LESSON 1 MANAGEMENT OF CARE

Concepts of Management and Supervision

 Review and understand standards, position statements, written policies/procedures before providing care
Board of nursing (U.S.)/regulatory body (Canada)
National Council of State Boards of Nursing (NCSBN)
Nursing organizations
American Nurses Association (ANA)
Canadian Nurses Association (CNA)
Health care institution/workplace
 Use critical thinking
 Understand the legal aspects of the nursing profession
Provide safe competent care
Advocate for client's rights
Provide care that is within the scope of practice
Provide care that is consistent with established standards of care
Don't Confuse these!
✓Scope of Practice - determined by a state's nurse practice act (or province/territory's nursing act)
✓Standards of Practice - established by the nursing profession (such as the ANA or CNA)
✓Standard of Care - institutional policy and procedure documents
QSEN & Priorities
 Use the six Quality and Safety Education for Nurses (QSEN) competencies as a guide for managing and
supervising care
1. Patient-centered care - the patient (or designee) is recognized as the source of control and full partner; care that
is provided is based on respect for patient's preferences, values, and needs
2. Teamwork and collaboration - open communication, mutual respect, and shared decision-making are used to
achieve quality patient care
3. Evidence-based practice - health care delivery is the integration of best current evidence with clinical expertise
and patient/family preferences and values
4. Quality Improvement - data is used to monitor the outcomes of care processes; improvement methods
continuously improve the quality and safety of health care systems
5. Safety - risk of harm to clients and providers is minimized through both system effectiveness and individual
performance
6. Informatics - information and technology is used to communicate, manage knowledge, mitigate error, and
support decision-making

 Establishing priorities
1. Prioritizing involves decisions of which needs or problems require immediate attention or action and which ones
can be delayed until a later time if they are not urgent
2. Needs that are life-threatening or could result in harm to the client if left untreated are high priorities
3. Actual problems or needs have higher priority than potential problems or needs
4. Problems or needs identified by client are of a higher priority
5. Consider Maslow's principles (hierarchy of needs) or the ABCs (airway, breathing, circulation) of emergency care
to guide decisions
6. Mutual decision-making for priorities may be made with the client based on the client's physiologic needs,
desires, and safety

Communication Skills & Conflict Resolution

 Communication skills and conflict resolution
 Communication
1. involves perception to receive a message
2. involves expectation - the unexpected may be ignored
3. makes demands on nurses to think and respond
4. is different than information

 Types of communication
1. downward - used to relate organizational policy such as position description and rules and regulations
2. upward - include such things as staff meetings
3. lateral - between staff members, i.e. to coordinate activities
4. diagonal - staff from different levels work together on a project
  Causes of conflict
1. inadequate communication
2. incorrect facts
3. unstable leadership or inadequate action plans
4. misunderstood roles or responsibilities
5. receiving directions from two or more delegators
6. lack of or limited staff input into decisions
7. inability to accept change
8. power issues

 Prevention of conflict includes

1. allocating resources fairly
2. avoiding unexplained changes
3. clearly stating expectations
4. addressing staff fears

 Dealing with conflict

a) take prompt action
b) help parties resolve conflict among themselves (communicate trust that parties can achieve resolution)
c) maintain an objective approach
d) avoid criticism
e) use problem solving approach
f) provide privacy for sensitive issues
g) negotiate for agreements - not winning or losing
h) focus on patient care interests
i) avoid emotional outbursts
j) include a third party when mediation seems the best choice

Communication & Collaboration

 Communication and collaboration techniques

SBAR technique - provides a standardized framework for communication between members of the health care team
 S = situation (a concise statement of the problem)
 B = background (pertinent and brief information related to the situation)
 A = assessment (analysis and considerations of options - what you found/think)
 R = recommendation (action requested/recommended - what you want)
"I PASS the BATON" - used to improve "handoffs" and transitions in health care, with opportunities to ask questions,
clarify, and confirm
 I = introduction (introduce yourself and your role/job)
 P = patient (name, identifiers, age, gender, location)
 A = assessment (presenting chief complaint, vital signs and symptoms and diagnosis)
 S = situation (current status/circumstances, including code status, recent changes, response to treatment)
 S = safety concerns (critical lab values/reports, socioeconomic factors, allergies, alerts such as falls, isolation,
etc.)
 B = background (co-morbidities, previous episodes, current medications, family history, etc.)
 A = actions (what actions were taken or are required and provide brief rationale)
 T = timing (level of urgency and explicit timing, prioritization of actions)
 O = ownership (who is responsible - nurse/doctor/team and patient/family responsibilities)
 N = next (what will happen next? anticipated change? what is the plan? what is the contingency plan?)
CUS - a process used to more effectively advocate for clients when there is a concern
 C = concern ("I am concerned...")
 U = uncomfortable ("I am uncomfortable...")
 S = safety ("this is unsafe...")
Delegation
II. Delegation
A. Definitions

1. Delegation: a process by which responsibility and authority for performing tasks are transferred from one
individual to another who accepts that authority and responsibility
 2. Delegation involves
a) responsibility: an obligation to accomplish a task
b) accountability: accepting ownership for the results or lack of
c) authority: right to act or empower over others

B. Delegation overview

1. A nurse can only delegate those tasks for which that nurse is responsible
2. The delegator remains accountable for the task
3. Along with responsibility for a task, the nurse who delegates must also transfer the authority necessary to
complete the task
4. The delegator knows how to perform the task being delegated
5. Delegation is a contractual agreement that is entered into voluntarily
Remember the steps in the Nursing Process - A Delicious PIE
 A = Assessment
 D = Diagnosis
 P = Planning
 I = Implementation
 E = Evaluation
Scope of Practice, Training & Education
C. Scope of practice, training and education of nursing personnel

1. Registered Nurses (RNs)

a) baccalaureate prepared nurses are equipped to care for individuals, families, groups and communities in both
structured and unstructured health settings
b) associate degree prepared nurses are equipped to care for individuals in a structured health care environment
c) RNs cannot delegate the following activities to unlicensed assistive personnel (UAP)
 assessment of clients
 evaluation of client data
 nursing judgment
 client/family education/counseling and evaluation
 nursing diagnosis/nursing care planning

2. Licensed Practical or Vocational Nurses (LPN/VN)

a) assist in implementing a defined plan of care and to perform procedures according to protocol
b) assessment skills involve collecting data and are directed at differentiating normal from abnormal
c) may reinforce information that has been given to the client by the RN
d) competence to care for physiologically stable clients with predictable conditions
e) the scope of practice for LPN/VNs is not the same in every jurisdiction

3. Unlicensed Assistive Personnel (UAP)

a) because they are unlicensed, they have no scope of practice
b) in general, nursing tasks that may be delegated include non-invasive and non-sterile treatments
c) 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)
d) perform indirect activities such as housekeeping, transporting people and stocking supplies
e) some states allow for the practice of medication administration in specific settings by medication aides - refer to
your jurisdiction's laws for specific information
Steps of Delegation
D. Steps of delegation

