Exam 1: NUR170 / NUR 170 (Latest 2026/2027 Update) Concepts of Medical-Surgical Nursing | Questions & Answers | 100% Correct | Galen

Exam 1: NUR170 / NUR 170 (Latest 2026/2027 Update) Concepts of Medical-Surgical Nursing | Questions & Answers | 100% Correct | Galen The client asks the nurse for a copy of their medical record. The nurse knows that this right is part of which regulation. A. The patient self-determination act. B. HIPAA C. The uniform anatomical gift act. D. The Americans with disabilities act. B. HIPPA Which communication strategies should the nurse use when working w/ a client who has difficulty speaking d/t weakness? A. Encourage the client to speak quickly B. Ask yes and no questions when able C. Have the client use a communication board D. Repeat what the client said to verify the message E. Use a pen and paper to communicate client needs. F. Encourage verbal communication to strengthen the client's voice. B. Ask yes and no questions when able D. Repeat what the client said to verify the message C. Have the client use a communication board E. Use a pen and paper to communicate client needs. A post-op pt says "Don't touch me, I will take care of myself". Which response is therapeutic? A. Fine, I won't touch you. B. Let's work together so you can do things for yourself. C. I have to change your dressing so I have to touch you. D. If that's what you want but I need to report this to the surgeon. B. Let's work together so you can do things for yourself. A nurse performing a home assessment on an older client having weakness would be concerned about which unsafe finding? A. Nonskid surfaces on slippers B. Nonskid backing on small rugs C. Electrical cords taped to the floor D. Bath mats on the shower stall floor E. Electrical appliances and cords near the sink. F. Full bathroom on the second floor E. Electrical appliances and cords near the sink. F. Full bathroom on the second floor The nurse understands that which are judgemental statements. A. I don't think you need to do that. B. Tell me about making that decision. C. I'm not sure that's what is best for you. D. When did you first notice you felt that way? E. I would like to be sure I understood what you said. F. It will be fine. We all feel that way sometimes. A. I don't think you need to do that. C. I'm not sure that's what is best for you. F. It will be fine. We all feel that way sometimes. The nurse is teaching a pt. about home safety. Which recommendations would they include? A. Remove wall-to-wall carpeting. B. Use nightlights during nighttime. C. Place handrails in bathtubs and showers. D. Check staircase railings for secureness and sturdiness. E. Place scatter rugs on hardwood floors and at the bottom of a staircase. F. Use extension cords for additional lamps to provide adequate lighting. C. Place handrails in bathtub and showers. B. Use nightlights during nighttime. D. Check staircase railings for secureness and sturdiness When discussing a health care plan with an Amish client, the nurse should perform which actions? A. Speak only to the client. B. Avoid using medical terms. C. Maintain adequate personal space. D. Use complex scientific terminology. E. Stand close to the client and speak softly. F. Establish a helping relationship C. Maintain adequate personal space. B. Avoid using medical terms F. Establish a helping relationship. The nurse understands that personal health information can be disclosed in which situations? A. Compliance with legal proceedings. B. For research purposes in limited circumstances. C. To a family member or significant other in an emergency. D. To nonessential medical personnel involved in client care. E. To appropriate military if a client is a member of the armed forces. F. During lunch break with colleagues who work in another unit. A. Compliance with legal proceedings B. For research purposes in limited circumstances C. To a family member or significant other in an emergency E. To appropriate military, if a client is a member of the armed forces The hospice nurse has established a helping relationship with the client + family. Which actions are most appropriate? A. Encouraging family discussions of feelings. B. Accepting the family's expressions of anger. C. Restricting client visit to scheduled hospital visiting hours. D. Facilitating the use of spiritual practices identified by the family. E. Keeping the family informed of changes in the client's condition. F. Making decisions for the family during the difficult moments. A. Encouraging family discussions of feelings E. Keeping the family informed of the changes in the client's condition B. Accepting the family's expressions of anger D. Facilitating the use of spiritual practices identified by the family A nurse is teaching a client how to self-administer tube feedings at home. The client expresses concern. Best response? A. Does your family know about this concern you have? B. Is there a family member or friend that is willing to help you? C. Do you want me to prescribe home visits from the nurse for you? D. Let's talk about what makes it hard for you to perform this procedure. D. Let's talk about what makes it hard for you to perform this procedure. Which nursing actions can result in disciplinary action by state boards of nursing? A. Release of client health information to a client's neighbor. B. Delegation of a dressing change to UAP. C. Release of client health information to the client's durable POA. D. Admin. of a routine immunization that resulted in an allergic reaction. E. Admin. of an injection to client who refused the