1. Advance directives- teaching Ans: Communicates the client wishes regarding end of
life care; are written before a client becomes ill
Nurses role is to provide info about advance directives Document
client's advance directive status
Ensure advance directives reflects clients current decision
Inform all members of the healthcare team of the client's advanced directives
2. Culture (client who speaks a different language) Ans: Use an interpreter always; try
to get someone around same age and gender as client
3. Delegation to UAP Ans: Stable/chronic clients; post-mortem care; they cannot teach,
assessed, or evaluate
4. Ethical (client need for information about treatment) Ans: Provide client with truth-
ful information so they can make an informed decision about their own health and well-
being
5. Discharge planning Ans: Determine ability to afford insulin and supplies
Make sure he has transportation to follow up appointments
6. Informed consent Ans: Nurses role is to witness the client signature and ensure that the
provider has obtained the informed consent responsibly
,Greater than 18 years of age or if the mother or father is a teenage parent they have the right t
sign the consent form
7. Client inquiry about surgery Ans: Consult health care provider/surgeon for proce-
dures/informed consent questions
8. Telephone prescriptions are Ans: Must write the order down before reading it back to
the provider
9. Identify Improper documentation Ans: Documenting should be factual
10. Subjective data documentation Ans: Quotes with quotation marks- what the client
states to the nurse
11. Objective data documentation Ans: What the nurses, smells, osculates do not use
derogatory words, judgment, or opinions
12. Intentional tort Ans: Doing harm (The act must be intentional, not merely reckless
or careless)
Assault, battery, false imprisonment, invasion of privacy, slander
13. Interprofessional team member consult Ans: PT- consulted for mobility issues
OT- assist clients to regain ADL skills
ST- Deals with speech and language disorders
, 14. Coordinated client care among healthcare team Ans: Social worker- Coordinates
care and community resources
15. Demonstrating client advocacy Ans: Nurses role is to provide support of the clients
health, wellness, safety, and personal rights, including privacy
16. Nursing role- client observation Ans: Share appropriate information among team
members
17. Prioritizing client care Ans: Follow ABC's (airway, breathing, circulation)
Unstable are seen before stable clients
Acute clients are seen before chronic clients
18. Ethical dilemma Ans: Follow autonomy, beneficence, Fidelity, justice, nonmalefi-
cence, and veracity principles
19. Disposition of valuables
(Admit/transfer/DC) Ans: Personal items include clothing, jewelry, money, credit cards,
hearing aides, eyeglasses, dentures, etc
Discourage the client from keeping valuables at bedside
Document communication with the client related to items left within the room
Valuables should be locked in the facilities safe
20. Identify negligence Ans: Failure to provide care as defined by a standard