NUR 280 UNIT 4 (Legal/Ethical) Review Questions and Answers

Suppose you had requested supervision for the medication administration but could not find your instructor. Who would be liable in this case and why? The clinical instructor can be liable if supervision was requested but not available for a student. The student has a duty to perform correct administration of meds, same as a registered nurse. It is the responsibility of the student to wait for the instructor or seek out the floor nurse in this situation. Try this practice question and include a rationale for your response: The mental health charge nurse is reviewing the least restrictive interventions with staff. Which of the following is considered the least restrictive intervention for a patient exhibiting unacceptable behavior that includes pacing and yelling at other patients? Provide a rationale for answer selected. a. Firmly tell the patient this behavior is unacceptable b. Remove the patient from the area and isolate c. Restrain the patient with meds/wrist restraints d. Seek assistance to remove other patients from the area Answer: d. Seek assistance to remove the other patients from the area. This is the least restrictive intervention listed. This patient needs more supervision. Clients who are angry need a large personal space. Don’t get too close. a is not correct. You would not speak firmly to the patient. A calm voice is indicated when communicating with an angry patient and would be one of the first interventions indicated. b is not correct as trying to remove the patient from the area may increase the aggressive behavior. c is not correct, restraining the patient with drugs or wrist restraints is not the least restrictive intervention. Thanks for your response. For #3: Use the guidelines below to analyze the ethical situation. Determine the facts of the situation: • The patient verbalizes a request for no life-sustaining measures in front of the nurse and family. • The physician decides to initiate a code, knowing the patient's wishes. • No documentation exists about the patient's wishes. • The nurse is unable to contact the family to make the decision. • The patient dies. Identify the ethical issues of the situation: • The patient has the right to autonomy and does make a decision. • The nurse is obligated to do good for the patient (beneficence) by informing the physician of the patient's wishes and attempting to contact the family. • The nurse has the duty to be faithful to commitments (fidelity) and attempts to abide by the patient's wishes by informing the physician prior to the code. We may be administering KCL via IV for patients if the K levels drops too low. What are nursing priorities when administering KCL IV? See drug alert box page 177 in IGGY for potassium guidelines. A NPSG is to never give K by IV push due to cardiac arrest. Iggy notes 5-10meq/hr is maximum recommended infusion rate and to not exceed 20meq/hr. Potassium is always diluted and infused slowly. It’s important to make sure the patient has adequate urine output before administering K. Also, skeletal muscle weakness is associated with hypokalemia and patients may be too weak to stand. Provide assistance for safety as patients with hypokalemia are at risk for falls. Cardiac monitoring is necessary, we will see PVCs and possibly other dysrhythmias when K level is low. Also, patients with low K levels should not be taking potassium depleting diuretics. Review the medication record to ensure medications that are contraindicated such as K depleting diuretics are not prescribed for these patients. Thanks for your response. For #1 Does this scenario meet the basic elements of malpractice? No. You do not have a professional nurse-patient relationship in this case because you were attending the event as a spectator, not in the role of the nurse. In this scenario, there is no duty to the child. This falls under the Good Samaritan law. See page 457 in the Nursing Today textbook. Good Samaritan statutes provide immunity from malpractice to professionals that attempt to give assistance at the scene of an accident. Know the laws in your state, nurses can be sued in some states if you provide grossly negligent care. Try this practice question and include a rationale for your response: The nurse is assigned four patients. After receiving shift report, in which order from first to last should the nurse assess these clients? 1. 85-year-old client with bacterial pneumonia, temp 102, and complaining of dizziness and shortness of breath when the UAP assisted the patient up to a chair. 2. 60-year-old client with chest tubes 2 days post op following thoracotomy for lung cancer is complaining of pain and BP changed from last reading 120/80 to 134/90 3. 35-year-old client receiving brachytherapy for cancer treatment and the 12-year- old son has been visiting for 90 minutes and is sitting next to the bed holding the clients hand. 4. 