 Lesson 1

Management of Care

Lesson 1

Lesson Introduction
Lesson 1: Management of Care: Evaluates a nurse’s ability to manage or direct nursing care
delivery that protects clients and health care personnel.

NCLEX Client Needs Category

Safe & Effective Care Environment evaluates the nurses' ability to promote the achievement
of client outcomes by providing and directing nursing care that enhances the care delivery
setting in order to protect clients and health care personal.

Pre-assessment Activity

This is the Lesson 1: Management of Care pre-assessment activity. There are 10 NCLEX-style
questions in this activity. When you have answered all 10 questions, you will be asked to submit
your answers. Your score will not be recorded until you submit your answers.

Go to the next page to start the activity.

Ref # 5027

A client asks the nurse for information about a living

will. Which statement made by the client
demonstrates an understanding of a living will?
(Select all that apply.)
"It lists all my assets and how they should be divided among my family after I die."
"I should sit down and discuss my wishes for end-of-life care with my loved ones."
 Correct!
"A living will must be renewed by a designated family member each time I am hospitalized."
"A living will is a legal document that becomes a permanent part of my health care record."
Correct!
"My wishes for end-of-life treatment are stated in writing."
Correct!
"I will need to identify someone to be my health care proxy."
Correct Response
Submit
An advance health care directive is also known as a living will. It is a legal document in which a
person specifies his or her wishes concerning medical treatments at the end-of-life, when s/he is
unable to make those decisions. Advance care planning involves sharing personal values and
wishes with loved ones and selecting someone, (called a medical power of attorney or health care
proxy) who will eventually make medical decisions on the client's behalf. A living will does not expire;
it remains in effect unless it is changed. A living will does not include information regarding assets or
a person's estate.

LESSON
Management of Care or Coordinated Care
Advance Directives
COURSE
RN & PN Review
KEYWORDS
living will
advance directive
proxy
wishes

CONFIDENCE
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Fair
Strong

Ref # 1871

2
A nurse manager suspects a staff nurse of
substance use disorder (SUD). Which approach
would be the best initial action by the nurse
manager?
Schedule a staff conference, without the nurse present, to collect information
Consult with human resources personnel about the issue and needed actions
Correct Response
Confront the nurse about the suspicions in a private meeting
Counsel the employee to resign to avoid investigation and rumors
Submit
The nurse manager needs to consult with human resources to determine the proper procedures for
documenting and reporting the nurse's behavior. The nurse manager could also consult the EAP if
one is available. If the staff nurse is also suspected of diversion, and a written policy exists, the
nurse manager would follow these procedures. Attempts should be made to help the nurse with SUD
by providing counseling and treatment for this disease.

Want a more detailed rationale? Listen to the Learning Extension's Question Dissection®
podcast. https://ww2.learningext.com/audio/QuestionDissection_July8_2014.mp3?
utm_source=LXCourse&utm_medium=AudioLink&utm_campaign=Rationale
Can't listen? Read the full transcript. https://ww2.learningext.com/audio/2014July8.pdf?
utm_source=LXCourse&utm_medium=TranscriptLink&utm_campaign=Rationale

LESSON
Management of Care or Coordinated Care
Concepts of Management or Supervision
COURSE
RN Review
KEYWORDS
substance use disorder
manager
intervention

CONFIDENCE
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3
Ref # 1972

The triage nurse identifies that a 16-year-old client is

legally married and has signed the consent form for
treatment. What would be an appropriate action by
the nurse?
Refer the teenager to a community pediatric hospital emergency department
Proceed with the triage process in the same manner as any adult client
Correct!
Ask the teenager to wait until a parent or legal guardian can be contacted
Withhold treatment until telephone consent can be obtained from their partner
Submit
Minors may become known as an "emancipated minor" through marriage, pregnancy, high school
graduation, independent living or service in the military. Therefore, this married client has the legal
capacity of an adult. Otherwise, the age for legal signatures is 18 years of age.

LESSON
Management of Care or Coordinated Care
Legal Rights and Responsibilites
COURSE
RN Review
KEYWORDS
legal
consent
emancipated minor

CONFIDENCE
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Strong

Ref # 4571

4
The registered nurse (RN) and the unlicensed
assistive person (UAP) are caring for clients on a
surgical unit. Which action(s) by the UAP warrant
immediate intervention? (Select all that apply.)
The UAP empties the indwelling catheter bag for the client who had a transurethral resection
of the prostate (TURP) yesterday
The UAP applies moisture barrier cream to the client's excoriated perianal area
The UAP assists a client, who received an IV narcotic analgesic 30 minutes ago, to ambulate
in the hall
Correct Response
The UAP applies a fingertip pulse oximeter on a client whose fingernail is painted dark blue
Correct!
The UAP assists a client, who had a total knee replacement two days ago, to shave using a
straight-edge razor
Correct Response
Submit
The UAP can perform a number of nursing tasks, such as emptying an indwelling urinary catheter
bag and applying moisture barrier cream after peri care. However, it is unsafe for the UAP to
ambulate a client who recently received an IV push narcotic. Although UAP can shave clients, it is
unsafe to shave someone using a straight-edge razor because a client who had knee replacement
surgery is probably taking an anticoagulant; only an electric razor should be used. Pulse oximeter
readings must be done on a finger that is warm and free from dark fingernail polish.