1. Right task - define the task and determine if it can be safely delegated
a) match the delegatee to the task
b) determine if the task is within the scope of practice for the delegatee
c) determine agency policies, procedures, and standards
d) understand standards of practice, e.g., the American Nurses Association (ANA) Standards of Practice and the
Canadian Nurses Association (CNA) Position Statements
 e) remember - nursing tasks that be delegated to unlicensed assistive personnel (UAP) are intended to assist, but
not replace, the nurse

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

3. Right person - is the right person delegating the right task to the right person to be performed on the right
patient?
a) determine if staff members have the necessary knowledge, skills, and abilities (KSA) to perform the delegated
tasks and if this information is documented
b) determine if the client's condition is stable with predictable outcomes prior to delegating care

4. Right direction/communication - clearly communicate the specific steps of the task, expectation about
performance, reporting, and documentation of the task
a) potential problems and solutions are discussed
b) the nurse intervenes if necessary
c) staff members must be able to decline without jeopardizing their jobs

5. Right supervision/evaluation - appropriate monitoring, intervention, evaluation, and ongoing feedback

a) the nurse must have the appropriate skills to assist, teach and guide the individual who is completing the task
b) the nurse will determine if client needs were met
c) the nurse can continue or withdraw the delegation
d) problems, particularly and sentinel events, are clarified or reported to supervisors
Five Rights of Delegation
✓Right Task
✓Right Circumstances
✓Right Person
✓Right Direction/Communication
✓Right Supervision/Evaluation
Client Care Assignments
E. Client care assignments
a) Assign the right task
b) Assign the task to the right person
c) The LPN may assign tasks to the unlicensed assistive personnel or nursing assistants (if allowed by the
jurisdiction's laws)
d) Unlicensed assistive persons (UAP) or nursing assistants cannot delegate to other UAPs or nursing assistants
The 4 C's of Communication
1. Clear - Does the team member understand what I am saying?
2. Concise - Have I confused the direction by giving too much unnecessary information?
3. Correct - Is the direction given according to policy, procedures, job description & the law?
4. Complete - Does the team member have all the information necessary to complete the task?
III. Quality Improvement
III. Quality Improvement (QI)

A. Involves the systematic activities that are organized and implemented by an organization to monitor, assess, and
improve the quality of health care
B. Requires involvement by the entire organization and the efforts of all health care professionals and clients (and
their families) to make changes that will lead to:
 Better client outcomes (health)
 Better system performance (care)
 Better professional development

C. Examples of tools used for QI - Total Quality Management (TQM), Continuous Quality Improvement (CQI)
D. Why quality improvement is essential to a health care organization
1. Identifies key areas for improvement, with an emphasis on safety
2. Involves proactive processes that recognize and solve problems before they occur
3. Improves communication
 4. Improves efficiency
5. Improves quality
6. Reduces costs

E. Almost all regulatory and voluntary accrediting agencies now require some form of quality improvement

Nursing Care Delivery Systems

IV. Nursing Care Delivery Systems
A. Functional nursing (task nursing)
1. Needs of clients are broken down into tasks
2. Tasks are assigned to various levels of health care workers according to licensure and skill
3. Example: RN gives medications and UAP give bed baths for one group of clients

B. Team nursing
1. Most common nursing care delivery system
2. A team of nursing personnel provides total care to a group of clients
3. Team leaders supervise client care teams, which usually consist of an RN, LPN, and UAP
4. Team leader reviews the client's plan of care and progress with team members during team conference

C. Total client care (case method)

1. An RN is responsible for all aspects of care of one or more clients
2. The LPN may be assigned to assist the RN
3. This type of care is usually provided in areas requiring high level of nursing expertise, such as the critical care
unit (CCU) or the post-anesthesia recovery unit (PACU)

D. Primary nursing
1. The RN maintains a client load of primary clients
2. The primary nurse designs, implements and is accountable for the nursing care of those clients during their
entire stay on the unit
 has the benefit of continuity of care but may not be feasible with varying schedules
 has been found to result in greater nurse satisfaction, more personalized care, less turn over, and fewer
negative outcomes for patients

E. Practice partnerships
1. An RN and an assistant (UAP, LPN, less-experienced RN, graduate nurse, or nurse intern) agree to be practice
partners
2. Partners work together on same schedule with same group of clients
3. Senior partner directs the work of the junior partner within the scope of each partner's practice

Case Management
F. Case management
1. Model for identifying, coordinating, and monitoring the implementation of services needed to achieve desired
client outcomes within a specified period of time
2. Organizes client care by major diagnosis or Diagnosis Related Group (DRG)
3. A collaborative health care team defines the expected outcomes of care and care strategies for a client
population by defining critical pathways
4. A registered nurse manager is assigned to coordinate, communicate, collaborate, problem solve, facilitate and
evaluate client care for a group of clients
5. Case manager usually does not provide direct client care but coordinates care provided by licensed and
unlicensed nursing personnel according to a critical pathway
6. Critical pathways are plans for providing care to the client and family
a) identify desired outcomes
b) state expected amount of time and resources to be used
c) focus on specific diagnoses or procedures that are high volume and or high resource use (and therefore costly)
d) promote collaboration among disciplines (health care professionals)

7. The essential components of case management include

a) collaboration of all health care team members
b) identification of expected patient outcomes with timeframes
c) use of principles of continuous quality improvement (CQI) and variance analysis
 d) promotion of professional practice

8. Client involvement and participation is key to successful case management

Differentiated Practice & Client-centered Care

G. Differentiated practice
1. Identifies distinct levels of nursing practice based on defined abilities that are incorporated into job descriptions
2. Structures nursing roles according to education, experience, and competency

H. Client-centered care
1. The RN coordinates a team of multi-functional unit-based caregivers
2. All client care services are unit-based, including admission, discharge, diagnostic testing and support services
3. Uses UAPs to perform delegated client care tasks
The basic concept of client-centered care can be expressed like this: "nothing about me without me."

