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Answer Key 1 2 Answer Key
22. Answer 2: Physiologic needs, such as eating always expect to get a private room with all
Answer Key and oxygenation, are the first priority accord- amenities.
ing to Maslow. 29. Answer 3: Health care workers are entitled to
23. Answer 4: Adolescence is time when love and respect from patients and also expect patients
belonging to a peer group are very important. to be responsible for their own behavior.
CHAPTER 1—THE EVOLUTION OF NURSING clinics, outpatient agencies, home health agen- Being part of a team is the best way to help him 30. Answer 3: LPN/LVNs never independently
cies, insurance companies, HCP offices, and the meet this need. alter the plan of care without the supervision of
Matching military services offer additional opportunities. 24. Answer 1, 3, 5: Patient can participate in smok- an RN.
1. b 14. Answer 1, 2, 4, 5: The LPN/LVN communi- ing cessation; stress, weight, and alcohol intake 31. Answer 4: For primary prevention, the nurse
2. d cates findings to members of the health care reduction; and control over own body and would encourage wellness activities and pre-
3. e team, demonstrates caring and empathy by health. Giving information about technology, emptive screening programs such colonoscopy
4. a using therapeutic communication skills with new medications, and costs may be of interest or glucose screening. Secondary prevention
5. f patients, administers care according to profes- to the patient, but these topics are less useful recognizes the presence of disease but seeks to
6. h sional standards and collects data from mul- in helping the patient take an active role in her reduce the impact of the condition by encour-
7. c tiple sources. The LPN/LVN would collaborate own health. aging behaviors to promote health, such as
8. g with the RN but would not independently cre- 25. Answer 4: Unlicensed assistive personnel dietary modification for recurrent hyperglyce-
9. j ate the care plan for a newly admitted patient. (UAP) are trained to assist patients with activi- mia. Tertiary prevention is applied by manag-
10. i 15. Answer 3: Reports indicate that challenges ties of daily living. The unit secretary orders ing care for those with serious health problems
related to feelings of social isolation, stereotyp- supplies using electronic or hardcopy requisi- with the goal of improving the quality of life
Multiple Choice ing about men who choose nursing, nursing tion forms. While the UAP or unit secretary can and reducing further loss of function.
11. Answer 4: NAPNES would assist a nurse instructors’ inability to incorporate masculine direct visitors, extreme caution should be used
who is seeking information about LPN/LVN styles of caring into the curriculum, and a lack in giving out patient information. (Note to stu- Critical Thinking Activities
standards. The purposes of NAPNES and Na- of male role models in the profession may be dent: Even acknowledging that a patient has 32.
tional Federation of Licensed Practical Nurses to blame for the high attrition of male nursing been admitted to the hospital can be viewed Wellness X Illness
(NFLPN) are to: students from nursing programs. as a violation of confidentiality.) Taking vital
Highest level of Diminished or impaired
Set standards for practical/vocational nursing 16. Answer 4: Advance directives could include a signs is acceptable; however, the pharmacist optimal health state of health
programs. health care power of attorney that states who generally restocks medications. Validating and
Promote and protect practical/vocational should make health care decisions if the per- interpreting are nursing responsibilities. This patient has some health problems and
nursing. son is unable to make them. A “living will” 26. Answer 2: Economical use of time and materi- some changes in her life, but she has a rela-
Educate and inform the general public about outlines wishes about end-of-life care. Ideally, als is the best way to contain costs for indi- tively high level of wellness. Her blood pres-
practical/vocational nursing. everyone should carefully consider advance vidual patients. Malpractice insurance does not sure is under control and she has adapted to a
For issues related to interpersonal conflict, directives and have discussions with family help to contain costs. While it is appropriate to major change (retirement), by taking on a new
the nurse would first attempt assertive com- members, caregivers, and the health care team. question the HCP about safety issues, it is not challenge of volunteering. Her positive outlook
munication with those who are bullying or 17. Answer 2: One of the primary problems of appropriate to question use of diagnostic test- on life allows her to find joy in the prospect of
harassing. If this is unsuccessful, it would be early nineteenth-century hospitals was poor ing. Diagnosis is an extremely complicated pro- sharing time with a new generation.
appropriate to go up the chain of command. hygienic practice. Hospitals were dirty and cess, which requires an extensive knowledge 33. a. Originally, the white pleated cap and the
Issues with nursing students can be reported to overcrowded and care was mostly given by about pathology. Referring patients to another apron signified respectability, cleanliness,
the nursing instructor or the education liaison. untrained persons. clinic shifts the financial burden to another part and servitude. Caps gradually became
For job seeking, the nurse would use personal 18. Answer 4: The population is aging rapidly and of the health care system. symbolic of office and achievement and
contacts, the Internet, or nurse recruiters. people with chronic illness are living longer. 27. Answer 1: Orem’s theory is based on helping were celebrated with capping ceremonies.
12. Answer 4: Case management is a modified sys- There is an increased need for nursing services the patient to attain self-care. Nightingale’s Uniforms became more informal and
tem to deliver care. The LPN/LVN assists the for this growing segment of the population. theory uses manipulation of the environment nurses complained that caps interfered
RN to achieve desired outcomes. The RN se- 19. Answer 3: “Nightingale Nurses” improved pa- (i.e., patient’s pillows). Benner and Wrubel with care, caused hair loss, took too much
lects the clinical pathway and coordinates and tient care and advanced the practice of nursing demonstrate caring by assisting the patient to time for washing and starching, and were a
plans patient care for individuals and groups through good hygiene, sanitation, patient ob- cope. Parse’s theory encourages the patient to source of bacteria. Health care facilities and
of patients. Cross-training is another type of servation, accurate recordkeeping, nutritional participate in the health experience. nursing schools typically have dress codes
modified system of care. While cross-training improvement, and the introduction and use of 28. Answer 1, 2, 3, 4, 6: Under the terms of this for style of uniform and/or color. Staff
is intended to expand the role of the employee, new equipment. document, patients are assured that they can members are generally required to wear
the LPN/LVN must not exceed scope of prac- 20. Answer 1: The four major concepts are nurse, expect high-quality hospital care, a clean and nametags and identification badges. Many
tice and cannot be expected to assume RN patient, health, and environment. safe environment, involvement in their care nurses do not approve of mandatory dress
responsibilities. 21. Answer 4: Poverty, homelessness, and unem- and the decision-making process, protection of codes. They argue that other health care
13. Answer 2: Long-term care facilities employ the ployment are barriers to accessing health care. privacy, help when leaving the hospital, and professionals do not depend on uniforms
majority of LPN/LVNs; however, hospitals, help with billing concerns. Patients cannot for their authority.