LESSON
Management of Care or Coordinated Care
Client Care Assignments or Assignment, Delegation and Supervision
COURSE
RN Review
KEYWORDS
intervention
safety

CONFIDENCE
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Strong

5
Ref # 1420

A client who is unconscious is brought to the

emergency department by an ambulance. What
document should the nurse give priority to when
preparing the care for this client?
A notarized original of the advance directive brought in by the partner
Correct!
Orders written by the health care provider in the emergency department
The national statement of client rights and the client self-determination act
The clinical pathway protocol of the agency and the emergency department
Submit
This document specifies the client's wishes of what actions are to be taken when the client becomes
unable to make health care decisions. The advance directive often includes a living will and the
power of attorney to whom will make the decisions for the client. The next document that would take
precedent are the orders written by the heath care provider. The clinical pathways are used to
evaluate the client's progress during therapy.

LESSON
Management of Care or Coordinated Care
Advance Directives
COURSE
RN Review
KEYWORDS
unconscious
advance directive

CONFIDENCE
Need Help
Fair
Strong

Ref # 1873

6
The new graduate nurse interviews for a position in
a nursing department of a large health care agency
that uses the approach of shared governance.
Which of these statements best illustrate the shared
governance model?
Staff groups are appointed to discuss nursing practice and client education issues
Non-nurse managers supervise nursing staff in groups of units
Nursing departments share responsibility for client outcomes
Correct Response
An appointed board oversees any administrative decisions
Submit
Shared governance or self-governance is a method of organizational design. It promotes
empowerment of nurses to give them responsibility for client care issues and outcomes with other
divisions in the agency.

LESSON
Management of Care or Coordinated Care
Concepts of Management or Supervision
COURSE
RN Review
KEYWORDS
shared governance
outcomes
responsibility

CONFIDENCE
Need Help
Fair
Strong

Ref # 1277

7
A nurse is named in a lawsuit. Which of these
factors will offer the best protection for that nurse in
a court of law?
Clinical specialty certification by an accredited organization
Complete and accurate documentation of assessments and interventions
Correct!
Above-average performance reviews prepared by nurse manager
Sworn statement that health care provider orders were followed
Submit
The medical record is a legal document. Documentation should include all steps of the nursing
process; it must be complete, accurate, concise and in chronological order. Inaccurate or incomplete
documentation will raise red flags and may indicate the nurse failed to meet the standards of care.
The attorney will review the medical record with the nurse before giving a deposition (sworn pretrial
testimony). Above-average performance reviews could be considered supporting information.
Certification is an "extra" based on the nurse's initiative; it is, however, unrelated to accurate
charting.

LESSON
Management of Care or Coordinated Care
Legal Rights and Responsibilites
COURSE
RN & PN Review
KEYWORDS
court
documentation
lawsuit

CONFIDENCE
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Fair
Strong

Ref # 1298

8
A nurse has been assigned to four clients in the
emergency department, with each client
experiencing one of these conditions. Which client
should the nurse check first?
Tension pneumothorax with slight tracheal deviation to the right
Correct Response
Viral pneumonia with atelectasis
Spontaneous pneumothorax with a respiratory rate of 38
Acute asthma with episodes of bronchospasm
Submit
Tracheal deviation indicates a significant volume of air being trapped in the chest cavity with a
mediastinal shift. In tension pneumothorax the tracheal deviation is away from the affected side. The
affected side is the side where the air leak is in the lung. This situation also results in sudden air
hunger, agitation, hypotension, pain in the affected side and cyanosis with a high risk of cardiac
tamponade and cardiac arrest.

LESSON
Management of Care or Coordinated Care
Establishing Priorities
COURSE
RN Review
KEYWORDS
emergency
myocardial infarction
pain

CONFIDENCE
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Fair
Strong

Ref # 4589

9
An elderly client is admitted to a home care agency
following hospitalization for exacerbation of heart
failure. The client lives alone, has difficulty
completing activities of daily living (ADLs) and is
unable to drive.

Reorder the steps in the case management process

by dragging and dropping the options below.
Assessment of biophysical and sociocultural considerations
Identification of nursing diagnoses
Referral to personal care attendant and transportation services
Reassessment of health status and ADL ability
Evaluation of progress towards client's goals
Submit
Show Solution
Case management is a collaborative process that assesses, plans, implements, coordinates,
monitors and evaluates options and services to meet an individual's health needs.
LESSON
Management of Care or Coordinated Care
Case and Resource Management
COURSE
RN Review
KEYWORDS
home care
heart failure
ADL
case management

CONFIDENCE
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Fair
Strong

10
Ref # 4599

The nurse, who is caring for a client with complex

and unique health needs, describes the nature of the
illness in an online social forum for nurses. Neither
the client's real name nor any other personal
identifiers are used. What, if any, consequence
could result from posting this information online?
There won't be any consequences because the information was posted on a website for
nursing professionals
The nurse could be reprimanded for not clearing the information first with hospital
administration
There won't be any consequences because the client's real name was not used
The nurse could be fired for breach of confidentiality
Correct!
Submit
Many health care facilities have adopted a social media policy; it is important to understand that
nurses can be fired for posting personal information about clients online, because this is an invasion
of privacy. In addition to being a HIPAA violation, the Health Information Technology for Economic
and Clinical Health Act (HITECH Act) gives states attorneys the right to pursue violations of patient
privacy.

