NR 226- exam 1 Questions and Answers

NR 226- exam 1 Questions and Answers Which are the correct elements to use when documenting a problem-based nursing diagnosis? Diagnostic label/related to statement/defining characteristics​ assessment Identifying the client's signs and symptoms evaluation example Monitoring the client for side effects of prescribed medications implementation example Administering medications planning example Describing desired outcomes needed to reach a goal diagnosis example Identifying a problem, risk, or health promotion need risk nursing diagnosis used when there are risk factors but no evidence of actual problems diagnosis factor + related to statement ex: Risk for infection related to compromised host defenses health promotion diagnosis established when a client desires enhanced wellness and well-being Health promotion nursing diagnosis: Readiness for enhanced resilience patient centered care Adapting care as the needs of an individual change and conveying respect for the individual's health and lifestyle choices​​ total patient care RN responsible for all care on a shift​ and requiring a high degree of interprofessional collaboration​ Case Management Clinicians focusing on groups of clients with specific illnesses with the goal of improving outcomes while reducing the overall cost of care responsibility the duty to act autonomy the choice to act authority the power to act accountability the ownership of the act 5 rights of delegation 1. Right task 2. Right circumstance 3. Right person 4. Right direction/communication 5. Right supervision/evaluation The nurse whose work focuses on lowering the cost of care without compromising quality is working in which role?​ the case manager A nurse who works on a medical unit is assigned to work on a mental health unit is an example of responsibility A nurse who administered the wrong medication to a client fails to document or report the error is breaking what? responsibility and accountability The nurse asks an unlicensed assistivepersonnel (UAP) to ambulate a client.​ Balanced RAAA A nurse accesses a neighbor's electronic health record (EHR) for someone who is not a caregiver but wants to find out what is wrong with the neighbor authority and accountability right task Tasks should be delegated to colleagues whose job description includes that activity right circumstance The patient should be stable and the task does not need the nurse's knowledge and skills to ensure the patient's safety. Additionally, the resources needed to complete the task should be readily available to the delegatee.​ right person Even though an individual is qualified to complete a task, the nurse delegating must ensure that the delegatee has the current experience and feels comfortable with the assignment right communication/ direction The nurse is expected to communicate specific instructions for the delegated activity to the delegatee; the delegatee, as part of two-way communication, should ask any clarifying questions. right supervision/ evaluation When delegating, the nurse is responsible for monitoring the delegated task, following up with the delegatee, and evaluating the patient outcomes. appropriate or inappropriate delegation? Asking the unlicensed assistive personnel (UAP) to give a client their morning medications. inappropriate appropriate or inapproproate? An experienced nurse asks a new nurse to ambulate a client so they can speak with a healthcare provider. appropriate Appropriate or inappropriate? Asking another registered nurse on the floor to watch a patient while you are at lunch. appropriate Appropriate or inappropriate? Assigning a licensed vocational nurse (LVN) to care for the same clients as the day before. appropriate Which aspects of nursing care should never be delegated to an unlicensed assistive personnel (UAP)? select all that apply nursing diagnosis client assessment delivering flowers bathing client who is on bedrest evaluation of client outcomes transporting client to test nursing diagnosis client assessment evaluation time dependent priorities medication peak and trough measurement intake and output client needs priorities low BP Cardiac arrest Client Preference priorities change of clothing softer pillow morals values an individual or group attaches to right and wrong. Influences a persons behavior and how they interpret others behaviors ethics the study of right and wrong applied to questions of correct behavior fidelity faithfulness veracity truthfulness beneficence Doing good or causing good to be done; kindly action autonomy independence Nonmaleficence do no harm justice fairness example of autonomy parents refusing to have a child vaccinated justice example contacting a healthcare provider to report that a client does not fully understand a course of treatment and will not sign informed consent without further info justice example advocating for a client in pain whose healthcare provider has not prescribed sufficient pain meds Nonmaleficence example concern that a patient is concealing info that may impact their health beneficence example rubbing a childs back while they fall asleep or bringing a clients preferred bev when administering meds autonomy example encouraging a client with dementia to select with clothes to wear steps in ethical dilemma 1. ask the question, is this a dilemma 2. gather info 3. clarify values 4. verbalize 5. identify course of action 6. negotiate plan 7. evaluate living will directs the client's healthcare in the event of a terminal illness or condition. durable power of attorney invoked when the client is no longer able to make decisions on their own behalf. The client may change an advance directive at any time.​ intentional tort examples assault, battery, false imprisonment Quasi-intentional torts -Breach of confidentiality -Defamation of character unintentional tort negligence and malpractice example of intentional assault The unlicensed assistive personnel (UAP) tells a school-aged client who is not cooperating at bedtime that the nurse will give them a shot if they don't behave. example of intentional false imprisonment The nurse seats Mrs. Baxter in a wheelchair with the brakes engaged at the table during lunch. After 5 minutes, Mrs. Baxter wants to leave the dining room. The nurse knows that the client is unable to unlock the wheelchair and ignores the request because they want Mrs. Baxter to sit long enough to eat her meal. example of quasi-intentional invasion of privacy When administering medications, the nurse knocks on the door to the client's room and enters without waiting for permission. The client is standing beside the bed urinating in full view of people in the hallway.​ example of unintentional negligence The nurse exits the client's room, who is on complete bed rest, without placing the phone within reach. When the nurse returns to the room, the client is lying on the floor and explains that they didn't want to bother the nurse and fell when trying to reach for the phone.​ examples of malpractice failure to:​ - Assess and/or monitor, including making a nursing diagnosis.​ -Notify the healthcare provider of significant changes in a client's status​. -Respond to or correctly implement new and existing orders​ -Ensure client safety, especially clients who have a history of falling, are sedated or confused, are frail, are mentally impaired, get up in the night, or are uncooperative​. -Follow policies and procedures​. -Properly delegate and supervise Good Samaritan Law When acting as a Good Samaritan, the nurse must act within their scope of practice as defined by the State Nurse Practice Act, including not abandoning the injured party to get help