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Answer Key 3 4 Answer Key
b. It is likely that as a nursing student and a Multiple Choice deficit or feelings of anxiety or self-doubt. Go- and calling for help first are appropriate emer-
soon-to-be nurse that looking professional 6. Answer 4: The student has initiated the nurse- ing with her and observing performance and gency actions.
is important to you. You may feel anxious patient relationship and therefore has the duty pulling her file would be appropriate after as- 17. Answer 1: Being competent and compassion-
to be rid of your current student uniform to act. All students are cardiopulmonary resus- sessment. Directing someone to do a task that ate are the best defenses. Knowing the legal
for a variety of reasons. Freedom of choice, citation (CPR)-certified so the student has to is beyond his or her ability and understanding definition may be helpful, but definitions are
unattractive style, and not being marked perform the duty in a reasonable and prudent is inappropriate supervision and the nurse abstractions and the nurse’s day is full of real-
as a student are frequent reasons cited by manner as would other nursing students. All of would be liable for the UAP’s performance. world events. Obtaining malpractice insurance
students. From the patients’ point of view, the other options are also likely to be necessary. 11. Answer 2: The first action is to locate the RN in is likely to make the nurse feel better, but it
they feel more comfortable and confident (Note to student: Discuss this situation with charge so that the blood can be started. HCPs does not decrease the chances of getting sued.
when they are easily able to distinguish your clinical instructor for advice about visit- can supervise nurses and they know the poten- Validating nursing actions with another nurse
nurses from other staff members. ing patients during the preclinical preparation tial adverse reactions of blood products; how- is always beneficial, but this is not a realistic
time.) ever, they are generally less familiar with the option for minute-to-minute care.
Next-Generation NCLEX™ (NGN) 7. Answer 4: A poor nurse-patient relationship policies and procedures related to the actual 18. Answer 2: The nurse is assessing the wound
34. a. Answer 1 d, 2 i, 3 e, 4 c, 5 f, 6 a, 7 b, 8 g, 9 h: increases the likelihood that the patient will administration. Explaining the policy is appro- during the dressing change and documentation
Registered nurse (RN)—provides direct seek legal action and harm has to occur for lia- priate, but the priority is patient care. should reflect the nurse’s attention to the stan-
patient care in the hospital and an RN from bility to be established. The family of the older 12. Answer 1, 2, 3, 4: Do not include any informa- dard of care. Documenting the type of dressing
a home health agency would also be in- patient could seek damages, but that is less tion that identifies the patient. Information may be necessary for continuity of care and
volved in the care of this patient. likely if they understand that the nurse and fa- such as the room number or the HCP’s name also for reimbursement. The other options are
LPN/LVN—works under the supervision cility will try their best to prevent falls but are may seem harmless but including those details incorrect.
of the RN in providing patient care. unable to physically restrain patients for the could lead to speculation about the patient’s 19. Answer 4: Disciplinary defense insurance
Physician or other HCPs—uses results of purpose of preventing falls. The angry patient identity. A clinical report must include infor- includes attorney; wage loss reimbursement;
diagnostic testing and physical assessment may report the nurse to the supervisor, but mation such as vital signs and medical condi- travel, food, and lodging expenses; and le-
to determine the medical diagnosis and if no harm is sustained, then any legal action tion. If in doubt, the clinical instructor should gal fees when the nurse has to go before the
prescribes treatment and medications. against the nurse will not be successful. The be consulted. board of nursing for disciplinary action. The
Social worker—provides counseling and family who complained at 3:00 Am may also be 13. Answer 1: Patients must be at least 18 years old other types of insurance are for malpractice
referral to community resources. very angry. The nurse’s decision to wait must to give consent. If younger than 18, the excep- protection.
Physical therapist—teaches and monitors be based on comprehensive assessment of the tions are marriage; court-approved emancipa- 20. Answer 4: Regardless of years of experience,
exercise and will assist this patient in learn- patient to ascertain that there is nothing to war- tion; self-supporting and living apart from nurses should always seek instruction and
ing techniques for safe ambulation, bend- rant calling at 3:00 Am. Careful documentation parents; military service; or for sexually trans- supervision for any unfamiliar procedures or
ing, and lifting. is necessary. Making an incident report in all of mitted infections, alcohol or drug abuse, sexual practices. Asking to be reassigned could be an
Dietitian—provides nutritional counseling. these situations would be a good idea. assault, or family planning. option if there is no time or personnel avail-
Respiratory therapist—supervises oxygen 8. Answer 1, 2, 3, 4, 6: In a health care–related 14. Answer 3: Policies about giving patient infor- able to supervise the new nurse. Reviewing
administration and performs pulmonary case, items may include policies and proce- mation over the phone will vary. For example, the procedure might be an option if the nurse
assessments. dures, standards of care, medical records, some facilities may not allow acknowledg- is confident that the information is sufficient
Unlicensed assistive personnel—assists the assignment sheets, personnel files, equip- ing that the patient is or is not there. Other to ensure safe performance. Giving feedback
patient in the hospital and at home with ment maintenance records, birth certificates, facilities require that the patient have a list of about orientation might be useful to improve
bathing and other activities of daily living. marriage certificates, medical bills, and other people who are allowed to call for information. the orientation program, but it is not possible
Financial counselor—assists the patients documents pertinent to the issues at hand. The Another variation is that selected callers are to cover all skills and all patient situations dur-
in understanding the hospital bill and to UAP’s personal health records are confidential given a phone code to reach the patient. The ing orientation.
make arrangements for paying out-of- and unrelated to the patient’s case. nurse should be familiar with hospital policy, 21. Answer 1: First, assess the patient’s feelings by
pocket costs. 9. Answer 2: Early discharge and high levels because the policies are designed to specifically encouraging expression. The patient may not
of patient acuity require excellent discharge comply with Health Insurance Portability and understand the advance directives or may have
teaching so patients can perform self-care and Accountability Act (HIPAA). issues that were triggered by the discussion.
CHAPTER 2—LEGAL AND ETHICAL ASPECTS self-monitoring and are therefore less likely to 15. Answer 3: Alert the HCP so the child can be The other options are also necessary.
OF NURSING suffer harm. Being able to take a limited num- examined for occult injury. The other options 22. Answer 2: The patient’s living will is the best
ber of high-acuity patients would be ideal, but may also be used to investigate the possibility protection, because it reflects the patient’s
Matching high acuity is the current trend. Having mal- of child abuse. wishes. Policies and procedures and the Joint
1. c practice coverage is good if litigation occurs; 16. Answer 2: Good Samaritan laws offer limited Commission may contain general guidance
2. e however, insurance payouts may actually be liability, except in cases of gross negligence. about giving excellent care to patients, but will
3. a contributing to the problem. Ensuring account- A prudent nurse would know that moving a not offer any specific help in this situation. The
4. b ability of others is not possible. trauma victim could result in spinal cord in- Patient Self-Determination Act supports the
5. d 10. Answer 1: Assess knowledge and readiness jury. Initiating cardiopulmonary resuscitation, use of living wills to define the individual’s
to perform. Barriers may include knowledge using available material to control bleeding choices about care and treatment.