Want a more detailed rationale? Listen to the Learning Extension's Question Dissection®
podcast. https://ww2.learningext.com/audio/QuestionDissection_March02_2015.mp3?
utm_source=LXCourse&utm_medium=AudioLink&utm_campaign=Rationale Can't listen? Read the
full transcript. https://ww2.learningext.com/audio/2015Mar02.pdf?
utm_source=LXCourse&utm_medium=TranscriptLink&utm_campaign=Rationale

LESSON
Management of Care or Coordinated Care
Confidentiality, Information Security
COURSE
RN & PN Review
KEYWORDS

11
confidentiality
online
website

CONFIDENCE
Need Help
Fair
Strong

QSEN

The National Quality and Safety Education for Nurses (QSEN) project's mission is to "Address the
challenge of preparing future nurses who will have the knowledge, skills and attitudes (KSAs)
necessary to continuously improve the quality and safety of the health care systems within which
they work." Use the six QSEN competencies as a guide for managing and supervising care.

Click on the competency label for more information.

01 Patient-centered Care

The client (or designee) is recognized as the source of control and full partner; care that is
provided is based on respect for client's preferences, values and needs.

02 Teamwork and Collaboration

Open communication, mutual respect and shared decision-making are used to achieve
quality client care.

03 Evidence-based Practice

Health care delivery is the integration of best current evidence with clinical expertise and
client/family preferences and values.

04 Quality Improvement

Data is used to monitor the outcomes of care processes; improvement methods continuously
improve the quality and safety of health care systems.

05 Safety

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 Risk of harm to clients and providers is minimized through both system effectiveness and
individual performance.

06 Informatics

Information and technology are used to communicate, manage knowledge, mitigate errors
and support decision-making.

NCSBN Learning Extension offers a continuing education course on each of these topics in its
Transition to Practice program. https://ww2.learningext.com/newnurses.htm

Learn more about the Quality and Safety Education for Nurses (QSEN) project.http://www.qsen.org/

Ethical Practice

Ethics are defined as a theory or system of moral values, based on ideas of right and wrong. Ethics
governs our relationships with others.

A code of ethics provides standards and values for a profession; nurses must integrate the values of
the profession with their own personal values.

Nonmaleficence
The principle of "do no harm." This is the core of medical oaths and nursing ethics.

This is directly tied to the nurse's duty to protect the client's safety.

Beneficence
The desire to do good and to take positive action to help clients.

Autonomy
Respect for a client's right to self-determination or to make decisions about their life without
interference from others.

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Clients have the right to have the information and facts necessary to make intelligent decisions and
the nurse has an obligation to advocate for the client. This right forms the basis for informed consent
in the health care system.

Justice
The principle of fairness and equality for all clients.

Privacy & Confidentiality

Privacy belongs to a client and cannot be taken away unless they wish to share it.

Confidentiality

The right to expect that information will be kept private or secret and shared on a need-to-know
basis only.

means that the information shared with other persons will be used for intended purposes only.

Clients have a right to have personal information kept confidential and distributed only to authorized
personnel per the Health Insurance Portability and Accountability Act (HIPPA). It is necessary to
obtain the client's permission to release information to family members or friends.

Fidelity
This principle involves loyalty, faithfulness, truthfulness and honoring commitments. Nurses must
always advocate for and honor their clients' wishes.

Fidelity is based upon the virtue of caring.

Learn more about the American Nurses Association's Code of Ethics for Nurses
https://www.nursingworld.org/practice-policy/nursing-excellence/ethics/code-of-ethics-for-nurses/
and the Canadian Nurses Association's Code of Ethics for Registered Nurses. https://www.cna-
aiic.ca/en/nursing-practice/nursing-ethics

14
NCSBN Learning Extension offers two continuing education courses
https://ww2.learningext.com/nurses.htmon the topic of ethics: Ethics of Nursing Practice and
Righting a Wrong: Ethics & Professionalism in Nursing.

Knowledge Check 1.1

A client's uncle calls for an update on the condition

of his nephew. What should the nurse do first before
providing the information to the caller?
Call the physician to verify the client's condition before you speak to the family member
Ask the family member that is currently at the client's bedside if it is okay to release the
information to the client's uncle
Consult with the client and obtain permission to update the client's uncle of his condition
Correct!
Refuse to release any information to the family member and remind them they must be
present to obtain an update
Submit
You must have permission by the client to release information to the family member. If your client is
unable to give permission and has a health care proxy, then information can only be given to the
health care proxy and all family members can obtain updates from the proxy. Remember, it is
difficult to know who is calling over the phone. Consult your organization's policy on condition
requests over the phone.