29-year-old client post abdominal surgery yesterday has an abdominal dressing over the wound and drainage has changed from sanguineous to serosanguinous since previous shift change. 5. Answer: 1, 3, 2, and 4. The elderly client with pneumonia and elevated temp with dizziness and SOB is the most acutely ill and should be the highest priority. Dizziness and SOB are always a concern. An elevated temp and shortness of breath can lead to a decrease in the clients oxygen levels. The client receiving brachytherapy is the next priority. If not for patient #1 with respiratory problems/dizzy this patient would be the top priority. Visitors for these patients should be at least 16 years old, limited to 30 minutes at a time, and remain at least 6 feet from the source of radiation, which is inside the patient. It’s important you know proper precautions for patients receiving radiation treatments including those with sealed implants. The client with chest tubes needing pain medication is the third priority. The BP has changed, but not enough to be the priority. A change of 20 points would be significant. The client with abdominal wound is not a priority. This is normal drainage. Thanks for your response. For #2: Was the nurse correct in telling the physician about the patient's wishes? Yes. Sometimes, doing what is correct can still lead to unanticipated outcomes. Nurses perform many roles in patient care including caregiver, educator, and advocate. The Nursing Today book notes advocacy is a critical role for nurses today. This includes advocating for patients’ rights with informed consent, advance directives, and treatment choices as well as interpreting information. It’s important to read the pages assigned in your textbook and know the nurse’s role regarding informed consent. As a nurse you are expected to advocate for patients, this is especially important if the client does not have family members to act as advocates. You learned about safety for pediatric patients in your Maternity/Peds class. What are important teaching points for parents regarding car seat safety for children? Infants should remain in a rear facing car seat for as long as possible, at least until age 2. All infants and toddlers should ride in a rear-facing seat until they reach the highest weight or height allowed by their car seat manufacturer. Most convertible seats have limits that will allow children to ride rear facing for 2 years or more. Children who have outgrown the rear-facing weight or height limit for their convertible seat should use a forward-facing seat with a harness for as long as possible, up to the highest weight or height allowed by their car seat manufacturer. Many seats can accommodate children up to 65 pounds or more. All children whose weight or height exceeds the forward-facing limit for their car safety seat should use a belt-positioning booster seat until the vehicle seat belt fits properly, typically when they have reached 4 feet 9 inches in height and are 8 through 12 years of age. All children younger than 13 years should ride in the back seat. When children are old enough and large enough for the vehicle seat belt to fit them correctly, they should always use lap and shoulder seat belts for the best protection. As noted above, in the back seat is appropriate for all children younger than 13. Thanks for your response. For 1, the nurse did not have a duty (was there as a spectator) and acted as any reasonable nurse would be expected to act. Good Samaritan Laws vary by state, be sure you are familiar with state level legislation to protect those that act in good faith. We are learning about informed consent this week in the legal unit. Informed consent is a legal concern, consent is a defense for intentional torts. What is informed consent according to our book? Remember that consent must be obtained prior to any procedure and it must be voluntary. The provider is responsible for explaining the procedure and answering all questions. The nurse may have the patient sign but only after the provider has explained the procedure. Per page 471, informed consent in the health care setting is a process whereby a patient is informed of: 1. The nature of the proposed care, treatment, services, medications, interventions, or procedures 2. The potential benefits, risks, or side effects, including potential problems related to recuperation. 