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Answer Key 5 6 Answer Key
23. Answer 4: The nurse, the 13-year-old girl, demonstrates beneficence. Encouraging inde- Falsifying documentation could be used by patient is incapacitated), the right to accept
and the mother all have very strong feelings pendent decision-making exemplifies the prin- the plaintiff in a malpractice suit. Gossiping or refuse treatment, and the right to partici-
about this emotional situation. First, the nurse ciple of autonomy. that results in ruining a person’s reputation is pate fully in health care–related decisions.
must reflect on and assess own values and 29. Answer 1, 2, 4, 5, 6: The nurse must know the defamation. b. When a patient refuses care, the nurse may
responses. The other options are likely to be signs and symptoms of abuse, which are often experience a personal feeling of rejection.
necessary, but this will be a difficult process hidden or subtle. Declines in health or physical Critical Thinking Activities The nurse has to recognize that refusal of
and other health care team members such as a abilities and loss of support and independence 33. a. Further assessment is needed to determine treatment is not a refusal of interaction or
social worker, family counselor, spiritual advi- cause feelings of helplessness. The older adult the underlying motivation for the action of compassion. It may be difficult, but the
sor, legal counsel, or obstetrician are likely to may be reluctant to report abuse for fear of re- these two nurses. It appears that Nurse A nurse should continue to check on the pa-
be involved. prisal or loss of caregiver support. Age of care- is reluctant to care for “those kinds of peo- tient as before and to spend as much time
24. Answer 1, 2, 3, 5: If the nurse observes another giver does not a predict abuse. ple” and the code specifies that the nurse as before, but the focus may shift from task
nurse being rude to a patient, the ethical thing 30. Answer 4: Careless handling of hard copies should provide care without discrimina- orientation to therapeutic communication.
to do would be to follow up so that patients are of notes, documents, charts, reports, etc., is a tion. Assessment of Nurse A’s behavior And of course, the patient always has the
respected. Texting should not be used as an ad- potential HIPAA violation because all patient may reveal that she lacks the confidence option to change his mind and accept se-
ditional method of passing gossip among staff. information should be safeguarded. Only team or skills to care for AIDS patients; thus, lected elements of care.
The other options demonstrate ethical profes- members who are directly involved in a pa- additional training is needed. Possibly, c. For nurses, this is an ethical dilemma. The
sional behavior. tient’s care should have access to information. the death of a close friend from AIDS may refusal of heroic measures is often easier to
25. Answer 3: The supervisor should be presented The breakroom is for the nursing staff; howev- have created an emotional barrier and thus accept because many nurses themselves do
with the facts. Theft is unethical and older resi- er, there may be some people who are allowed she may need grief counseling. Nurse B not want to be kept “alive by machines.”
dents are in an especially vulnerable position; to enter the breakroom (e.g., nursing students, is attempting to help Nurse A, which is a However, it seems cruel and inhuman if
thus, Nurse B is not giving good care. Talking housekeeping staff, friends or family of nurs- laudable action; however, to maintain a basic needs like food or hygiene are not
to the residents or families will be part of the ing staff) but are not involved in the direct care high degree of personal and professional provided. Nurses have worked for cen-
investigation that is conducted by the supervi- of the patient. behavior, which is also part of the code turies trying to prevent pressure injuries
sor. The supervisor could recommend that both 31. Answer 3: The nurse would offer to witness of ethics, Nurse B should talk to Nurse A and to improve patient outcomes. Nurses
nurses seek assistance for values clarification. that the patient is signing the consent and is about the comment, rather than ignoring it. may also believe that immunization is par-
26. Answer 3: First, Nursing Student Orange aware of the treatment, risks, alternatives, and b. Nurse B should initiate the process of val- tially for the protection of the individual,
would give Apple the opportunity to take consequences of accepting or rejecting care. ues clarification, either by herself or with but also for “herd immunity.” Nurses are
responsibility to discuss the incident with the The surgeon is required to disclose the risks or assistance from a counselor or supervisor. trained to be problem-solvers and doers.
instructor. Using social media in this manner benefits involved with the treatment or proce- This process includes thinking about a Doing nothing for the patient may seem
is unethical. It is also a HIPAA violation that dure. Ideally, the nurse should accompany the belief or behavior, deciding its value, and difficult but remember that supporting the
could result in dismissal from the nursing surgeon during the explanation and the form incorporating the value into a response. patient emotionally and psychologically is
program or a lawsuit. Details of patient care should be signed at that time. If the surgeon is Nurse B could talk directly to Nurse A to also a nursing function.
should only be shared with other health care hostile or rejects the nurse’s offer of witnessing, see if Nurse A is actually discriminating 35. The nurse has gone up the chain of command
workers who are involved in the direct care of the nurse would ask the charge nurse to clarify against a certain type of patient or if there and reported her concerns to the supervisor;
the patient. If Student Apple refuses to inform how nurses are dealing with the consent forms. is some other problem such as knowledge/ however, the nurse could still be involved in
the instructor, then Student Orange is ethically It is possible that surgeons are explaining the skills deficit. Nurse B may also decide to a legal action if there is an occurrence where a
obligated to report this misconduct. procedures and the nurses are later assessing report Nurse A’s unethical behavior by fol- patient is harmed. The nurse could report the
27. Answer 4: The nurse should encourage the the patients’ understanding and contacting lowing the appropriate chain of command, conditions to the state board of nursing, but
patient to express feelings and thoughts related the surgeon if the patient has additional ques- explaining the facts clearly, and document- change is likely to come slowly, if at all. The
to a situation without contributing personal tions or needs clarification. If the patient has no ing the incident objectively and accurately. nurse may opt to make personal notes or inci-
opinions. The nurse must be aware of cultural questions, the nurse will then ask the patient 34. a. First, the nurse needs to involve other dent reports related to working conditions or
differences and should avoid: (1) transferring to sign the form; however, this is not the best members of the health care team, such as discussions with supervisors.
personal expectations to patients; (2) making situation for the nurses. The nurse could also the HCP and the psychiatric social worker. The ethical implications are that the nurse
generalizations based on personal views; (3) discuss the process with a nursing supervisor Physical causes for depression or changes is employed in a situation that is constantly
assuming patients can understand what is be- because the nurses may be at risk for practic- in cognition should be investigated, as well putting the patients at risk; however, in some
ing said just because they speak English; and ing outside scope of practice. If a patient later as psychological causes of depression. A ways, if the nurse opts to quit and seek another
(4) treating each patient the same. claims misunderstanding, the involved nurse psychiatrist or psychiatric clinical nurse job, then the patients have lost an advocate and
28. Answer 4: Nonmaleficence means to do no could be liable if the patient suffers harm from specialist should assess the patient for signs a caregiver. In addition, this scenario is not un-
harm. The nurse seeks to prevent harm from the procedure. of suicide. If the patient is deemed of sound common and could occur in other facilities.
a high dose of medication by clarifying the 32. Answer 2: Battery is unlawfully touching mind, then he has the right to refuse care. If the nurse opts to stay, then teamwork is es-
prescription with the HCP. Providing care for another person without informed consent. The Patient Self-Determination Act requires pecially important under these conditions and
all patients regardless of financial, social, or The nurse who leaves a patient without giv- that institutions maintain written policies watching out for each other and all of the pa-
ethnic factors demonstrates the principle of ing handover report could be charged with and procedures regarding advance direc- tients becomes more important when everyone
justice. Advocating for the good of the patient abandonment, if the patient sustains harm. tives (including the use of life support if the is tired and stressed.