Client's Rights

Clients have the right to:

Be informed of their treatment options

Accept treatment options or refuse treatment, even life-sustaining treatments
Advance Directives

An advance directive

*A legal document (such as a living will) signed by a living competent person in order to provide
guidance for medical and health-care decisions (e.g., the termination of life support and organ
donation) in the event that the person becomes unable to make such decisions.*

15
is a written statement of a person's wishes regarding medical treatment. It often includes a living will

*A document in which the signer requests to be allowed to die rather than be kept alive by artificial
means in the event of becoming disabled beyond a reasonable expectation of recovery.*

and identifies a durable power of attorney for health care (also called medical power of attorney,
health care agent or health care proxy).

Advance directives do not expire. However, one state's advance directive does not always work in
another state.

Video 1.1 What are Advance Directives?

https://www.youtube.com/watch?v=OaQ8Z9XFK8E&feature=emb_title

Read a summary

See a description of four advance directives, which are important for older adults to consider. For
more information, view the End of Life topic on the National Institutes of Health website.

of the content if you cannot view the video.

Nurses and other members of the health care team are required to:

Assess the client's knowledge of advance directives and their status regarding the advance
directive process
Provide information and assistance to the client in developing advance directives
Plan care that incorporates the client's decision regarding advance directives

Living will
A living will identifies a client's wishes for his or her care should they become unable to communicate
these wishes.
DNR

16
Do not resuscitate (DNR) is a medical order, usually written by a physician. It instructs health care
providers not to perform cardiopulmonary resuscitation (CPR) if a client's breathing stops or if the
client's heart stops beating. The DNR order may also include identification of medications that may
be given without any defibrillation attempts.

The client or health care proxy can withdraw the order at any time.
AND

Allow natural death (AND) is a medical term limiting or prohibiting the use of life-extending
measures.

This order acknowledges that the client is dying and everything that is being done for the client,
including the withdrawal of nutrition and hydration, will allow the dying process to occur as
comfortably as possible.
Organ Donation

Nurses advocate for and support families throughout the organ and tissue donation process.

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.
Informed Consent

Informed consent

*A client's consent to surgery or a subject's consent to participation in a medical experiment, after

achieving an understanding of what is involved.*

grants permission to perform a test or procedure. The health care provider is legally obligated to
provide a complete description of the test or procedure, as well as the possible risks and benefits.
Informed consent is also important for clients who wish to leave a health care facility against medical
advice (AMA).

The client must have the capacity to understand:

The purpose of the procedure and expected results

Anticipated risks and discomforts
Potential benefits

17
 Any reasonable alternative treatments

The informed consent form must be signed by a competent adult. The person signing the document
must be able to understand the information given by the health care professional. If the person is
unable to understand the information due to a language barrier or hearing impairment, a trained
medical interpreter must be present.

Nurses will cosign the document, attesting that they witnessed the client or designated person sign
the consent form.

The client and/or designated proxy can withdraw consent at any time.

https://www.youtube.com/watch?v=nNgR95P9b1k&feature=emb_title

Video 1.1 Minute for Medicine - Informed Consent Done Right

Read a summary

Informed consent is an ongoing, dynamic process when done correctly, but few patients receive a
true informed consent before entering the hospital or outpatient center for a procedure. This short
video shares what true informed consent really is, and how patients and providers benefit when it is
done right.

of the content if you cannot view the video.

Read more about informed consent.

Informed Consent
According to the American Medical Association (AMA), informed consent is a process of
communication between a physician and a client that results in the client's authorization or
agreement to undergo a specific medical intervention.
Informed consent is both an ethical obligation and a legal requirement in all 50 states
A mentally competent adult client must give his or her own consent; parents or legal
guardians may give consent for minors

Client Requirements
A client needs to understand the following information before giving consent:
The diagnosis

18
 The nature and purpose of the treatment or procedure
Any reasonable alternatives, regardless of the cost or whether or not the alternative is
covered by insurance
Risks, consequences and benefits of the procedure and the alternative(s)
Risks and consequences if the treatment or procedure is refused

Nurse's Role
The nurse's role is:
To be the client's advocate
To protect the client's dignity
To identify any fears
To determine the client's degree of comprehension and approval of the care he or she is to
receive
The nurse may be assigned the task of obtaining and witnessing the client's signature
The nurse who is concerned about the validity of an informed consent has a legal obligation
to tell the physician and the nursing supervisor about the concern
The nurse is not responsible for providing details about the treatment or procedure
Read the AMA's complete definition of informed consent.
https://cme.ama-assn.org/Activity/5674416/Detail.aspx

Freedom from Restraints

A restraint is a measure or condition that limits a client's movement. Restraints can also help keep a
client from getting hurt or doing harm to others.

Activity 1.1
Advanced Directives

Watch the video, https://www.youtube.com/watch?v=OaQ8Z9XFK8E which reviews the

different types of advance directives.

Reflection Questions
The nurse is responsible for making sure the client understands advance directives and then
integrating them into the client's plan of care. Often nurses and clients will discuss advance
directives such as living wills, appointing a health care proxy/power of attorney and/or a do not
resuscitate form. Have you ever had this type of discussion with a client or loved one or considered

19
creating advance directives for yourself? What is the benefit of creating an advance directive? Why
might this conversation be difficult to have?
Feedback

Having an advanced directive allows clients to specify their wishes to family and health care
providers for when they are unable to provide clear guidance. There are multiple treatment options
for clients with life-threatening illness and through an advance directive they can avoid unnecessary
procedures, hospitalizations or pain. Living wills are created by competent clients and indicates what
life-saving measures may be or not be applied to them (surgery, CPR, dialysis, respirator, tube
feedings etc.). This form is critical when clients are no longer able to express their wishes.