Documentation
V. Information & Documentation
A. Types of patient records
1. Problem-oriented medical record (POMR)
a) a decision is made on the nature of the client's problem or problems and these problems are assessed regularly
b) recorded using a standardized format, by narrative notes in the S.O.A.P. format or by flow sheets
c) discharge summary relates the overall assessment of progress during treatment and plans for follow-up care,
encouraging continuity of care
d) four parts
 data base: the client's present health status
 problem list: numbered list of health problem(s)
 initial plan: plan to help overcome health problem(s)
 progress notes: all disciplines chart on the same page
2. Source-oriented
a) most traditional type of charting, with different disciplines charting on separate forms
b) drawback: records become very bulky, very quickly

Documentation has six key components (CO-ACTS)

 Confidential
 Organized (chronologically)
 Accurate
 Complete
 Timely
 Subjective and objective data
Types of Charting
B. Methods (styles) of charting
1. Narrative charting
a) the nurse records observations, data (including reactions from the client) in a sequential and chronological order
b) baseline charted every shift
c) source-oriented
2. S-O-A-P: problem-oriented charting; comes from a medical model
 S = subjective; what client tells you
 = objective; what you observe, see, etc.
 A = assessment; what you think is going on based on the data
 P = plan; what you are going to do
3. D-A-R
 D = data - collecting information about a problem
 A = action - the task to be completed about the problem
 R = response - the client's response to the problem
4. Focus charting
a) charting on an acute condition, a potential problem, a treatment or procedure, or a client behavior
b) components of this type of charting include: information about the condition/problem, action, and client's
responses
5. A P-I-E charting - uses the nursing process
  A = assessment
 P = problem
 I = intervention
 E = evaluation
6. Charting by exception
a) uses flowsheets
b) emphasis on abnormal (or what is abnormal for this particular client); normal routine is presumed as having
been done, without any problems

Documentation Guidelines
C. Documentation guidelines
1. General
a. check that you have the correct chart
b. record the facts as accurately as possible
c. chart as you go
d. never chart for another person
e. do not mention incident reports
f. avoid the use of abbreviations - when in doubt, write it out!
 all health care institutions have a list of accepted abbreviations
 refer to the Joint Commission's official "Do Not Use" list of abbreviations
g.never alter a client's record (altering a client chart is a criminal offense)
h. six things that nurses must document
 assessment
 nursing diagnosis and client needs
 interventions
 care provided
 client response to care
 client's ability to manage continuing care after discharge

Documentation Guidelines 2
2. Legal guidelines for charting
a. electronic health record (EHR) charting
 never share access or password with another person
 change your password frequently
 maintain confidentiality of documented information printed from the computer
 carefully check your information before you press enter
 access information for clients under your care only
 log off when you are finished
 date and time are automatically recorded
b. paper-ink
1. do
 write in chronological order
 use permanent black ink
 chart the time and date for each entry
 include consent for or refusal of treatment, client responses to interventions, calls made to other health care
professionals
 write legibly
 cross through the error once, date and initial the change
 correct any errors in a timely manner
2. do not
 erase, scratch out or use correction fluid (Liquid Paper or White Out®)
 document for others or change documentation by others
 leave blank spaces
 recopy any charting form
 make photocopies without permission

Nursing & the Law

VI. & the Law
A. Public law
 1. Deals with an individual's relationship to the state
a) Constitutional law (U.S.) - laws the define and/or limit the powers of government
b) administrative law - the body of law that regulates the operation and procedures of government agencies, such
as a board of nursing (U.S.) or regulatory body (Canada)
c) criminal law

2. Nurse practice act (NPA)

1. enacted by state legislation and enforced by a board of nursing/regulatory body
2. intent of the NPA: to protect the public's health by overseeing and ensuring the safe practice of nursing
3. information included in most NPAs
 standards and scope of nursing practice or conduct
 requirements for entry-to-practice and licensure
 types of title and licenses
 grounds for disciplinary action

3. Constitutional law often involves issues related to privacy (the HITECH Act & HIPAA in the U.S.) and citizen's
rights (American's with Disabilities Act, Mental Health Parity Act, & the Patient Self-Determination Act in the
U.S.)
At least once a year, be sure to read your nurse practice act and understand your legal scope of practice.

Nursing & the Law 2

B. Civil law
1. Crimes against a person or persons related to contracts, torts, and protective reporting laws
2. Tort law: a (unintentional or intentional) wrongful act that results in injury to a person, his property or reputation
a) as a result of the wrongdoing, the injured person can take civil action against the person who injured him or her
and is entitled to compensation for damages or injuries suffered
b) intentional torts include: assault, battery, invasion of privacy, false imprisonment, defamation, fraud
c) negligence is failing to exercise the proper care required by the situation; malpractice is failing to act as any
prudent professional with similar background, knowledge, and education would act under similar circumstances
d) 4 conditions must be present for malpractice
 duty - the nurse has a legal obligation to provide reasonable care according to a certain standard of care
 breach - the nurse has broken that duty or standard of care
 proximate cause - any harm or damage that resulted can be linked to the duty owed
 damages - the nurse's acts or omissions caused the injury, loss or harm
e. common malpractice issues for nurses:
 failing to recognize and report a change in a client's condition
 failing to institute a fall protocol
 failing to use the proper procedure for a specific skill
 incorrect use of equipment
 medication administration errors
3. Nurses may be subject to civil action, discipline by a board of nursing, as well as criminal lawsuits for some acts of
negligence, such as diverting drugs

Nursing & the Law 3

C. Nursing responsibilities
1. Comply with state and/or federal regulations for reporting client conditions, e.g., abuse, neglect, communicable
diseases, gunshot wounds, dog bites
2. Report unsafe practice by nurses, e.g., suspected substance abuse, diverting drugs or improper care
a) use the chain of command to report
b) mandatory reporting to a board of nursing is required by many nurse practice acts

3. Identify and manage client valuables according to facility/agency policy

D. Strategies to prevent errors, reduce risk and ensure client safety
a) Use effective communication and interpersonal skills - with colleagues, clients and their families
b) Practice within your scope of practice
c) Follow facility policies and procedures
d) Maintain nursing skills and competencies through continuing educaiton
e) Document... everything
VII. Professional Misconduct
A. The impaired professional and substance use disorder (SUD)
1. Remember that the impaired nurse compromises client care
2. Be sure that the problem exists and can be proven
3. Communicate specific concerns to appropriate persons such as a nurse manager or risk manager
4. Document incidents in terms of behaviors, specific times, dates - be objective
5. File a report according to workplace policies and procedures
B.Boundary crossings & violations
1. Boundary crossing: usually a brief excursion across a professional boundary; it may be purposeful or
unintentional
2. Boundary violation: an act of abuse in the nurse-client relationship; behaviors are intentional, unprofessional,
unethical and even criminal
3. Guiding principles in determining professional boundaries
a) the nurse-client relationship is professional, not personal
b) the nurse is responsible for setting and keeping boundaries
c) once a nurse becomes involved in the patient's personal life, professional objectivity is compromised
d) failure to adhere to professional boundaries can never be blamed on the client
C.Consequence of professional misconduct
1. A board of nursing must protect the public and is required to take action against the licenses of nurses who have
exhibited unsafe nursing practice
2. A board of nursing may impose penalties for professional misconduct, ranging from probation, censure, and
reprimand, to suspension or even revocation of licensure
Privacy
VIII. Client Rights
A. Privacy
1. Confidential information may only be released by signed consent of the client
2. Unauthorized release of client data may be an invasion of privacy
3. Health Insurance Portability and Accountability Act of 1996 (HIPAA)
 provides individuals with access to their medical records and more control over how their personal health
information is used
 provides privacy protection for consumers of health care