Copyright © 2023, 2019, 2015, 2011, 2006, 2003, 1999, 1995, 1991 by Elsevier Inc. All rights reserved. Copyright © 2023, 2019, 2015, 2011, 2006, 2003, 1999, 1995, 1991 by Elsevier Inc. All rights reserved.
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Answer Key 7 8 Answer Key
Next-Generation NCLEX™ (NGN) Multiple Choice Incident reports are reviewed by nurse manag-
36. 13. Answer 4: When making a late entry, the nurse ers and risk managers so errors can be identi-
would note it as a late entry and then proceed fied and corrected. Routine charting can be
Breach Proximate with the notation; for example, “Late entry randomly audited for quality assurance, as-
Actions and Events Duty of Duty Harm Cause ,” or as dictated by facility sessment, and improvement.
policy. 17. Answer 4: Narrative notes should include a
7:00 RN assigns LPN/LVN to monitor an IV potassium
X 14. Answer 2: In charting by exception, complete complete description of the patient’s response
infusion prescribed to infuse over 4 hours.
physical assessments, observations, vital signs, to any therapies. As a student, you write evalu-
7:45 Patient reports pain (1/10) at the site. LPN/LVN intravenous (IV) site and rate, and other perti- ation statements on a care plan, but in the hos-
assesses the site and says, “Potassium is irritating to the X nent data are charted at the beginning of each pital, it is unlikely that you will see the actual
veins, some discomfort is expected.” shift. During the shift, the only notes the nurse care plan format that you use in school. The
8:30 Patient reports that pain (5/10) is increasing. LPN/ will make will be for additional treatments Kardex is a tool that outlines therapies, orders,
LVN observes redness around insertion site, flushes IV done or planned treatments withheld, changes and activities, but there is no space for docu-
with normal saline and notices that slight swelling oc- X in patient condition, and new concerns. Focus mentation of outcomes. Medication adminis-
curs during flushing. Warm pack applied and nurse says, charting uses the nursing process and the fo- tration times are recorded on the medication
“Everything is fine. The warmth will relieve the pain.” cus is sometimes a current patient concern or administration record, but usually there is no
behavior, and sometimes a significant change space for additional notations.
10:00 Patient reports severe pain (9/10). Redness and
in patient status or behavior, or a significant 18. Answer 3: Documentation can always be im-
swelling are markedly increased. LPN/LVN stops infusion X
event in the patient’s therapy. DARE (data [D], proved; however, it is particularly important to
and notifies the RN.
action [A], response and evaluation [R], and document patient condition on discharge and
Several days later, extensive necrotic tissue damage is not- [E] education and patient teaching) is one ac- any follow-up instructions. If the patient goes
ed. The HCP informs the nurse manager that there may be X ronym that is used in focus charting. Narrative home and immediately dies, the nurse, who
permanent scarring or nerve damage. charting is an abbreviated story form of patient is the last professional to see the patient, has
care. It is used for both computerized and made no note to indicate that the patient was
The LPN/LVN agrees to accept the task and duty is established. At 7:45, duty is met. The nurse per- stable on leaving the hospital.
noncomputerized nurse’s notes and includes
forms the assessment and gives accurate information (potassium infusions can be irritating and uncom- 19. Answer 2: In a large hospital, there could be
subjective and/or objective data, consultations,
fortable) and the patient’s discomfort is minimal. At 8:30, a breach of duty occurs. The nurse observes
care and treatments, and response to therapy. many employees who would have a legitimate
redness and then flushes the IV with normal saline. Swelling after flushing indicates a problem; the reason to look at the patient’s chart; however,
Some facilities require a minimum of three en-
saline is getting pushed into the tissue rather than flowing through the vein. Pain has increased and red- for document security and patient confiden-
tries and a flow sheet for narrative charting. In
ness suggests tissue irritation. At this point, the LPN/LVN should have reported findings to the RN and
acute care facilities (e.g., hospitals) taking vital tiality, the nurse is obligated to question any
referred to a procedure manual or talked to the RN before applying a warm pack (warm packs are used
signs every 4 hours and increasing frequency unfamiliar person. If the person identifies self
for some infiltrations but depending on the drug or fluid, a warm pack may worsen the damage). At and the nurse is still not sure if access is ap-
as needed is common practice regardless of the
10:00, the nurse recognizes and reports the problem, but tissue damage has occurred as a result of the IV
documentation system that is used. propriate, the charge nurse or security could be
infiltration. Several days later, permanent harm is obvious; thus, all four criteria for liability are present. contacted for advice.
15. Answer 1, 2, 3, 4: The five basic purposes for
accurate and complete patient records are: (1) 20. Answer 4: Computer access and time for docu-
documented communication, (2) permanent re- mentation can always be a problem, so making
cord for accountability, (3) legal record of care, notes for personal use is an alternative. The
CHAPTER 3—DOCUMENTATION reimbursement because patients’ eligibility
(4) teaching, and (5) research and data collec- student can always ask the instructor for ad-
and services provided by the nurses must be
tion. The nurse would not interpret or discuss vice, but there is nothing the instructor can do
Matching documented to justify payment by Medicare,
the HCP’s notes with the patient. If the patient about lack of functional computers. Hardcopy
1. d Medicaid, or private insurance companies.
does not understand the medical diagnosis, the charting is usually reserved for total system
2. i The charting is not usually done on the same
nurse would assist the patient to formulate a shutdown for prolonged periods of time. Wait-
3. f time schedule or with the same frequency as
list of questions and then contact the HCP to ing until the end of the shift is never the best
4. j that of the acute care facility. An interdisci-
talk directly with the patient. option.
5. g plinary approach must be documented in the
16. Answer 1: A peer review is an appraisal by 21. Answer 3: The nurse would meet the patient’s
6. h notes along with evidence of compliance with
professional coworkers of equal status. Peer immediate need for the medication. Since the
7. b state and federal regulations. For home health
review appraises the way an individual nurse vital sign data are missing, the nurse applies
8. c care, nurses carry written records with them
conducts practice, education, or research. Jour- nursing process and assesses the blood pres-
9. a or use a laptop computer to maintain patient
nal articles frequently undergo peer review. sure (BP) and pulse before administering the
10. e documentation.
Queries or clarification of orders or prescrip- medication. Then the nurse documents the BP
tions should always occur if the nurse has a and pulse and the administration of the medi-
Short Answer Table Activity
question. This is standard practice and nurse cation. Next, the nurse would find the UAP
11. Home health care and long-term care 12. See Table 3.1, Essential Elements of
would not anticipate any type of review. and ask about the vital signs. (Ask about other
documentation are directly related to Documentation. patients too; the UAP should have finished and
Copyright © 2023, 2019, 2015, 2011, 2006, 2003, 1999, 1995, 1991 by Elsevier Inc. All rights reserved. Copyright © 2023, 2019, 2015, 2011, 2006, 2003, 1999, 1995, 1991 by Elsevier Inc. All rights reserved.