Knowledge Check 1.2

A client is being prepped for a surgical procedure

and the nurse is reviewing the informed consent with
the client. The client asks, "Is there any other way to
take care of this without having surgery?" The nurse
has a duty to first:
Reassure the client that the surgery is the best treatment option
Tell the client if they don't want the surgery, they don't have to have it
Notify the surgeon that the client has additional questions about alternatives to surgery
Correct!
Call the surgeon and cancel the surgery until the consent form is signed
Submit
The client has a right to an explanation of the treatment and its expected results, anticipated risks
and benefits, possible alternative treatment options and all questions answered before a consent
form is signed. Remember, the client is not asking you for your opinion. The client is asking about
alternative treatments for the condition. Notify the appropriate health care provider if the client needs
additional information that you cannot answer. Once the client has all the necessary information then
they can decide not to sign the informed content and cancel the surgery.

Professional Misconduct

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Professional accountability can be defined as a condition in which nurses maintain the established
standards of practice in order to provide safe, appropriate and ethical care.

Professional misconduct involves an act of breaking or failing to observe a law, agreement or ethical
code of conduct. This conduct may involve deceiving, defrauding or harming the public.

Professional negligence (also known as malpractice) is failing to act as other prudent nurses with a
similar background, knowledge and education would act under similar circumstances. It involves an
action or inaction that results in unintended harm to the client.

Common situations that require incident reports include, but are not limited to:

Medication errors
Complications from diagnostic or treatment procedures
Incorrect sponge counts in surgery
Failure to report a client's change in condition
Falls
Burns
Aseptic technique
Refusal of treatment/client
Family is dissatisfied with care

SUD
Substance use disorder (SUD) encompasses a pattern of behaviors that range from misuse to
dependency or addiction to alcohol or (legal and/or illegal) drugs. SUD is a treatable illness or
chronic brain disease, not an "impairment" or a personal failure.

SUD may be manifested by behavior changes, physical signs of the disease and drug diversion.

The impaired nurse compromises client care. If you observe or suspect a nurse is working impaired,
it is your professional and ethical responsibility to protect the client and communicate concerns to

21
the nurse manager or other first line manager in the chain of command. In some states/jurisdictions,
you are legally obligated to report this behavior to the board of nursing/regulatory body (BON/RB)

Professional Boundaries
A therapeutic relationship is one that allows nurses to apply their professional knowledge, skills,
abilities, and experiences towards meeting the health needs of the client. This relationship is
dynamic, goal-oriented and client-centered because it is designed to meet the needs of the client.

The therapeutic nurse-client relationship protects the client's dignity, autonomy, privacy and allows
for the development of trust and respect.

The guiding principles of professional boundaries in nursing include:

The nurse-client relationship is professional, not personal

The nurse is responsible for setting and keeping boundaries
Once a nurse becomes involved in the client's personal life, professional objectivity is
compromised
Failure to adhere to professional boundaries can never be blamed on the client

Boundary violation is an act of abuse in the nurse-client relationship; behaviors are intentional,
unprofessional, unethical and even criminal (such as criminal sexual misconduct).

Consequence of Professional Misconduct

A board of nursing/regulatory body (BON/RB) must protect the public and is required to take action
against the licenses of nurses who have exhibited unsafe nursing practice.

A BON/RB may impose penalties for professional misconduct, ranging from probation, censure and
reprimand, to suspension or even revocation of licensure.

For more information on these topics, you might be interested in these NCSBN Learning Extension's
continuing education courses: Understanding Substance Use Disorder in Nursing, Professional
Boundaries in Nursing and Professional Accountability & Legal Liability.

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Knowledge Check 1.3

A nurse has unintentionally given an incorrect dose

of medication to their client. No harm was done to
the client. What is the next action, if any, required by
the nurse?
The nurse is not required to report the mistake because the client was not harmed
The nurse is not responsible for the mistake because they have not been provided current
education by their employer
The nurse will immediately be suspended and their license will be revoked
The nurse will report the incident to their nurse manager and follow their organizational
procedures for reporting
Correct!
Submit
Although the client was not harmed as a result of the mistake, the incident still needs to be reported.
Nurses are responsible for their practice and for staying current and competent by becoming lifelong
learners. In this case, neither an immediate suspension nor revoking a license are warranted.

Nursing Team

Nursing Team

An essential element in a culture of safety is teamwork. The nursing team consists of the registered
nurse (RN), possibly a licensed practical or vocational nurse (LPN/VN) and an unlicensed assistive
person (UAP). Both RNs and LPN/VNs have a legal scope of practice that is outlined in the nurse
practice act/administrative rules. In addition to laws, rules and regulations, there are also
professional standards of practice for nurses.

RNs
The practice of professional nursing means the performance of services requiring substantial
specialized knowledge of the biological, physical, behavioral, psychological and sociological
sciences and of nursing theory as a basis for the nursing process: assessment, nursing analysis,
planning, nursing intervention and evaluation.