4. Health care workers must release information when a court orders it or when statutes require it (as in child
abuse or communicable diseases)
5. Special regulations apply to release of information about psychiatric illness or HIV
Advance Directives
B. Advance directives
1. As part of the Omnibus Budget Reconciliation Act (OBRA) of 1990, the U.S. Congress established the Patient Self-
Determination (PSDA); this requires states to provide written information to clients outlining their rights to
make health care decisions
2. These rights include:
 the right to refuse or accept treatment
 the right to formulate advance directives

3.Nurses and other members of the health care team are required to
a)assess the clients knowledge of advance directives and their status regarding the advance directive process
b)provide information and assistance to the client in developing advance directives
c)plan care that incorporates the clients decisions regarding advance directives; three common advance directives
are:
 living will - identifies what a client wishes for his care should he become unable to communicate these wishes
 durable power of attorney for health care decisions - the client has appointed a person to make decisions about
their care if they are unable to do so.
 do not resuscitate (DNR) status - this has been expanded to include identification of medications that may be
given without any defibrillation attempts (comfort measures only)
 follow the facility policy on obtaining and implementing DNR orders
 generally, the order must be written by a physician; some facilities may have a policy to allow verbal orders
under specific conditions
 the order must be communicated clearly to all personnel caring for the client
 the client or her or his health care proxy can withdraw the order at any time
  a nurse who attempts to resuscitate a client with a valid DNR order may be committing battery
 allow natural death (AND) status
Refusal of Treatment & Freedom from Restraints
C. Refusal of treatment - competent clients may refuse treatment, even life-sustaining treatment
D. Freedom from safety devices/restraints
1. Physical restraints/safety devices require a signed, dated physician's order specifying the type of restraint/safety
device and a time limit for its use
2. Types of restraints/safety devices
a) drug or medication - central nervous system depressants, paralytics
b) any manual methoc (physical or mechanical device, material or equipment) - vest restraints, side rails

3. Use the least restrictive form of restraint/safety device

4. Know agency guidelines for use of restraints
5. The nurse must document three factors
a) why restraints/safety devices were used
b) how the client responded
c) whether the client needs continued restraints/safety devices

6. Restraining clients without consent or sufficient justification may be interpreted as false imprisonment
Informed Consent
E. Informed consent
1. Basic requirements
a) capacity
b) voluntariness
c) information
 health care provider is legally obligated to provide a complete description of the treatment/procedure,
description of the potential harm, pain, and discomfort that may occur, options for other treatments, and the
right to refuse treatment
 the nurse should verify client comprehends and consents to care
2. The client must understand
a) purpose of the procedure and expected results
b) anticipated risks and discomforts
c) potential benefits
d) any reasonable alternatives
e) that consent may be withdrawn at any time
3. Requirements for signing an informed consent form
a) must be signed by a competent adult
b) individual who is signing must be able to understand the information given by the health care professional (if the
person is unable to understand the information due to language barrier or hearing impairment, a trained
medical interpreter must be present)
F.Transition planning - recognizes that clients are not discharged from care but moved across the continuum to another
level of care
G. Organ donation
1. Nurses advocate for and support families throughout the organ and tissue donation process
2. Nurses involved in the process of organ and tissue donation should be knowledgeable of the ethical, cultural,
religious and social issues related to organ and tissue donation
3. There is no cost to a family for the gift of organ or tissue donation
Become familiar with the NCLEX Test Plan's distribution of questions and use this to make notes, like “I understand” or “I
need to review.” Use the “I need to review” list to help you to select the questions where you need more practice.
IX. Ethical Practice
IX Ethics in Nursing
A. Ethics
1. A theory or system of moral values, based on the ideas of right and wrong
2. It governs our relationships with others

B. A code of ethics provides standards and values for a profession; individuals must integrate the values of the
profession with their own values
C. Ethical principles
1. Respect for others: The right of the individual to make their own decision
 2. Autonomy: Respect for an individuals right to self determination
3. Nonmaleficence: the principle of "do no harm"
4. Beneficence: do good and avoid evil
5. Justice: the principle of fairness
6. Veracity: the ethical duty to tell the truth
7. Confidentiality: the respect for privacy
8. Fidelity: loyalty, faithfulness and honoring commitments

Points to Remember
o Nursing practice is governed by laws and professional standards.
o Standards of nursing practice apply to all nurses in all practice settings.
o Standards of care are based on facility policy and procedure, nursing education, experience, and publications of
professional nursing associations and accrediting groups.
o Delegation and supervision overview:
 The RN must monitor delegated and/or assigned tasks and evaluate the outcomes.
 Final responsibility for any delegated and/or assigned task resides with the RN.
o What a nurse can do depends on the state's nurse practice (and province/territory's nursing act) in which the
nurse is licensed.
o The LPN/VN cares for physiologically stable clients with predictable conditions.
o Good communication skills are essential when interacting with members of the health care team.
 S-B-A-R = situation, background, assessment and recommendation
 I P-A-S-S the B-A-T-O-N = introduction, patient, assessment, situation, safety concerns, background,
actions, timing, ownership, and next
 C-U-S = concern, uncomfortable, and safety
o An effective leader modifies his/her style according to situational conditions.
o Each state/province/territory defines what constitutes professional misconduct.
 The board of nursing/regulatory body has the authority to impose a penalty for professional misconduct.
 Penalties include probation, censure, reprimand, suspension or revocation of the license.
o To avoid negligence:
 Provide care within the legal scope of practice
 Know the standard of care
 Be competent in your practice
 Follow your workplace's policies and procedures
 Document care accurately and in a timely manner
o The only employee of a health care organization who may be the legal witness to the signing of an advance
directive is a clinical social worker.
o Ethics guide the nurse toward client advocacy and the development of a therapeutic relationship.
o In most situations, individuals have the right to accept or refuse treatment.