3. The likelihood of achieving care, treatment, and services goal. 4. Reasonable alternatives and their respective risks and benefits including the alternative of refusing of all interventions. Check the Jan 12th announcement for your assigned group starting week 2. For #1 in this scenario: The patients right to autonomy for decision-making was not followed. There is an obligation on the part of the nurse to do good for the patient (beneficence) by informing the physician of the patient's wishes and attempting to contact the family. The principle of Nonmaleficence for this scenario is related to providing nursing care designed to prevent harm to the patient. The nurse has the duty to be faithful to commitments (fidelity) and attempts to abide by the patient's wishes by informing the physician prior to the code. The principle of Veracity includes a duty to tell the truth. The patient does not want heroic measures taken. It can be challenging to recall specific manifestations of diseases covered in 265. Endocrine topics were covered in week 5/6 of NUR265. To refresh: What are the key manifestations associated with hyperthyroidism and how do these differ from hypothyroidism s/s? Hyperthyroidism (sometimes referred to as Graves Disease) – chart 63-1 in IGGY 9th edition: • Emotional instability/manic hyperactive behavior • Diaphoretic/moist skin • Intolerance to heat • Tachycardia and Hypertension • Visual changes (photophobia, blurred/double vision) • Increased libido • Bulging Eyes (exophthalmos) • Restlessness and Irritability • Goiter • HyperThyroid Storm Hypothyroidism - chart 63-6 in IGGY 9th edition: • Lethargy • Intolerance to cold • Dry, cool skin and Brittle nails/hair • Prolonged menstrual periods or amenorrhea • Decreased libido • Bradycardia and Hypotension • Cold intolerance decreased body temp • Facial and eyelid edema, thick tongue • Constipation • HypoMyxedemaMyxedema Coma Thanks for your response. For #1: Who is liable for the actions of the student nurse— you (because you gave the medications), the staff nurse (who checked the medications), or the instructor (who was supervising)? You retain liability because, as a student, you are held to the standard of a registered nurse. You should not have medicated both patients at the same time. Be sure to view the video in Unit 4 about negligence, which includes failure to document, medication errors, failure to provide a safe environment, patient falls, equipment failure, failure to assess, monitor, and obtain assistance, failure to communicate adequately, and failure to report. The basic elements of negligence include: 1. you must have a duty (professional nurse-patient relationship) 2. you must have breached that duty (did not meet standard of care) 3. your breach of duty must have been a foreseeable cause of the injury 4. injury must have occurred Comprehensive exams, ATI, and NCLEX will test content learned in Maternity/Peds. Here is a practice question related to this content. What are the priorities for routine newborn care after an uncomplicated vaginal birth? Priorities for newborn care after an uncomplicated vaginal delivery include stabilization of the infant. Airway is a priority as is temperature regulation. Babies born vaginally do not usually have issues with too much fluid in the lungs. Establish a patent airway by cleaning the nasopharynx and maintaining adequate oxygenation. Thermoregulation for the maintenance of body temperature is also important. Preheat a radiant warmer, warm a stethoscope and other instruments, and pad a scale before weighing the newborn. The newborn should be placed directly on the mother’s chest and covered with a warm blanket. Stable infants are placed on the mother’s bare chest or abdomen as a preferred method of thermoregulation. A hat may also be added to prevent heat loss from the head. A physical assessment with APGAR score, measurements, and lab studies will also be done but these are not the first priority. Thanks for your response. For #3: If you are the first aid nurse in this scenario, what specific actions should you take immediately following the accident? How could this protect you from a possible lawsuit? Because you are functioning as a nurse, you should immediately document your assessment, interventions, and outcomes. Documentation provides a record of actions taken and conformity with standards of nursing care. Try this practice question and include a rationale for your response. A pediatric nurse would be concerned by which of the following? a. Newborn: HR 165, RR 45 b. 15-month-old: HR 154, RR 50 c. 10-year-old: HR 88, RR 19 d. 13-year-old: HR 70, RR 18 Answer: B would be a concern. A 15-month-old child should not have a HR of 154 and RR of 50. The other findings are expected for the age range noted. I recommend you know normal VS for children/newborns so you can recognize abnormal. Thanks for your response. For #2, If you were working or volunteering at a first aid station and this scenario occurred, would the basic elements of malpractice apply? Why or why not? In this case, there is a duty because your presence is as a nurse. The professional duty would be to act as a reasonable nurse under the same or similar circumstances. The nurse meets the professional duty in that the leg was assessed and interventions implemented as indicated by the situation. You learned about restraints in fundamentals. What are nursing responsibilities for client’s in restraints? Nursing responsibilities when caring for client’s in restraints include: • Explain the need for the restraints to the client and family, emphasizing