910)
- This regulates what we can and cannot do.

➢ Sheppard-TownerAct(1921)
- In charge of prenatal care.

➢ Hill-BurtonAct(1950)
- Hospital funding

➢ Medicare program(1965)
- Funding for geriatric population

➢ Renal disease program(1972)
- Dialysis care program

➢ Diagnosis-related groups (DRGs)(1983)

➢ Patient Protection and Affordable Care Act(2010)

Question 27

Examples and Levels of health policy

Answer 27

🔸 Complex, dynamic process
➢ Enactment of legislation and accompanying rules and regulations that carry the weight of law
➢ Administrative decisions made by various governmental agencies
➢ Judicial decisions that interpret the law

🔸 Involves numerous individuals and groups
➢ Elected officials & governmental agency officials
➢ Experts in the related area
➢ Stakeholders such as corporate representatives
➢ Representatives from special interest groups
➢ Other affected citizens

🔸 Involves all three branches of government
➢ Executive- president and department heads
➢ Legislative- senate and house of reps
➢ Judicial- supreme court and other courts

Question 28

Health Policy development

Answer 28

• Societal problems that may qualify for a policy solution are those brought to the attention of a policymaker who is willing to take definitive action

Question 29

Staffing Needs

Answer 29

➢ Number of patients
➢ Intensity of care required (Patient system)
➢ Contextual issues (architecture of the environment; available technology)
➢ Staff experience and preparation
➢ Quality of the nurses’ work life

Question 30

Care Delivery Models

Answer 30

🔸 Total Patient Care (doing everything)
- Nurse is responsible for planning, organizing, and performing all patient care during the assigned shift
➢Oldest method of organizing patient care, sometimes referred to as case nursing
➢ Nursing student typically performs total patient care for assigned patients

🔸 Functional Nursing
* Staff members are assigned to complete certain tasks for a group of patients rather than care for specific patients
* Lines of responsibility and accountability
➢ RN nurse manager assigns responsibility for completion of tasks to a group of health care workers
➢ RN is responsible for planning care and supervising workers
➢ RN retains accountability for the patient care provided

🔸 Team Nursing
* RN functions as a team leader and coordinates care for a small group of patients
* Lines of responsibility and accountability
➢ RN team leader is responsible for the following:
* Planning care
* Assigning duties
* Directing, supervising, and assisting team members * Giving direct care
➢ RN retains accountability for all patient care
➢ RN team leader is responsible for encouraging a cooperative environment and maintaining clear communication

🔸 Modular Nursing (subsets of team nursing)
* Modification of team nursing
➢ Patient unit divided into modules; same team of caregivers assigned consistently to same geographic location
➢ Each location or module has RN as team leader
➢ Goal is to increase the involvement of the RN in
planning and coordinating care
➢ Designated modules should contain all the supplies needed by the staff to maximize efficiency

Question 31

Case Management

Answer 31

🔸 Collaborative approach to:
➢ provide and coordinate healthcare services
➢ identify and facilitate options and services for meeting health needs
➢ decrease fragmentation and duplication of care
➢ enhance quality, cost-effective clinical outcomes

🔸 Nurse case manager “manages” a “case load” of patients from pre admission (onset of illness) to discharge (resolution of illness)

🔸 Case management is generally reserved for the chronically ill; the seriously ill or injured; and long-term, high-cost cases

Question 32

Patient-Centered care

Answer 32

🔸 Not a nursing care delivery model but a philosophy of care that is an essential component of any nursing care delivery model

🔸 Methods to engage patients, families, and significant others as partners in care
➢ Include them in developing care plans and discharge plans
➢ Include them in change-of-shift or handoff reports ➢ Provide them with the information and education
needed to make informed decisions
➢ Establish “family advisory councils” to engage patients and families in decision making

Question 33

Patient acuity

Answer 33

➢ Each patient is scored on a 1-to-4 scale (1, stable patient; 2, moderate-risk patient; 3, complex patient; 4, high-risk patient) based on the clinical patient characteristics and the care involved (workload.)

➢ Each nurse scores his or her patients, based on acuity, for the upcoming shift and relays this information to the charge nurse, who then assigns patients before the shift change.

➢ The handoff report between RNs allows each to validate patients’ current acuity and care needs.

Question 34

Clinical pathways

Answer 34

(Critical Paths, Practice Protocols, Care Maps)

➢ Delineates a predetermined written plan of care for a particular health problem
➢ Specifies desired outcomes and the interdisciplinary intervention required within a specified period for a particular diagnosis or health problem
➢ Written to address common medical diagnoses such as heart failure and pneumonia, common nursing care needs such as immobility, and medical complications such as weaning from mechanical ventilation

Question 35

Essential Components of Clinical Pathways

Answer 35

• Physical assessment guidelines
• Laboratory and diagnostic tests
• Medications and procedures
• Safety and self-care activities
• Nutrition
• Patient and family education needs
• Discharge planning
• May address triggers—potential or actual variations in the patient’s response to the planned interventions

Question 36

Wong (Hockenberry et al., 2007) describes learning right from wrong as being based on developmental stages. At what developmental stage is a human first able to integrate values of significant others into his or her behavioral system?