TRUE OR FALSE
Question 1
Advance directives are required for all clients.
o True
o False
Question 2
The nurse has an obligation to carry out the health care provider’s written orders, whether the orders are appropriate
for the client or not.
o True
o False
Question 3
The nurse is responsible for reporting any breach of client privacy or confidentiality.
o True
o False
Question 4
The nurse has a legal duty to provide nursing care to clients.
o True
o False
Question 5
Nurses should only access client information for those clients directly under their care
o True
o False
Question 6
The nurse has a legal duty to abide by the scope of practice set forth in the nurse practice act/nursing act.
o True
o False
Question 7
Nurses rarely participate in the organ donation process with clients’ families.
o True
o False
Question 8
Negligence involves any action or inaction that results in unintended harm to a client.
o True
o False
Question 9
Nurses participate in quality improvement activities which are intended to promote safety and improve quality of care.
o True
o False
Question 10
Before the client signs a surgical consent form, the nurse must ensure the client has the ability to understand the
information in the document.
o True
o False

ANOTHER SET OF QUESTIONS:

1_Ref # 4548
All of the following clients are using morphine patient controlled analgesia (PCA) pumps and are two days post-op.
Which client should the nurse check first?
A. 70 year-old following surgical repair of a femur fracture, no bowel movement since before surgery
B. 67 year-old following hip surgery, who just had a wound drain removed, with some bloody drainage on the
dressing
C. 62 year-old following knee replacement surgery, BP 120/68, pulse 68, respirations 8
D. 79 year-old following tumor resection of shoulder head, whose reported pain level is 8 out of 10

2_Ref # 4554
A woman dressed in a business suit with no visible identification is at the nurse’s station looking at client charts. What
nursing action is most appropriate?
A. Report to the nurse manager about the witnessed suspicious activity
B. Ignore the person; many outside vendors check charts to set up a transfer or to coordinate care
C. Immediately call security for this breach in client confidentiality
D. Request to see identification and an explanation as to why the woman is viewing client charts

3_Ref # 1716
A nurse receives an illegible hand-written medication order. Which statement to the health care provider reflects
assertive communication?
A. "Would you please clarify what you have written so I am sure I am reading it correctly?"
B. "Please print in the future so I do not have to spend extra time attempting to read your writing."
C. "I cannot give this medication as it is written. I have no idea of what you mean."
D. "I am having difficulty reading your handwriting. It would save me time if you would be more careful."

4_Ref # 4569
The registered nurse (RN) has just accepted a position as a public health nurse. Which question might be the most
relevant as the nurse begins employment?
A. "Which nursing assistants can I refer clients to?"
B. "Which groups are at the greatest risk for problems?"
C. "Which clients should I see as I begin my day?"
D. "Which physicians will I be more closely collaborating with?"
5_Ref # 2184
A client is admitted with a diagnosis of schizophrenia. The client refuses to take any medication and states, “I don’t think
I need those medications. They make me too sleepy and drowsy. I want you to explain their use and side effects of these
medications.” The nurse should respond with an understanding of which statement?
A. The client has a right to know about the use and side effects of the prescribed medications
B. Such education is an independent decision of the individual nurse whether or not to teach clients about their
medications
C. A referral is needed to the psychiatrist who should provide the client with answers to the request
D. Clients with schizophrenia are at a higher risk of psychosocial complications when they know about their
medication's uses and side effects

6_Ref # 4590
A registered nurse (RN) is working on the medical/surgical unit of a large medical center and needs to contact the health
care provider regarding a change in a client's status.
List the order the nurse should present the following information by dragging and dropping the options below.
 "Mr. Richmond reports increased pain in his knee. His heart rate is now 112 beats a minute, up from 80 beats a
minute; his respiratory rate is 20; and he is afebrile. The ibuprofen 800 mg every 12 hours by mouth is not
controlling his pain."
 "I am calling about Mr. Stanley Richmond. He was admitted last night."
 "I would like to recommend a change in pain medication. He has no known allergies to medications."
 "Hello Dr. White, this is Pat Davis, an RN at University Hospital on the third floor med-surg unit."
 "Okay, Dr. White, I will write the order for oxycodone and acetaminophen (Percocet) 2.5 mg/325 mg - 1 or 2
tablets by mouth every 6 hours as needed for pain."

7_Ref # 5018
The client is two days post-op following a hip replacement and is not transferring well from bed to chair. The nurse
checks and then confirms that the client is not progressing on any part of the mobility training program. What action is
the nurse's priority?
A. Instruct physical therapy to increase treatments to four times a day
B. Inform the case manager of the variance in the critical pathway
C. Discuss the problem with the client's surgeon
D. Contact the family to discuss preoperative mobility problems

8_Ref # 2236
The charge nurse is making assignment for the health care team. Which of these tasks can be safely delegated to the
licensed practical nurse (LPN)?
A. Teach the initial ostomy care to a client and family members
B. Provide stoma care for a client with a well-functioning ostomy
C. Care for a recent complicated double barrel colostomy
D. Assess the function of a newly created ileostomy

9_Ref # 4568
A Bosnian Muslim woman who does not speak English seeks care at a community center. Through physical gestures, the
woman indicates that she has pain originating in either the pelvic or genital region. Assuming several people are
available to interpret, who would be the most appropriate choice?
A. The client's adult daughter
B. A female neighbor of the client who is also from Bosnia
C. A Bosnian male, who is a certified medical interpreter
D. A female interpreter who does not know the client

10_Ref # 2438
The 83 year-old client, who lives in a retirement community, is admitted to the hospital. The daughter reports the client
no longer calls her every day, has not been participating in previously enjoyed activities, such as weekly card games, and
has allowed the garden to become overgrown with weeds. The nurse should assign this client to a room with which of
the following clients?
A. A middle-aged person who has been on the unit for 72 hours with a diagnosis of persistent depressive disorder
B. An adolescent who was admitted the day before with a diagnosis of disruptive mood dysregulation
C. A young adult who was admitted 24 hours ago for treatment following detoxification
 D. An elderly person who was admitted three hours ago with a diagnosis of cyclothymia

11_Ref # 4512
A 90 year-old is readmitted to the hospital, less than 2 weeks after being discharged, for the same health concern. What
factors contribute to hospital readmissions among older adults? (Select all that apply.)
A. Excellent primary care
B. Family preferences
C. Client health status
D. Reconciliation of medications
E. Poor communication among providers

12_Ref # 4600
The nurse receives an order for a medication from the hospitalist. Knowing the drug is contraindicated for the client, the
nurse twice verbalizes concerns about the contraindication to the hospitalist, who does not change the order. What
action should the nurse take next?
A. Page the attending physician to express the same concern
B. Ask another staff nurse to discuss the same concerns with the hospitalist
C. Administer the medication as ordered
D. Request a consult with the in-house pharmacist

13_Ref # 1877
The nurse manager is discussing the goals of total quality management (TQM) with the health care team. Which
statement correctly identifies a key element of TQM?
A. All employees participate in systematically working toward common goals
B. Top administrators are responsible for establishing plans for problem management
C. It is an incident management technique that focuses on employee retention
D. It is a reactionary approach used to investigate the root cause of a problem

14_Ref # 1874
The nurse manager overhears a health care provider loudly criticize one of the staff nurses within hearing range of other
staff and visitors. Which approach by the nurse manager is indicated in this situation?
A. Stay neutral and allow the staff nurse to handle this situation independently
B. Walk up to the health care provider and quietly state: "Stop this unacceptable behavior."
C. Request an immediate private meeting with the health care provider and staff nurse
D. Notify the chief nursing officer about the breach of professional conduct

15_Ref # 4604
The charge nurse in the emergency department (ED) receives a call from the ambulance crew stating that there has
been a two car accident with multiple casualties. What action would the nurse take first, before the victims arrive in the
ED?
A. Set up multiple 1000 mL NaCl IV solutions with tubing and notify the blood bank
B. Prepare the trauma room and select supplies
C. Notify the nursing supervisor and request additional staff
D. Activate the disaster plan