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cPSD|
30089585
30089585
Answer Key 1 2 Answer Key
22. Answer 2: Physiologic needs, such as eating always expect to get a private room with all
Answer Key and oxygenation, are the first priority accord- amenities.
ing to Maslow. 29. Answer 3: Health care workers are entitled to
23. Answer 4: Adolescence is time when love and respect from patients and also expect patients
belonging to a peer group are very important. to be responsible for their own behavior.
CHAPTER 1—THE EVOLUTION OF NURSING clinics, outpatient agencies, home health agen- Being part of a team is the best way to help him 30. Answer 3: LPN/LVNs never independently
cies, insurance companies, HCP offices, and the meet this need. alter the plan of care without the supervision of
Matching military services offer additional opportunities. 24. Answer 1, 3, 5: Patient can participate in smok- an RN.
1. b 14. Answer 1, 2, 4, 5: The LPN/LVN communi- ing cessation; stress, weight, and alcohol intake 31. Answer 4: For primary prevention, the nurse
2. d cates findings to members of the health care reduction; and control over own body and would encourage wellness activities and pre-
3. e team, demonstrates caring and empathy by health. Giving information about technology, emptive screening programs such colonoscopy
4. a using therapeutic communication skills with new medications, and costs may be of interest or glucose screening. Secondary prevention
5. f patients, administers care according to profes- to the patient, but these topics are less useful recognizes the presence of disease but seeks to
6. h sional standards and collects data from mul- in helping the patient take an active role in her reduce the impact of the condition by encour-
7. c tiple sources. The LPN/LVN would collaborate own health. aging behaviors to promote health, such as
8. g with the RN but would not independently cre- 25. Answer 4: Unlicensed assistive personnel dietary modification for recurrent hyperglyce-
9. j ate the care plan for a newly admitted patient. (UAP) are trained to assist patients with activi- mia. Tertiary prevention is applied by manag-
10. i 15. Answer 3: Reports indicate that challenges ties of daily living. The unit secretary orders ing care for those with serious health problems
related to feelings of social isolation, stereotyp- supplies using electronic or hardcopy requisi- with the goal of improving the quality of life
Multiple Choice ing about men who choose nursing, nursing tion forms. While the UAP or unit secretary can and reducing further loss of function.
11. Answer 4: NAPNES would assist a nurse instructors’ inability to incorporate masculine direct visitors, extreme caution should be used
who is seeking information about LPN/LVN styles of caring into the curriculum, and a lack in giving out patient information. (Note to stu- Critical Thinking Activities
standards. The purposes of NAPNES and Na- of male role models in the profession may be dent: Even acknowledging that a patient has 32.
tional Federation of Licensed Practical Nurses to blame for the high attrition of male nursing been admitted to the hospital can be viewed Wellness X Illness
(NFLPN) are to: students from nursing programs. as a violation of confidentiality.) Taking vital
Highest level of Diminished or impaired
Set standards for practical/vocational nursing 16. Answer 4: Advance directives could include a signs is acceptable; however, the pharmacist optimal health state of health
programs. health care power of attorney that states who generally restocks medications. Validating and
Promote and protect practical/vocational should make health care decisions if the per- interpreting are nursing responsibilities. This patient has some health problems and
nursing. son is unable to make them. A “living will” 26. Answer 2: Economical use of time and materi- some changes in her life, but she has a rela-
Educate and inform the general public about outlines wishes about end-of-life care. Ideally, als is the best way to contain costs for indi- tively high level of wellness. Her blood pres-
practical/vocational nursing. everyone should carefully consider advance vidual patients. Malpractice insurance does not sure is under control and she has adapted to a
For issues related to interpersonal conflict, directives and have discussions with family help to contain costs. While it is appropriate to major change (retirement), by taking on a new
the nurse would first attempt assertive com- members, caregivers, and the health care team. question the HCP about safety issues, it is not challenge of volunteering. Her positive outlook
munication with those who are bullying or 17. Answer 2: One of the primary problems of appropriate to question use of diagnostic test- on life allows her to find joy in the prospect of
harassing. If this is unsuccessful, it would be early nineteenth-century hospitals was poor ing. Diagnosis is an extremely complicated pro- sharing time with a new generation.
appropriate to go up the chain of command. hygienic practice. Hospitals were dirty and cess, which requires an extensive knowledge 33. a. Originally, the white pleated cap and the
Issues with nursing students can be reported to overcrowded and care was mostly given by about pathology. Referring patients to another apron signified respectability, cleanliness,
the nursing instructor or the education liaison. untrained persons. clinic shifts the financial burden to another part and servitude. Caps gradually became
For job seeking, the nurse would use personal 18. Answer 4: The population is aging rapidly and of the health care system. symbolic of office and achievement and
contacts, the Internet, or nurse recruiters. people with chronic illness are living longer. 27. Answer 1: Orem’s theory is based on helping were celebrated with capping ceremonies.
12. Answer 4: Case management is a modified sys- There is an increased need for nursing services the patient to attain self-care. Nightingale’s Uniforms became more informal and
tem to deliver care. The LPN/LVN assists the for this growing segment of the population. theory uses manipulation of the environment nurses complained that caps interfered
RN to achieve desired outcomes. The RN se- 19. Answer 3: “Nightingale Nurses” improved pa- (i.e., patient’s pillows). Benner and Wrubel with care, caused hair loss, took too much
lects the clinical pathway and coordinates and tient care and advanced the practice of nursing demonstrate caring by assisting the patient to time for washing and starching, and were a
plans patient care for individuals and groups through good hygiene, sanitation, patient ob- cope. Parse’s theory encourages the patient to source of bacteria. Health care facilities and
of patients. Cross-training is another type of servation, accurate recordkeeping, nutritional participate in the health experience. nursing schools typically have dress codes
modified system of care. While cross-training improvement, and the introduction and use of 28. Answer 1, 2, 3, 4, 6: Under the terms of this for style of uniform and/or color. Staff
is intended to expand the role of the employee, new equipment. document, patients are assured that they can members are generally required to wear
the LPN/LVN must not exceed scope of prac- 20. Answer 1: The four major concepts are nurse, expect high-quality hospital care, a clean and nametags and identification badges. Many
tice and cannot be expected to assume RN patient, health, and environment. safe environment, involvement in their care nurses do not approve of mandatory dress
responsibilities. 21. Answer 4: Poverty, homelessness, and unem- and the decision-making process, protection of codes. They argue that other health care
13. Answer 2: Long-term care facilities employ the ployment are barriers to accessing health care. privacy, help when leaving the hospital, and professionals do not depend on uniforms
majority of LPN/LVNs; however, hospitals, help with billing concerns. Patients cannot for their authority.