23
The RN works in a collaborative relationship with other health care providers to make self-directed
judgments and act independently. The RN is responsible for providing nursing care to individuals
and groups, including:

Assess the client's physical condition, analyze and interpret data, intervene based on
important data and evaluate
Implement critical thinking decision-making and problem solving

*The deliberate process of collecting, interpreting, analyzing and drawing conclusions about
information. In nursing, critical thinking is the process by which nurses make a judgment (i.e., a
clinical decision) about what to believe and what to do in a particular situation.*

Health promotion and maintenance

Provide client education
Offer counsel and support
Help clients restore optimall functioning and comfort

LPN/VNs
The practice of practical nursing means the performance of services requiring basic knowledge of
the biological, physical, behavioral, psychological and sociological sciences and of nursing
procedures. LPN/VNs assist in implementing a defined plan of care and to perform procedures
according to protocol.

Assist with the implementation of a defined plan of care

Provide care for physiologically stable clients with predictable conditions
Collect data for assessment, differentiate abnormal from normal to report to the RN
Maintain knowledge of asepsis and dressing changes
Depending on their education background and state nurse practice act, an LPN may be able
to administer medications

The scope of practice for LPN/VNs is not the same in every jurisdiction/state.

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UAP
Unlike nurses, UAPs do not have a legally-defined scope of practice, which is why they can be
trained to perform a variety of tasks in different health care settings. Regardless of the specific tasks,
their main role is to provide basic care to patients and assist them with activities of daily living.
Please refer to your jurisdiction/state laws for more specific information. UAPs limited scope includes
(but may not be limited to) assisting with direct client care, such as bathing, feeding, toileting,
obtaining vital signs, input and output, and recording height and weight.

Examples of UAP include certified nursing assistants (CNAs), home health aides and patient care
technicians.

Remember the steps in the RN Nursing Process - A Delicious PIE

Figure 1.1: A Delicious PIE

Knowledge Check 1.4

Which of these activities can be assigned to an

unlicensed assistive person (UAP)?
Reinforce teaching to the client
Create a plan of care for the client
Care for a stable client
Provide basic care to the client
Correct Response

Interprofessional Team

Effective teamwork can be defined as functioning effectively within nursing and interprofessional
teams through open communication, mutual respect and shared decision making, in order to achieve
quality client care (QSEN, 2013).

Collaborative health care acknowledges the expertise and contribution of all members of the team to

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improve outcomes. Interprofessional teams are most successful when they work together to
understand the client's situation from the client's perspective, and recommend a plan of care that's
culturally sensitive, relevant and cost effective.

Emotional Maturity
Emotional maturity is also needed for effective collaboration. Emotional maturity refers to your ability
to understand and manage your emotions so that you can express your feelings appropriately and
act intelligently, especially when you are under stress.

To promote a culture of safety and a healthy work environment, nurses should demonstrate
behaviors that create a supportive, respectful, civil and safe environment.

Managing Conflict
Negative behaviors can come from clients, families, physicians and even other nurses. Disruptive
behaviors threaten the morale and emotional well-being of staff and undermine client safety.
The following guidelines can help you make the process of conflict resolution more positive:
Listen for what is felt as well as what is said – be in the moment
Make conflict resolution the priority – as opposed to "winning" or "being right"
Focus on the present – you can't move forward if you are stuck in the past
Pick your battles – conflicts can be draining, so consider whether the issue is worth your time
and energy
Be willing to forgive – and release the urge to punish
Know when to let something go – if you can't come to an agreement, agree to disagree
Skilled communication can help decrease conflict.

Assignment & Delegation

RNs must supervise others when they delegate an activity or make an assignment. This involves
monitoring the performance of the activity, providing feedback and assuring successful completion of
the activity. This also includes compliance with all standards of practice, policies and procedures.

Prioritizing care requires RNs to determine which tasks they must do and what tasks can be
assigned or delegated to others.

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The RN is meeting the standard of care if:

The nurse has provided specific directions and communication about a task
The nurse knows the LPN/VN or UAP has the training and experience to perform the activity
The nurse is available to monitor and supervise the activity
The nurse requires the LPN/VN or UAP to provide feedback to the RN about the care
provided

Assignment

Providing patient care includes appropriate assignment to and supervision of LPN/VNs and UAPs.
Matching the needs of the patient to the skills of the members of the nursing team requires the RN's
professional judgment.

The RN makes patient assignments based on the scope of practice of the nurses and/or training and
employer policies. Assignments to perform specific tasks are based on the needs of the patient, the
complexity of the work and the competency of the individual accepting the assignment.

UAPs can never be assigned to provide any type of care that requires nursing knowledge, skill or
judgment. Also, UAPs may not reassign an assigned task.

UAPs are always personally responsible for any care they provide under the legal theory of
individual accountability.

Delegation
Delegation

*Transferring to a competent individual the authority to perform a selected nursing task in a selected
situation. The nurse retains accountability for the delegation.*

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involves a specific nursing activity, skill or procedure that is beyond the team member's traditional
role and not routinely performed. For example, the RN can delegate measuring blood glucose to
UAPs in an acute care setting. The RN cannot delegate nursing judgment, assessment or critical
decision-making.