16_Ref # 4553
A newly graduated nurse, who has recently completed orientation, voices concern about her assignment: "I have never
taken care of anyone with a lumbar drain before." Which action would be most appropriate for the charge nurse?
A. Assign the graduated staff nurse to be transferred to another floor for the shift
B. Check with the nurse and the client often during the shift
C. Change the assignment; reassign the client with the lumbar drain to a different nurse
D. Provide an immediate one-on-one, personal in-service about the drain

17_Ref # 2371
The nurse observes a student nurse inserting an indwelling urinary catheter for a female client. After the student inserts
the catheter, no urine appears and the student begins to remove the catheter. What should the nurse do at this time?
A. Ask the student in a calm voice: "Did you do something wrong?"
B. In a speaking tone of voice, explain: "The tubing is probably in the vagina."
C. Walk up and whisper in the student's ear: "Stop. Leave the catheter in place. I'll get a new sterile catheter."
 D. State strongly: "Stop. Tell me why there's no urine in the tubing."

18_Ref # 2310
A registered nurse from the float pool is assigned to the critical care unit on the evening shift. Which of these clients
should be assigned to the float pool nurse?
A. Pacemaker insertion on the day shift
B. Tracheostomy of 24 hours with the client showing some respiratory distress
C. Dopamine IV drip with vital signs monitored every five minutes
D. Report of unstable angina with continuous telemetry monitoring

19_Ref # 4465
The health care provider has finished writing admission orders for a client diagnosed with pneumonia and sepsis who
has a history of type 1 diabetes. Prioritize how the nurse should complete the orders listed below (with 1 being the top
priority).
 Blood and sputum cultures
 Oxygen 2 liters nasal cannula
 Fingerstick before each meal and at bedtime
 Ceftriaxone (Rocephin) 1 gram every 12 hours IVPB
 IV normal saline at 100 mL/hr

20_Ref # 2495
The nurse is caring for a client whose pain is not well controlled. Which statement about pain management is a priority
ethical consideration that can help guide the nurse?
A. Nurses should not prejudge a client's pain using their own values
B. The client's self-report of pain is the most important consideration
C. Clients have the right to have their pain relieved
D. Cultural sensitivity is fundamental to pain management

RATIONALE:
Question 1
Advance directives are required for all clients.
 True
 False
An advance directive is a legal document that indicates client preferences for treatment or life-saving measures. Clients
are encouraged, but not required, to have an advance directive.

Question 2
The nurse has an obligation to carry out the health care provider’s written orders, whether the orders are appropriate
for the client or not.
 True
 False
The nurse should never carry out a health care provider’s order that is unclear or inappropriate. The nurse should contact
the HCP immediately to clarify the order.

Question 3
The nurse is responsible for reporting any breach of client privacy or confidentiality.
 True
 False
According to ethical principles, many laws (including most nurse practice acts), and agency policies, it is the legal duty of
nurses to protect client confidentiality. Nurses should report violations of client confidentiality and/or privacy.

Question 4
The nurse has a legal duty to provide nursing care to clients.
 True
 False
The care the nurse provides must be within the legally defined scope of practice, as well as the nurse's education and
experience.
Question 5
Nurses should only access client information for those clients directly under their care.
 True
 False
Nurses can legally access information that is required to provide nursing care for clients assigned to them. Accessing
client information for purposes other than providing nursing care is a breach of confidentiality.

Question 6
The nurse has a legal duty to abide by the scope of practice set forth in the nurse practice act/nursing act.
 True
 False
Each nurse practice act/nursing act defines the scope of activities that constitute the duty of a nurse licensed in that
state/province/territory.

Question 7
Nurses rarely participate in the organ donation process with clients’ families.
 True
 False
Nurses serve an important role in the organ donation process through providing families with support and resources.
Nurses are responsible for knowing their local laws and institutional policies about organ donation.

Question 8
Negligence involves any action or inaction that results in unintended harm to a client.
 True
 False
Negligence means doing something that a "reasonably prudent" person, under similar circumstances, would not do.
Negligent conduct can be an act, or a failure to act, that causes (unintended) harm to the client.

Question 9
Nurses participate in quality improvement activities which are intended to promote safety and improve quality of care.
 True
 False
Quality improvement is essential for all health care providers. Nurses engage in quality improvement initiatives to
facilitate collaborative practice, improve client outcomes, and enhance overall quality of care.

Question 10
Before the client signs a surgical consent form, the nurse must ensure the client has the ability to understand the
information in the document.
 True
 False
The nurse reviews the information in the consent form with the client and witnesses the client's signature. The nurse
verifies the client has the capacity to make choices and understands the consequences prior to the client signing the
consent.

RATIONALE FOR ADDITIONAL QUESTIONS:

1_REF 4548
All of the following clients are using morphine patient controlled analgesia (PCA) pumps and are two days post-op.
Which client should the nurse check first?
A. 70 year-old following surgical repair of a femur fracture, no bowel movement since before surgery
B. 67 year-old following hip surgery, who just had a wound drain removed, with some bloody drainage on the
dressing
C. 62 year-old following knee replacement surgery, BP 120/68, pulse 68, respirations 8
D. 79 year-old following tumor resection of shoulder head, whose reported pain level is 8 out of 10
A surgical client using a narcotic PCA is at risk for respiratory depression, which is potentially life-threatening, and
therefore the top priority. The other clients need assessment and attention, but the priority is given to the client with a
respiratory rate of 8. Some bloody drainage on a dressing is expected after a drain is removed and of course the nurse
would monitor this. Constipation is a side effect of narcotics but is not life-threatening. Pain control is also important but
does not take priority over respiratory depression.
2_REF 4554
A woman dressed in a business suit with no visible identification is at the nurses station looking at client charts. What
nursing action is most appropriate?
A. Report to the nurse manager about the witnessed suspicious activity
B. Ignore the person; many outside vendors check charts to set up a transfer or to coordinate care
C. Immediately call security for this breach in client confidentiality
D. Request to see identification and an explanation as to why the woman is viewing client charts
Nurses have a duty to protect the confidentiality of client records. In fact, HIPAA and other confidentiality laws require
that nurses verify the identity and authority of individuals requesting information. Acceptable verification may include a
photo ID and a copy of the documentation supporting legal authority to access information. The nurse needs to
determine who the person is, ask to see a valid ID, and ask for the reason for reading the chart. Security may need to be
called, but the nurse first needs more information. It is each nurse's duty to do this and no one should pass it off to a
manager or ignore the situation.