that the restraints keep the client safe and are temporary. • Ask the client or guardian to sign a consent form. • Follow manufacturer’s instructions for correct application. o Assess skin integrity, provide skin care according to the facility’s protocol, usually every 2 hr. o Offer food and fluid. o Provide a means for hygiene and elimination. o Monitor vital signs. o Offer range-of-motion exercises of extremities. • Pad bony prominences to prevent skin breakdown. • Use a quick-release knot (loose knot that is easy to remove) to tie the restraints to the bed frame where they will not tighten when raising or lowering the bed. • Make sure the restraints are loose enough for range of motion and that there is enough room to fit two fingers between the restraints and the client. • Remove or replace restraints frequently to ensure good circulation to the area and allow for full range of motion to the limbs. • Conduct an ongoing evaluation of the client. • Regularly determine the need to continue using the restraints. • Never leave the client alone without the restraints. Documentation will include: • Precipitating events and behavior of the client prior to seclusion or restraints • Alternative actions to avoid seclusion or restraints • Time of application and removal of the restraints • Type of restraints and location • The client’s behavior while in restraints • Type and frequency of care (range of motion, neurosensory checks, removal, integumentary checks) • Condition of the body part in restraints • The client’s response at removal of the restraints • Medication administration Thanks for your response. For #2: Did the instructor meet the standards for supervisory liability? The instructor did her job. As long as the instructor met all the requirements below, she is not held liable. • Proper assignment to a worker competent to safely perform it: Yes • Adequate supervision available if needed: Yes • Appropriate follow-up and evaluation of the task: Yes Try this ATI Practice Question on Management of Care, Collaboration with Interdisciplinary Team. Provide a rationale for your response. A nurse is assessing a 12-month-old infant during a well-child visit. Which of the following findings should the nurse report to the provider? 1. Closed anterior fontanel 2. Eruption of six teeth 3. Birth weight doubled 4. Birth length increased by 50% Answer: 3. By the age of 12 months, the infant’s birth weight should have tripled. Therefore, the nurse should report this finding to the provider. 1 does not need reported. By the age of 12 to 18 months, the infant’s anterior fontanel should close. 2 does not need reported. By the age of 12 months, the infant should have six to eight teeth erupted. 4 does not need reported. By the age of 12 months, the infant’s birth length should increase by 50% Thanks for your response. The ethical issues of the situation include the patients right to autonomy for decision-making. His wishes were not followed. There is an obligation on the part of the nurse to do good for the patient (beneficence) by informing the physician of the patient's wishes and attempting to contact the family. The nurse has the duty to be faithful to commitments (fidelity) and attempts to abide by the patient's wishes by informing the physician prior to the code. These principles are covered in the supplemental ethics lecture I posted and also in the textbook chapter assigned for reading. You learned about vaccines in the pediatric course. Often there are misconceptions that administering several vaccines at one time will overload the child’s immune system. This is a misconception and not supported by research. There are often other misconceptions around contraindications for vaccines with pediatric patients. What are the contraindications for pediatric vaccines? The peds presentation includes contraindications for vaccines, which are: • Condition which increases the risk for a serious adverse reaction (e.g., not administering a live virus vaccine to a severely compromised child). • The general contraindication for all immunizations is a severe febrile illness. (not mild fever) • In general, live virus vaccines such as varicella and MMR should not be administered to persons who are severely immunocompromised. Multiplication of the virus may be enhanced, causing a severe vaccine-induced illness. • Another contraindication to live virus vaccines (e.g., MMR and varicella) is the presence of recently acquired passive immunity through blood transfusions, immunoglobulin, or maternal antibodies. Administration of MMR and varicella vaccines should be postponed for a minimum of 3 months after passive immunization with immunoglobulins and blood transfusions (except washed red blood cells (RBCs), which do not interfere with the immune response). • A known allergic response to the vaccine. Only a history of anaphylactic reaction to neomycin, gelatin, or the vaccine itself is considered a contraindication to their use.