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Answer Key 3 4 Answer Key
b. It is likely that as a nursing student and a Multiple Choice deficit or feelings of anxiety or self-doubt. Go- and calling for help first are appropriate emer-
soon-to-be nurse that looking professional 6. Answer 4: The student has initiated the nurse- ing with her and observing performance and gency actions.
is important to you. You may feel anxious patient relationship and therefore has the duty pulling her file would be appropriate after as- 17. Answer 1: Being competent and compassion-
to be rid of your current student uniform to act. All students are cardiopulmonary resus- sessment. Directing someone to do a task that ate are the best defenses. Knowing the legal
for a variety of reasons. Freedom of choice, citation (CPR)-certified so the student has to is beyond his or her ability and understanding definition may be helpful, but definitions are
unattractive style, and not being marked perform the duty in a reasonable and prudent is inappropriate supervision and the nurse abstractions and the nurse’s day is full of real-
as a student are frequent reasons cited by manner as would other nursing students. All of would be liable for the UAP’s performance. world events. Obtaining malpractice insurance
students. From the patients’ point of view, the other options are also likely to be necessary. 11. Answer 2: The first action is to locate the RN in is likely to make the nurse feel better, but it
they feel more comfortable and confident (Note to student: Discuss this situation with charge so that the blood can be started. HCPs does not decrease the chances of getting sued.
when they are easily able to distinguish your clinical instructor for advice about visit- can supervise nurses and they know the poten- Validating nursing actions with another nurse
nurses from other staff members. ing patients during the preclinical preparation tial adverse reactions of blood products; how- is always beneficial, but this is not a realistic
time.) ever, they are generally less familiar with the option for minute-to-minute care.
Next-Generation NCLEX™ (NGN) 7. Answer 4: A poor nurse-patient relationship policies and procedures related to the actual 18. Answer 2: The nurse is assessing the wound
34. a. Answer 1 d, 2 i, 3 e, 4 c, 5 f, 6 a, 7 b, 8 g, 9 h: increases the likelihood that the patient will administration. Explaining the policy is appro- during the dressing change and documentation
Registered nurse (RN)—provides direct seek legal action and harm has to occur for lia- priate, but the priority is patient care. should reflect the nurse’s attention to the stan-
patient care in the hospital and an RN from bility to be established. The family of the older 12. Answer 1, 2, 3, 4: Do not include any informa- dard of care. Documenting the type of dressing
a home health agency would also be in- patient could seek damages, but that is less tion that identifies the patient. Information may be necessary for continuity of care and
volved in the care of this patient. likely if they understand that the nurse and fa- such as the room number or the HCP’s name also for reimbursement. The other options are
LPN/LVN—works under the supervision cility will try their best to prevent falls but are may seem harmless but including those details incorrect.
of the RN in providing patient care. unable to physically restrain patients for the could lead to speculation about the patient’s 19. Answer 4: Disciplinary defense insurance
Physician or other HCPs—uses results of purpose of preventing falls. The angry patient identity. A clinical report must include infor- includes attorney; wage loss reimbursement;
diagnostic testing and physical assessment may report the nurse to the supervisor, but mation such as vital signs and medical condi- travel, food, and lodging expenses; and le-
to determine the medical diagnosis and if no harm is sustained, then any legal action tion. If in doubt, the clinical instructor should gal fees when the nurse has to go before the
prescribes treatment and medications. against the nurse will not be successful. The be consulted. board of nursing for disciplinary action. The
Social worker—provides counseling and family who complained at 3:00 Am may also be 13. Answer 1: Patients must be at least 18 years old other types of insurance are for malpractice
referral to community resources. very angry. The nurse’s decision to wait must to give consent. If younger than 18, the excep- protection.
Physical therapist—teaches and monitors be based on comprehensive assessment of the tions are marriage; court-approved emancipa- 20. Answer 4: Regardless of years of experience,
exercise and will assist this patient in learn- patient to ascertain that there is nothing to war- tion; self-supporting and living apart from nurses should always seek instruction and
ing techniques for safe ambulation, bend- rant calling at 3:00 Am. Careful documentation parents; military service; or for sexually trans- supervision for any unfamiliar procedures or
ing, and lifting. is necessary. Making an incident report in all of mitted infections, alcohol or drug abuse, sexual practices. Asking to be reassigned could be an
Dietitian—provides nutritional counseling. these situations would be a good idea. assault, or family planning. option if there is no time or personnel avail-
Respiratory therapist—supervises oxygen 8. Answer 1, 2, 3, 4, 6: In a health care–related 14. Answer 3: Policies about giving patient infor- able to supervise the new nurse. Reviewing
administration and performs pulmonary case, items may include policies and proce- mation over the phone will vary. For example, the procedure might be an option if the nurse
assessments. dures, standards of care, medical records, some facilities may not allow acknowledg- is confident that the information is sufficient
Unlicensed assistive personnel—assists the assignment sheets, personnel files, equip- ing that the patient is or is not there. Other to ensure safe performance. Giving feedback
patient in the hospital and at home with ment maintenance records, birth certificates, facilities require that the patient have a list of about orientation might be useful to improve
bathing and other activities of daily living. marriage certificates, medical bills, and other people who are allowed to call for information. the orientation program, but it is not possible
Financial counselor—assists the patients documents pertinent to the issues at hand. The Another variation is that selected callers are to cover all skills and all patient situations dur-
in understanding the hospital bill and to UAP’s personal health records are confidential given a phone code to reach the patient. The ing orientation.
make arrangements for paying out-of- and unrelated to the patient’s case. nurse should be familiar with hospital policy, 21. Answer 1: First, assess the patient’s feelings by
pocket costs. 9. Answer 2: Early discharge and high levels because the policies are designed to specifically encouraging expression. The patient may not
of patient acuity require excellent discharge comply with Health Insurance Portability and understand the advance directives or may have
teaching so patients can perform self-care and Accountability Act (HIPAA). issues that were triggered by the discussion.
CHAPTER 2—LEGAL AND ETHICAL ASPECTS self-monitoring and are therefore less likely to 15. Answer 3: Alert the HCP so the child can be The other options are also necessary.
OF NURSING suffer harm. Being able to take a limited num- examined for occult injury. The other options 22. Answer 2: The patient’s living will is the best
ber of high-acuity patients would be ideal, but may also be used to investigate the possibility protection, because it reflects the patient’s
Matching high acuity is the current trend. Having mal- of child abuse. wishes. Policies and procedures and the Joint
1. c practice coverage is good if litigation occurs; 16. Answer 2: Good Samaritan laws offer limited Commission may contain general guidance
2. e however, insurance payouts may actually be liability, except in cases of gross negligence. about giving excellent care to patients, but will
3. a contributing to the problem. Ensuring account- A prudent nurse would know that moving a not offer any specific help in this situation. The
4. b ability of others is not possible. trauma victim could result in spinal cord in- Patient Self-Determination Act supports the
5. d 10. Answer 1: Assess knowledge and readiness jury. Initiating cardiopulmonary resuscitation, use of living wills to define the individual’s
to perform. Barriers may include knowledge using available material to control bleeding choices about care and treatment.