3_REF 1716
A nurse receives an illegible hand-written medication order. Which statement to the health care provider reflects
assertive communication?
A. "Would you please clarify what you have written so I am sure I am reading it correctly?"
B. "Please print in the future so I do not have to spend extra time attempting to read your writing."
C. "I cannot give this medication as it is written. I have no idea of what you mean."
D. "I am having difficulty reading your handwriting. It would save me time if you would be more careful."
Assertive communication respects the rights and responsibilities of both parties. This statement is an honest expression
of concern for safe practice and a request for clarification without self-depreciation. It reflects the right of the
professional to give and receive information.

4_REF 4569
The registered nurse (RN) has just accepted a position as a public health nurse. Which question might be the most
relevant as the nurse begins employment?
A. "Which nursing assistants can I refer clients to?"
B. "Which groups are at the greatest risk for problems?"
C. "Which clients should I see as I begin my day?"
D. "Which physicians will I be more closely collaborating with?"
Public health nursing is focused on improving the health status of the entire community. Although all the options are
good to know, it is most important that the RN understands which groups in the community have the greatest health
needs. Public health nurses collaborate with physicians, as well as with other health care providers, to assess and
prioritize major health problems in the community. They also assist individuals and families to take action to improve
their health status. Nursing assistants provide care for individual clients and families, but this question is more
appropriate for a visiting or home health nurse.

5_REF 2184
A client is admitted with a diagnosis of schizophrenia. The client refuses to take any medication and states, “I don’t think
I need those medications. They make me too sleepy and drowsy. I want you to explain their use and side effects of these
medications.” The nurse should respond with an understanding of which statement?
A. The client has a right to know about the use and side effects of the prescribed medications
B. Such education is an independent decision of the individual nurse whether or not to teach clients about their
medications
C. A referral is needed to the psychiatrist who should provide the client with answers to the request
D. Clients with schizophrenia are at a higher risk of psychosocial complications when they know about their
medication's uses and side effects
Clients have a right to informed consent, which includes detailed information about medications, treatments and
diagnostic studies. The other options are incorrect approaches.

6_REF 4590
A registered nurse (RN) is working on the medical/surgical unit of a large medical center and needs to contact the health
care provider regarding a change in a client's status.
List the order the nurse should present the following information by dragging and dropping the options below.
1. "Hello Dr. White, this is Pat Davis, an RN at University Hospital on the third floor med-surg unit."
2. "I am calling about Mr. Stanley Richmond. He was admitted last night."
 3. "Mr. Richmond reports increased pain in his knee. His heart rate is now 112 beats a minute, up from 80 beats a
minute; his respiratory rate is 20; and he is afebrile. The ibuprofen 800 mg every 12 hours by mouth is not
controlling his pain."
4. "I would like to recommend a change in pain medication. He has no known allergies to medications."
5. "Okay, Dr. White, I will write the order for oxycodone and acetaminophen (Percocet) 2.5 mg/325 mg - 1 or 2
tablets by mouth every 6 hours as needed for pain."
Using the acronym "I-SBAR-R" is an effective, structured, and easy method to use when communicating with other health
care providers. QSEN has recommended this to be used as the standard. "I-SBAR-R" stands for: I = introduction, S =
situation, B = background, A = assessment, R = recommendation, R = read back.

7_REH 5018
The client is two days post-op following a hip replacement and is not transferring well from bed to chair. The nurse
checks and then confirms that the client is not progressing on any part of the mobility training program. What action is
the nurse's priority?
A. Instruct physical therapy to increase treatments to four times a day
B. Inform the case manager of the variance in the critical pathway
C. Discuss the problem with the client's surgeon
D. Contact the family to discuss preoperative mobility problems
Variances in the critical pathway need to be reported to the case manager. Certain goals need to be met to move the
client forward in recovery and transfer to an appropriate venue for continued rehabilitation. The RN cannot order
physical therapy treatment. Previous mobility problems are not priority post-operatively. The surgeon needs to be
informed about the client's lack of progress, but this is not the priority.

8_REF 2236
The charge nurse is making assignment for the health care team. Which of these tasks can be safely delegated to the
licensed practical nurse (LPN)?
A. Teach the initial ostomy care to a client and family members
B. Provide stoma care for a client with a well-functioning ostomy
C. Care for a recent complicated double barrel colostomy
D. Assess the function of a newly created ileostomy
The care of a mature stoma and the application of an ostomy appliance may be delegated to a LPN. The condition of this
client is stable, there's a low likelihood of any emergency and care of this client is not too complex. The other options
require higher level care by the RN. The RN is the manager of care and is responsible for any initial teaching; the LPN can
reinforce information once it has been introduced by the RN.

9_REF 4568
A Bosnian Muslim woman who does not speak English seeks care at a community center. Through physical gestures, the
woman indicates that she has pain originating in either the pelvic or genital region. Assuming several people are
available to interpret, who would be the most appropriate choice?
A. The client's adult daughter
B. A female neighbor of the client who is also from Bosnia
C. A Bosnian male, who is a certified medical interpreter
D. A female interpreter who does not know the client
When the nurse and the client do not speak the same language, or have limited fluency, the services of an interpreter is
needed. But, it may be inappropriate to have a male interpreter for a female client because the client may not be as
forthcoming. The client may also feel it is inappropriate to have private matters interpreted by her daughter (especially if
they are of a sexual nature or involve infidelity). To avoid a breach of confidentiality, the nurse should avoid using an
interpreter from the same community as the client. The best response is to have a female interpreter who does not know
the client.

10_REF 2438
The 83 year-old client, who lives in a retirement community, is admitted to the hospital. The daughter reports the client
no longer calls her every day, has not been participating in previously enjoyed activities, such as weekly card games, and
has allowed the garden to become overgrown with weeds. The nurse should assign this client to a room with which of
the following clients?
A. A middle-aged person who has been on the unit for 72 hours with a diagnosis of persistent depressive disorder
B. An adolescent who was admitted the day before with a diagnosis of disruptive mood dysregulation
C. A young adult who was admitted 24 hours ago for treatment following detoxification
D. An elderly person who was admitted three hours ago with a diagnosis of cyclothymia
These findings suggest depression. The most therapeutic milieu for this client includes double occupancy with someone
who has similar issues and/or whose condition is more stable. A secondary consideration is matching roommates’ ages
as closely as possible, because they potentially would share similar developmental challenges and needs. The most stable
client is the one with persistent depressive disorder. Cyclothymia is an illness that’s similar to bipolar disorder and
disruptive mood dysregulation disorder is characterized by irritability and episodes of extreme, out-of-control behavior.

11_REF 4512
A 90 year-old is readmitted to the hospital, less than 2 weeks after being discharged, for the same health concern. What
factors contribute to hospital readmissions among older adults? (Select all that apply.)
A. Excellent primary care
B. Family preferences
C. Client health status
D. Reconciliation of medications
E. Poor communication among providers
Avoidable hospitalization, especially among older adults living in skilled nursing facilities, usually results from multiple
system failures. The reasons most often cited include inadequate primary care (including inadequate discharge planning
and lack of reconciliation of medications), poor care coordination, poor skilled nursing facility quality of care, poor
communication among providers and even family preferences. Not all illnesses can be anticipated and clients with more
complex health issues are readmitted more often, regardless of quality or coordination of care.