Figure 1.2: Five Rights of Delegation

Don't confuse these!

Scope of Practice - determined by a state's nurse practice act (or province/territory's nursing
act)

*The procedures, actions and processes that a health care practitioner is permitted to
undertake, in keeping with the terms of their professional license.*

Standards of Practice - established by the nursing profession (such as the ANA or CNA)
Standard of Care - institutional policy and procedural documents

*What a reasonable and prudent nurse with similar training, knowledge and experience
would do or would not do in the same or similar situation.*

Knowledge Check 1.5

A nurse can delegate a task to a team member by

determining their responsibility through which of the
following documents? (Select all that apply.)
Nurse practice act
Correct!
Organization's standard of care
Correct Response
Organization's job description
Correct!
Team member's acceptance of task
Team member's relationship with the client

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Submit
If the nurse is unclear about a task they can delegate then they may need to review the nurse
practice act and/or their organization's standards of care or delegatee job description.

Although it is important that the team member accepts the task, that does not mean the task is an
appropriate assignment for that team member. A team member's relationship to the client may
determine if the nurse assigns the task or not, but the relationship does not tell you if it is an
appropriate task.

Establishing Priorities

Prioritizing care involves choosing which needs or problems require your immediate attention or
action and which ones can be delayed until a later time because they are not urgent.

Guiding principles include:

Needs that are life-threatening or could result in harm to the client if left untreated are high
priorities.
Actual problems or needs have higher priority than potential problems or needs.

Consider Maslow's principles (hierarchy of needs) or the ABCs & P (airway, breathing, circulation &
pain) to guide your decisions.

Figure 1.3: Maslow's Hierarchy of Needs

Many times, problems or needs that your client brings to your attention are of a higher priority.
Mutual decision-making can be made with the client based on their physiologic needs, desires and
safety.

Communication

Collaborative practice requires communication that is clear, concise, accurate and timely. There are
many different tips and mnemonic tools you can use to standardize communication.

Figure 1.4: The 4 C's of Communication

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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 and the law?
4. Complete - Does the team member have all the information necessary to complete the task?

https://www.youtube.com/watch?v=5oLJsIHuHCA&feature=emb_title

Video 1.2 Minute for Medicine - Communication For Safer Care

Read a summary of the content if you cannot view the video.

Communication, or the lack therof, has been identified as a key contributing factor to harm that
occurs in the healthcare workplace. This short video is a reminder that good communication
practices keep patients safe.

SBAR

Using SBAR (which is an acronym for situation, background, assessment and recommendation) is
an effective and efficient way to communicate important information (IHI, n.d.).

Figure 1.5: SBAR

S = situation (a concise statement of the problem)

B = background (pertinent and brief information related to the situation)
A = assessment (analysis and consideration of options - what you found/think)
R = recommendation (action requested/recommended - what you want)

https://www.youtube.com/watch?v=Pl2EcTFWB4A&feature=emb_title
Video 1.3 Minute for Medicine - SBAR and Good Handoffs

Read a summary of the content if you cannot view the video.

30
SBAR, or Situation, Background, Assessment, Recommendation, is a way health care professionals
have been communicating for years. This video will outline how SBAR keeps patients safe, and
reinforces how standard communication overall is key to keeping patients safe.

The SBAR technique was originally developed by Kaiser Permanente. Read more about SBAR from
the federal Agency for Healthcare Research and Quality.
https://innovations.ahrq.gov/qualitytools/sbar-technique-communication-situational-briefing-model

SBAR, or Situation, Background, Assessment, Recommendation, is a way health care professionals

have been communicating for years. This video will outline how SBAR keeps patients safe, and
reinforces how standard communication overall is key to keeping patients safe.
CUS

Figure 1.6: CUS

CUS is a process used to effectively advocate for clients when there is a concern.

ARCC

If you have a concern, speak up and use the ARCC approach.

Figure 1.7: ARCC

https://www.youtube.com/watch?v=b9Gnz4yNwlY&feature=emb_title
Video 1.4 Minute for Medicine - Using ARCC and Validate and Verify for Patient Safety
Read a summary of the content if you cannot view the video.

ARCC and validating and verifying daily tasks in the health care workplace are key tools used by
high reliability organizations. ARCC lays a framework for questioning things that don’t feel, or seem
right. Validating and verifying anything in the care environment that does not seem right ensures
patients stay safe.

ARCC and validating and verifying daily tasks in the health care workplace are key tools used by
high reliability organizations. ARCC lays a framework for questioning things that don’t feel, or seem
right. Validating and verifying anything in the care environment that does not seem right ensures
patients stay safe.

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Two-challenge Rule

The two-challenge rule is a strategy you can use when your viewpoint does not coincide with that of
the decision-maker (such as a physician), especially if you believe there is a safety breach. Similar
to CUS, you will draw attention to an issue of concern but now you will also offer a solution.

With the two-challenge rule, it is your responsibility to assertively and firmly voice your concern at
least two times, just to make sure that what was actually heard. The team member who is being
challenged must acknowledge that the concern was heard.