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Answer Key 5 6 Answer Key
23. Answer 4: The nurse, the 13-year-old girl, demonstrates beneficence. Encouraging inde- Falsifying documentation could be used by patient is incapacitated), the right to accept
and the mother all have very strong feelings pendent decision-making exemplifies the prin- the plaintiff in a malpractice suit. Gossiping or refuse treatment, and the right to partici-
about this emotional situation. First, the nurse ciple of autonomy. that results in ruining a person’s reputation is pate fully in health care–related decisions.
must reflect on and assess own values and 29. Answer 1, 2, 4, 5, 6: The nurse must know the defamation. b. When a patient refuses care, the nurse may
responses. The other options are likely to be signs and symptoms of abuse, which are often experience a personal feeling of rejection.
necessary, but this will be a difficult process hidden or subtle. Declines in health or physical Critical Thinking Activities The nurse has to recognize that refusal of
and other health care team members such as a abilities and loss of support and independence 33. a. Further assessment is needed to determine treatment is not a refusal of interaction or
social worker, family counselor, spiritual advi- cause feelings of helplessness. The older adult the underlying motivation for the action of compassion. It may be difficult, but the
sor, legal counsel, or obstetrician are likely to may be reluctant to report abuse for fear of re- these two nurses. It appears that Nurse A nurse should continue to check on the pa-
be involved. prisal or loss of caregiver support. Age of care- is reluctant to care for “those kinds of peo- tient as before and to spend as much time
24. Answer 1, 2, 3, 5: If the nurse observes another giver does not a predict abuse. ple” and the code specifies that the nurse as before, but the focus may shift from task
nurse being rude to a patient, the ethical thing 30. Answer 4: Careless handling of hard copies should provide care without discrimina- orientation to therapeutic communication.
to do would be to follow up so that patients are of notes, documents, charts, reports, etc., is a tion. Assessment of Nurse A’s behavior And of course, the patient always has the
respected. Texting should not be used as an ad- potential HIPAA violation because all patient may reveal that she lacks the confidence option to change his mind and accept se-
ditional method of passing gossip among staff. information should be safeguarded. Only team or skills to care for AIDS patients; thus, lected elements of care.
The other options demonstrate ethical profes- members who are directly involved in a pa- additional training is needed. Possibly, c. For nurses, this is an ethical dilemma. The
sional behavior. tient’s care should have access to information. the death of a close friend from AIDS may refusal of heroic measures is often easier to
25. Answer 3: The supervisor should be presented The breakroom is for the nursing staff; howev- have created an emotional barrier and thus accept because many nurses themselves do
with the facts. Theft is unethical and older resi- er, there may be some people who are allowed she may need grief counseling. Nurse B not want to be kept “alive by machines.”
dents are in an especially vulnerable position; to enter the breakroom (e.g., nursing students, is attempting to help Nurse A, which is a However, it seems cruel and inhuman if
thus, Nurse B is not giving good care. Talking housekeeping staff, friends or family of nurs- laudable action; however, to maintain a basic needs like food or hygiene are not
to the residents or families will be part of the ing staff) but are not involved in the direct care high degree of personal and professional provided. Nurses have worked for cen-
investigation that is conducted by the supervi- of the patient. behavior, which is also part of the code turies trying to prevent pressure injuries
sor. The supervisor could recommend that both 31. Answer 3: The nurse would offer to witness of ethics, Nurse B should talk to Nurse A and to improve patient outcomes. Nurses
nurses seek assistance for values clarification. that the patient is signing the consent and is about the comment, rather than ignoring it. may also believe that immunization is par-
26. Answer 3: First, Nursing Student Orange aware of the treatment, risks, alternatives, and b. Nurse B should initiate the process of val- tially for the protection of the individual,
would give Apple the opportunity to take consequences of accepting or rejecting care. ues clarification, either by herself or with but also for “herd immunity.” Nurses are
responsibility to discuss the incident with the The surgeon is required to disclose the risks or assistance from a counselor or supervisor. trained to be problem-solvers and doers.
instructor. Using social media in this manner benefits involved with the treatment or proce- This process includes thinking about a Doing nothing for the patient may seem
is unethical. It is also a HIPAA violation that dure. Ideally, the nurse should accompany the belief or behavior, deciding its value, and difficult but remember that supporting the
could result in dismissal from the nursing surgeon during the explanation and the form incorporating the value into a response. patient emotionally and psychologically is
program or a lawsuit. Details of patient care should be signed at that time. If the surgeon is Nurse B could talk directly to Nurse A to also a nursing function.
should only be shared with other health care hostile or rejects the nurse’s offer of witnessing, see if Nurse A is actually discriminating 35. The nurse has gone up the chain of command
workers who are involved in the direct care of the nurse would ask the charge nurse to clarify against a certain type of patient or if there and reported her concerns to the supervisor;
the patient. If Student Apple refuses to inform how nurses are dealing with the consent forms. is some other problem such as knowledge/ however, the nurse could still be involved in
the instructor, then Student Orange is ethically It is possible that surgeons are explaining the skills deficit. Nurse B may also decide to a legal action if there is an occurrence where a
obligated to report this misconduct. procedures and the nurses are later assessing report Nurse A’s unethical behavior by fol- patient is harmed. The nurse could report the
27. Answer 4: The nurse should encourage the the patients’ understanding and contacting lowing the appropriate chain of command, conditions to the state board of nursing, but
patient to express feelings and thoughts related the surgeon if the patient has additional ques- explaining the facts clearly, and document- change is likely to come slowly, if at all. The
to a situation without contributing personal tions or needs clarification. If the patient has no ing the incident objectively and accurately. nurse may opt to make personal notes or inci-
opinions. The nurse must be aware of cultural questions, the nurse will then ask the patient 34. a. First, the nurse needs to involve other dent reports related to working conditions or
differences and should avoid: (1) transferring to sign the form; however, this is not the best members of the health care team, such as discussions with supervisors.
personal expectations to patients; (2) making situation for the nurses. The nurse could also the HCP and the psychiatric social worker. The ethical implications are that the nurse
generalizations based on personal views; (3) discuss the process with a nursing supervisor Physical causes for depression or changes is employed in a situation that is constantly
assuming patients can understand what is be- because the nurses may be at risk for practic- in cognition should be investigated, as well putting the patients at risk; however, in some
ing said just because they speak English; and ing outside scope of practice. If a patient later as psychological causes of depression. A ways, if the nurse opts to quit and seek another
(4) treating each patient the same. claims misunderstanding, the involved nurse psychiatrist or psychiatric clinical nurse job, then the patients have lost an advocate and
28. Answer 4: Nonmaleficence means to do no could be liable if the patient suffers harm from specialist should assess the patient for signs a caregiver. In addition, this scenario is not un-
harm. The nurse seeks to prevent harm from the procedure. of suicide. If the patient is deemed of sound common and could occur in other facilities.
a high dose of medication by clarifying the 32. Answer 2: Battery is unlawfully touching mind, then he has the right to refuse care. If the nurse opts to stay, then teamwork is es-
prescription with the HCP. Providing care for another person without informed consent. The Patient Self-Determination Act requires pecially important under these conditions and
all patients regardless of financial, social, or The nurse who leaves a patient without giv- that institutions maintain written policies watching out for each other and all of the pa-
ethnic factors demonstrates the principle of ing handover report could be charged with and procedures regarding advance direc- tients becomes more important when everyone
justice. Advocating for the good of the patient abandonment, if the patient sustains harm. tives (including the use of life support if the is tired and stressed.