12_REF 4600
The nurse receives an order for a medication from the hospitalist. Knowing the drug is contraindicated for the client, the
nurse twice verbalizes concerns about the contraindication to the hospitalist, who does not change the order. What
action should the nurse take next?
A. Page the attending physician to express the same concerns
B. Ask another staff nurse to discuss the same concerns with the hospitalist
C. Administer the medication as ordered
D. Request a consult with the in-house pharmacist
The scenario is an example of the "two-challenge rule." It is the nurse's responsibility to assertively voice concerns at
least two times to ensure that it has been heard. If the outcome is still not acceptable, the nurse needs to take a stronger
course of action by either contacting a supervisor or the attending physician to express the same concerns. The nurse
must be an advocate for the client.

13_REF 1877
The nurse manager is discussing the goals of total quality management (TQM) with the health care team. Which
statement correctly identifies a key element of TQM?
A. All employees participate in systematically working toward common goals
B. Top administrators are responsible for establishing plans for problem management
C. It is an incident management technique that focuses on employee retention
D. It is a reactionary approach used to investigate the root cause of a problem
TQM uses a strategic and systematic approach for continual improvement of processes, products, services and the
workplace culture. The focus is on improving customer satisfaction. TQM involves all employees, not just top
administrators. It is a proactive, not reactive, approach to solving problems.

14_REF 1874
The nurse manager overhears a health care provider loudly criticize one of the staff nurses within hearing range of other
staff and visitors. Which approach by the nurse manager is indicated in this situation?
A. Stay neutral and allow the staff nurse to handle this situation independently
B. Walk up to the health care provider and quietly state: "Stop this unacceptable behavior."
C. Request an immediate private meeting with the health care provider and staff nurse
D. Notify the chief nursing officer about the breach of professional conduct
Assertive communication respects the needs of all parties to express themselves, but not at the expense of being in front
of non-involved staff, visitors or clients. The nurse manager first needs to protect clients and other staff from this display
of negative behavior and come to the assistance of the nurse employee. Privacy is a priority, as well as limiting the
communication to only those involved.

15_REF 4604
The charge nurse in the emergency department (ED) receives a call from the ambulance crew stating that there has
been a two car accident with multiple casualties. What action would the nurse take first, before the victims arrive in the
ED?
A. Set up multiple 1000 mL NaCl IV solutions with tubing and notify the blood bank
B. Prepare the trauma room and select supplies
C. Notify the nursing supervisor and request additional staff
D. Activate the disaster plan
The ED charge nurse needs to assess, supervise and coordinate staff and to maintain full readiness of ED. The priority is
for the ED charge nurse to notify the nursing supervisor that additional nursing staff will be needed. Preparing the
trauma room will be next. The clients will need to be assessed prior to the administration of any IV solution and/or blood
products. There is no need to activate a disaster plan for a two car accident.

16_REF 4553
A newly graduated nurse, who has recently completed orientation, voices concern about her assignment: "I have never
taken care of anyone with a lumbar drain before." Which action would be most appropriate for the charge nurse?
A. Assign the graduated staff nurse to be transferred to another floor for the shift
B. Check with the nurse and the client often during the shift
C. Change the assignment; reassign the client with the lumbar drain to a different nurse
D. Provide an immediate one-on-one, personal in-service about the drain
One of the first principles of safe assignments is to match skills with the task. New nurses should not be assigned tasks for
which they are not competent. The assignment needs to be changed. The other options simply help support the nurse but
may be dangerous for the client. And, of course, the new nurse will need training about caring for a client with a lumbar
drain.

17_REF 2371
The nurse observes a student nurse inserting an indwelling urinary catheter for a female client. After the student inserts
the catheter, no urine appears and the student begins to remove the catheter. What should the nurse do at this time?
A. Ask the student in a calm voice: "Did you do something wrong?"
B. In a speaking tone of voice, explain: "The tubing is probably in the vagina."
C. Walk up and whisper in the student's ear: "Stop. Leave the catheter in place. I'll get a new sterile catheter."
D. State strongly: "Stop. Tell me why there's no urine in the tubing."
When no urine appears after inserting a catheter into a female client, the catheter may be in the vagina. This catheter
can be left in place and used as a landmark indicating where not to insert the new, sterile catheter. The best approach is
for the nurse is to calmly remind the student about this technique and offer assistance. The other options are
unprofessional and/or they may upset the client and the student.

18_REF 2310
A registered nurse from the float pool is assigned to the critical care unit on the evening shift. Which of these clients
should be assigned to the float pool nurse?
A. Pacemaker insertion on the day shift
B. Tracheostomy of 24 hours with the client showing some respiratory distress
C. Dopamine IV drip with vital signs monitored every five minutes
D. Report of unstable angina with continuous telemetry monitoring
The nurse from the float pool should be assigned to care for the most stable client, which is the client who had the
pacemaker inserted on the day shift. The other clients are unstable and have potentially life-threatening conditions. In
most critical care units, the nurse can titrate dopamine upward or downward; this requires the expertise of the nurse
who normally works on this unit. Although tracheostomies are not limited to critical care units, a nurse unexperienced in
critical care should not be assigned to the client with a newly created tracheostomy.

19_REF 4465
The health care provider has finished writing admission orders for a client diagnosed with pneumonia and sepsis who
has a history of type 1 diabetes. Prioritize how the nurse should complete the orders listed below (with 1 being the top
priority).
1. Blood and sputum cultures
2. Oxygen 2 liters nasal cannula
3. Fingerstick before each meal and at bedtime
4. Ceftriaxone (Rocephin) 1 gram every 12 hours IVPB
5. IV normal saline at 100 mL/hr
For establishing priorities, first look at the ABCs. Oxygen administration is the first priority (and the client’s oxygen
saturation is probably low given the patient has pneumonia). The next priority would be to have the lab come and draw
blood for the cultures; this must be done prior to starting the antibiotics. Then an IV must be started (the antibiotic is
ordered IV). Even though the patient is diabetic and it is dinner time, a finger stick is the last thing on the list to complete.

20_REF 2495
The nurse is caring for a client whose pain is not well controlled. Which statement about pain management is a priority
ethical consideration that can help guide the nurse?
A. Nurses should not prejudge a client's pain using their own values
B. The client's self-report of pain is the most important consideration
C. Clients have the right to have their pain relieved
D. Cultural sensitivity is fundamental to pain management
Pain is a complex phenomenon that is perceived differently by each individual. This is why the self-report is the most
reliable way to determine a client's pain. Nurses should apply ethical standards, such as respect for autonomy (the right
of people to make their own decisions about healthcare), when assessing pain. The other statements are correct but they
are not the most important considerations.