Example
Nurse: "Doctor, do you really want me to give Phenergan-Codeine to this 3-month-old in
room 2?"
Doctor: "Yes, that is my order."
Nurse, using two-challenge rule: "Doctor, do you really want me to give Phenergan-Codeine
to a newborn… who might stop breathing?"
Doctor: "No. I want the toddler who is coughing and vomiting in room 5 to have that
medication!"

Documentation

Documentation is one of the most important methods of determining whether a nurse was negligent
or not. Poor charting can make even the most competent nurse appear negligent.

Nurses should document the client's condition at the point of care, even if it is stable or unchanged
from the previous assessment. If the client's condition is deteriorating, the nurse must document that
the treating practitioner was contacted.
Paper

The acronym "FLAT" is essential for any type of charting involving paper and pen: information
entered in the patient's record must be factual, legible, accurate and timely.

Figure 1.8: FLAT

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Errors
When using paper for documentation, the practice of drawing a line through an error in charting
along with the nurse's initials and the date is still considered the best method for correcting an error.
Using Wite-Out®, removing pages or entries from a medical record, or rewriting notes in response to
an incident makes the records suspect and may imply guilt on your part even if there is no
professional negligence.

Late Entries
Late entries are acceptable practice so long as they are marked as such with the correct date of
entry and time. A nurse who attempts to conceal a professionally negligent nursing action by
entering false information in a medical record is committing fraud.

Documentation has six key components (CO-ACTS)

Figure 1.9 CO-ACTS

Knowledge Check 1.6

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The nurse has called a physician to obtain orders
about their mutual client. Below is the transcript of
the call:

Hello Dr. B this is Nurse A calling about our client

Mr. F. The client is a 63-year-old male 24 hours
post-surgical appendectomy who is having pain. He
has a history of hearing loss and urinary tract
infections. I would like to increase Mr. F's morphine
from 0.5 mg per hour as needed to 1 mg per hour as
needed.

What communication step did the nurse forget to

include?
Submit
Assessment

Continuity of Care

Continuity of care is a process that coordinates the delivery of care over a period of time with a focus
on the client's health needs. Discharge planning, case management and care coordination are
different approaches you may use to achieve continuity of care.

Nurses can offer support, education, information and resources to help their clients navigate the
health system and access the right services at the right time, which leads to better care outcomes.
Handoffs

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A handoff is the transfer of client information and knowledge, along with authority and responsibility,
from one practitioner (or team of practitioners) to another practitioner (or team of practitioners)
during transitions of care across the continuum (ACOG, 2012).

During a change of shift:

It is your responsibility to know that the oncoming nurse is aware that s/he is assuming
responsibility
You are accountable for client care until the oncoming nurse is aware of the transfer of
responsibility
You cannot give up your responsibility until the oncoming nurse acknowledges that the
handoff is understood and accepted
Care Transitions

Transition planning recognizes that clients are not discharged from care but moved across the
continuum to another level of care.

To communicate information during handoffs at a change of shift, when transferring a client from one
unit to another or when discharging a client from one health care setting to another health care
setting or outpatient facility, you can use the mnemonic: I PASS the BATON.

Figure 1.10: I PASS the BATON

Quality Improvement

Quality improvement (QI) involves the systematic activities that are organized and implemented by
an organization to monitor, assess and improve the quality of health care.

QSEN (2014) defines QI as using data to monitor the outcomes of care processes and using
improvement methods to design and test changes. The goal is to continuously improve the quality
and safety of health care systems.

Figure 1.11: Quality Improvement steps

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Almost all regulatory and voluntary accrediting agencies now require some form of quality
improvement. Two of the more commonly used tools for QI include: Total Quality Management
(TQM) and Continuous Quality Improvement (CQI).
Client Education

Many clients return to the hospital or health care setting due to ineffective client teaching. By
assessing their needs, addressing compliance, creating a plan and then evaluating your
effectiveness, you'll help clients leave your care better prepared.

Assessment
What kind of learning will help my client best (cognitive, psychomotor or affective)? What knowledge
do they need considering their needs and motivation?

Diagnose
Have I considered how to effectively communicate, including what factors might influence their
compliance?

Plan/Implement
Set priorities and realistic goals
Consider involving friends and family if applicable
Non-judgmental approach
Provide demonstration and visuals as needed
Client will provide a return demonstration of a skill if applicable and allow for practice time
Review benefits of changed behavior

Evaluate
Is the client able to verbalize understanding and/or paraphrase learning?
Can the client demonstrate a skill?
Has the teaching/learning goal been reached?

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Lesson Conclusion

Congratulations! You have completed Lesson 1: Management of Care (Safe & Effective Care
Environment)! The purpose of this lesson is to ensure the nurse is able to provide and direct care
that enhances the care delivery setting in order to protect clients and health care personnel. Content
in this lesson included, but was not limited to: ethical practice, client's rights, the health care team
(including assignment and delegation), establishing priorities, communication, continuity of care and
quality improvement.

Next, we encourage you to complete the Lesson 1 Practice Test. It is an opportunity for you to apply
the reviewed content, reinforce learning and practice answering NCLEX-style questions. Receiving a
passing grade of 75% or more on all the Practice Tests will allow you to receive a certificate of
completion for this course.

You do not have to complete the Practice Test to go to the next lesson.

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