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Answer Key 7 8 Answer Key
Next-Generation NCLEX™ (NGN) Multiple Choice Incident reports are reviewed by nurse manag-
36. 13. Answer 4: When making a late entry, the nurse ers and risk managers so errors can be identi-
would note it as a late entry and then proceed fied and corrected. Routine charting can be
Breach Proximate with the notation; for example, “Late entry randomly audited for quality assurance, as-
Actions and Events Duty of Duty Harm Cause ,” or as dictated by facility sessment, and improvement.
policy. 17. Answer 4: Narrative notes should include a
7:00 RN assigns LPN/LVN to monitor an IV potassium
X 14. Answer 2: In charting by exception, complete complete description of the patient’s response
infusion prescribed to infuse over 4 hours.
physical assessments, observations, vital signs, to any therapies. As a student, you write evalu-
7:45 Patient reports pain (1/10) at the site. LPN/LVN intravenous (IV) site and rate, and other perti- ation statements on a care plan, but in the hos-
assesses the site and says, “Potassium is irritating to the X nent data are charted at the beginning of each pital, it is unlikely that you will see the actual
veins, some discomfort is expected.” shift. During the shift, the only notes the nurse care plan format that you use in school. The
8:30 Patient reports that pain (5/10) is increasing. LPN/ will make will be for additional treatments Kardex is a tool that outlines therapies, orders,
LVN observes redness around insertion site, flushes IV done or planned treatments withheld, changes and activities, but there is no space for docu-
with normal saline and notices that slight swelling oc- X in patient condition, and new concerns. Focus mentation of outcomes. Medication adminis-
curs during flushing. Warm pack applied and nurse says, charting uses the nursing process and the fo- tration times are recorded on the medication
“Everything is fine. The warmth will relieve the pain.” cus is sometimes a current patient concern or administration record, but usually there is no
behavior, and sometimes a significant change space for additional notations.
10:00 Patient reports severe pain (9/10). Redness and
in patient status or behavior, or a significant 18. Answer 3: Documentation can always be im-
swelling are markedly increased. LPN/LVN stops infusion X
event in the patient’s therapy. DARE (data [D], proved; however, it is particularly important to
and notifies the RN.
action [A], response and evaluation [R], and document patient condition on discharge and
Several days later, extensive necrotic tissue damage is not- [E] education and patient teaching) is one ac- any follow-up instructions. If the patient goes
ed. The HCP informs the nurse manager that there may be X ronym that is used in focus charting. Narrative home and immediately dies, the nurse, who
permanent scarring or nerve damage. charting is an abbreviated story form of patient is the last professional to see the patient, has
care. It is used for both computerized and made no note to indicate that the patient was
The LPN/LVN agrees to accept the task and duty is established. At 7:45, duty is met. The nurse per- stable on leaving the hospital.
noncomputerized nurse’s notes and includes
forms the assessment and gives accurate information (potassium infusions can be irritating and uncom- 19. Answer 2: In a large hospital, there could be
subjective and/or objective data, consultations,
fortable) and the patient’s discomfort is minimal. At 8:30, a breach of duty occurs. The nurse observes
care and treatments, and response to therapy. many employees who would have a legitimate
redness and then flushes the IV with normal saline. Swelling after flushing indicates a problem; the reason to look at the patient’s chart; however,
Some facilities require a minimum of three en-
saline is getting pushed into the tissue rather than flowing through the vein. Pain has increased and red- for document security and patient confiden-
tries and a flow sheet for narrative charting. In
ness suggests tissue irritation. At this point, the LPN/LVN should have reported findings to the RN and
acute care facilities (e.g., hospitals) taking vital tiality, the nurse is obligated to question any
referred to a procedure manual or talked to the RN before applying a warm pack (warm packs are used
signs every 4 hours and increasing frequency unfamiliar person. If the person identifies self
for some infiltrations but depending on the drug or fluid, a warm pack may worsen the damage). At and the nurse is still not sure if access is ap-
as needed is common practice regardless of the
10:00, the nurse recognizes and reports the problem, but tissue damage has occurred as a result of the IV
documentation system that is used. propriate, the charge nurse or security could be
infiltration. Several days later, permanent harm is obvious; thus, all four criteria for liability are present. contacted for advice.
15. Answer 1, 2, 3, 4: The five basic purposes for
accurate and complete patient records are: (1) 20. Answer 4: Computer access and time for docu-
documented communication, (2) permanent re- mentation can always be a problem, so making
cord for accountability, (3) legal record of care, notes for personal use is an alternative. The
CHAPTER 3—DOCUMENTATION reimbursement because patients’ eligibility
(4) teaching, and (5) research and data collec- student can always ask the instructor for ad-
and services provided by the nurses must be
tion. The nurse would not interpret or discuss vice, but there is nothing the instructor can do
Matching documented to justify payment by Medicare,
the HCP’s notes with the patient. If the patient about lack of functional computers. Hardcopy
1. d Medicaid, or private insurance companies.
does not understand the medical diagnosis, the charting is usually reserved for total system
2. i The charting is not usually done on the same
nurse would assist the patient to formulate a shutdown for prolonged periods of time. Wait-
3. f time schedule or with the same frequency as
list of questions and then contact the HCP to ing until the end of the shift is never the best
4. j that of the acute care facility. An interdisci-
talk directly with the patient. option.
5. g plinary approach must be documented in the
16. Answer 1: A peer review is an appraisal by 21. Answer 3: The nurse would meet the patient’s
6. h notes along with evidence of compliance with
professional coworkers of equal status. Peer immediate need for the medication. Since the
7. b state and federal regulations. For home health
review appraises the way an individual nurse vital sign data are missing, the nurse applies
8. c care, nurses carry written records with them
conducts practice, education, or research. Jour- nursing process and assesses the blood pres-
9. a or use a laptop computer to maintain patient
nal articles frequently undergo peer review. sure (BP) and pulse before administering the
10. e documentation.
Queries or clarification of orders or prescrip- medication. Then the nurse documents the BP
tions should always occur if the nurse has a and pulse and the administration of the medi-
Short Answer Table Activity
question. This is standard practice and nurse cation. Next, the nurse would find the UAP
11. Home health care and long-term care 12. See Table 3.1, Essential Elements of
would not anticipate any type of review. and ask about the vital signs. (Ask about other
documentation are directly related to Documentation. patients too; the UAP should have finished and
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