A. Infant
B. Toddler
C. School-age child
D. Adolescent

Answer 36

B. Toddler

Question 37

In determining the competencies of staff to whom the RN may delegate, the RN should review the annual staff competencies required by:

A. Licensing bodies such as the American Nurses Association

B. Certifying bodies such as the American Association of Critical-Care Nurses

C. Accrediting agencies such as The Joint Commission

D. Third-party payers such as private insurance and Medicaid

Answer 37

C. Accrediting agencies such as The Joint Commission

Question 38

Prioritization- Acute vs. Chronic

A nurse is receiving a hand-off report at the beginning of the shift for four clients. Which of the following clients should the nurse assess first?

A client who has macular degeneration and does not want to take his medication.

B. A client who is taking insulin and has a HbA1c of 7%.

C. A client who has Graves’ disease and has exophthalmos.

D. A client who is taking digoxin and is experiencing anorexia.

Answer 38

D. A client who is taking digoxin and is experiencing anorexia.

(The Pt is experiencing Digoxin toxicity - N & V, Halo effect, confusion, anoroxia, headaches )

Question 39

Prioritization - Maslow’s Hierarchy of Needs

A nurse is planning care for a client who has bipolar disorder and is experiencing an acute manic episode. Which of the following is the highest priority intervention the nurse should include in the plan of care?

A. Give the client simple directions for completing ADLs.

B. Offer the client high-calorie fluids frequently.

C. Provide the client with structured solitary activities.

D. Keep the client’s valuables in a locked area.

Answer 39

B. Offer the client high-calorie fluids frequently.

Question 40

Prioritization - Airway, Breathing, & Circulation (ABC)

A nurse is caring for a client who is wheezing and gasping for breath just after receiving a dose of amoxicillin. Which of the following action is the nurse’s priority?

A. Administer Epinephrine parenteral injection.
B. Provide reassurance to the client.
C. Initiate an IV infusion of 0.9% sodium chloride.
D. Place client on a cardiac monitor.

Answer 40

A. Administer Epinephrine parenteral injection.

(It opens up the Airway)

Question 41

Prioritization- Urgent vs. Nonurgent

A nurse is caring for a client who has peripheral arterial disease. Which of the following findings should the nurse report to the provider immediately?

A. Report of intermittent claudification
B. Shiny, hairless lower extremities
C. Absent dorsalis pedis pulse
D. Dependent rubor

Answer 41

C. Absent dorsalis pedis pulse

Question 42

Which of the following would have the highest priority when one is determining to whom to delegate a task?

A. How many times the person has performed the
task

B. Whether the employee wants to perform the task

C. The amount of time needed to complete the task

D. The credentials of the person to whom the task is being delegated

Answer 42

D. The credentials of the person to whom the task is being delegated

Question 43

A charge nurse assigns two RNs to provide care as a team for laboring patients. What are the supervisory needs of each of these RNs?

A. Because they have equal status, each RN is responsible for supervising the other RN

B. Supervision is not necessary because each RN is responsible and accountable for his or her own practice.

C. RNs cannot delegate to other RNs, so supervision is not possible in this situation

D. The charge nurse who made the assignment is responsible for supervising each of the RNs

Answer 43

D. The charge nurse who made the assignment is responsible for supervising each of the RNs

• (The Charge nurse supervises the other RNs only when they work as a Team.)

Question 44

A proposed city ordinance is pending with the local government that will require public buildings and restaurants to be smoke and tobacco free. Which action by the nurse should have the greatest effect on passage of the bill?

A. Explain the rationale for the bill to your book club and gain their support

B. Contact the elected representative’s office by phone to request support for the bill

C. Support a health advocate to run for election as city councilman

D. Tell all fellow students about the bill

Answer 44

B. Contact the elected representative’s office by phone to request support for the bill

Question 45

When participating in grassroots political strategies, the nurse should:

A. Refuse to vote in all elections until access to health care is universal

B. Withdraw membership to professional nursing organizations until the nurse/patient ratio is reduced nationally

C. Educate candidates about the effects of the nursing shortage on the quality of patient care and patient safety

D. Avoid raising issues of economic uncertainty in health care

Answer 45

C. Educate candidates about the effects of the nursing shortage on the quality of patient care and patient safety

Question 46

The nursing shortage escalates, and certain geographic areas must institute delivery models that require fewer numbers of registered nurses. Which type of nursing delivery models would be appropriate?

A. Total patient care and primary nursing
B. Team nursing and functional nursing
C. Total patient care and functional nursing
D. Primary care and team nursing

Answer 46

B. Team nursing and functional nursing

Question 47

A patient receives care for heart failure on a nursing unit in which the inter-professional team members— including nurses, physicians, and therapists—are committed to including the patient and spouse in change of shift reports and to seeking their input in all decisions affecting the patient’s care. What type of care model is represented in this unit?

A. Functional care
B. Primary care
C. Patient-centered care
D. Case management

Answer 47

C. Patient-centered care