medication. F. Diverting medication from the medication dispensing system. A. Release of client health information to a client's neighbor E. Admin. of an injection to a client who refused the medication B. Delegation of a dressing change to UAP F. Diverting medication from the medication dispensing system Which clients may be assigned to a LPN/LVN? A. A client requiring oral medication. B. A client requiring an admission assessment. C. A client requiring an intravenous injection. D. A client requiring a subcutaneous injection. E. A client requiring an intramuscular injection. F. A client requiring insertion of a urinary catheter. A. A client requiring oral medication E. A client requiring an intramuscular injection D. A client requiring a subcutaneous injection F. A client requiring insertion of a urinary catheter Which tasks would be appropriate for the nurse to delegate to UAP? A. Assist new post-op client to the bathroom. B. Set up the clients' lunch trays. C. Change a central line dressing. D. Teach a client how to administer discharge medications B. Set up the clients lunch trays Which are the best resources to refer to for information r/t scope of practice? A. Hospital policies and procedures. B. Nurse Practice Act. C. Ordering physician. D. Hospital pharmacist. E. Food and Drug Administration. F. The nursing process. A. Hospital policies and procedures B. Nurse Practice Acts Pt is admitted w/ dx of a stroke and hx of dementia. Which nursing dx has the highest priority? A. Bathing/hygiene self-care deficit. B. Potential for injury. C. Impaired physical mobility. D. Disrupted thought process. B. Potential for injury Which of these actions by the nurse has the most effective means of preventing infection? A. Rub hands with Clorox wipes when visibly dirty. B. Perform hand hygiene before reporting for work. C. Wear sterile gloves when giving IV medications. D. Use alcohol-based sanitizer when hands are not visibly soiled. D. Use alcohol-based sanitizer when hands are not visibly soiled. The nurse finds pt on the floor. After examining and assisting the pt back to bed, which action should the nurse take 1st? A. File an incident report. B. Put the bed alarm back on. C. Place the client in 1:1 observation. D. Notify the nurse manager. B. Put the bed alarm back on Which statements describe current US health care delivery practices? A. Access to care depends on ability to pay, not availability of services. B. The pt protection and ACA provides private health insurance to underserved C. All insurance plans in the Marketplace offers comprehensive coverage. D. 50 years ago 50% of doctors practiced primary care, today it's 1 in 3. E. Quality of care = the right care for the right person at the right time. C. All insurance plans in the Marketplace offer comprehensive care E. Quality of care = the right care for the right person at the right time D. 50 years ago, 50% of doctors practiced primary care, today it's 1 in 3 Which of these patients is receiving secondary health care? A. A patient enters a community clinic w/ signs of strep throat. B. A patient is admitted to the hospital following a heart attack. C. A mother brings her son to the ED following a seizure. D. A pt w/ osteogenesis imperfecta is being treated in a medical center. E. A father brings his son to a specialist to correct a congenital heart defect F. A woman has a hernia repair in an ambulatory care center. C. A mother who brings her son to the ED following a seizure B. A patient is admitted to the hospital following a heart attack F. A woman has a hernia repair in an ambulatory care center How would the nurse explain respite care? A. Respite care is a service that allows time away for caregivers B. Respite care is a special service for those who are terminally ill. C. It is direct care provided to people in a LTC facility. D. It provides living units for people without regular shelter. A. Respite care is a service that allows time away for caregivers Which patients would the nurse consider high risk for falls? A. A patient older than 50. B. A patient who has already fallen twice. C. A patient who is taking antibiotics. D. A patient who experiences postural hypotension. E. A patient who is experiencing nausea from chemotherapy. F. A 70 y/o who is transferred to LTC. B. A patient who has already fallen twice D. A patient who experiences postural hypotension F. A 70-year-old who is transferred to long-term care A nurse orients an older adult to the safety features in her hospital room. What is a priority component of this admission routine? A. Explain how to use the telephone. B. Introduce the patient to their roommate. C. Review the hospital policy on visiting hours. D. Explain how to use the call bell. D. Explain how to use the call bell Which point indicates that the nurse possesses the ability to write objectives clearly and concisely? A. Inclusion of the timeline and deadline. B. Expectations are open to interpretation of health care providers. C. Uses medical terminology with Latin origins only. D. Specifying multiple dates for the attainment of a goal. A. Inclusion of the timeline and deadline A nurse explains evidence-based practice to a new grad by stating... A. Nursing care is based on tradition. B. Scholarly inquiry of nursing and biomedical research literature. C. It's a problem-solving approach that integrates the best current evidence. D. Quality nursing is provided in an efficient and economically sound manner. C. Its a problem-solving approach that integrates the best current evidence A nurse reassuring oneself of being prepared to speak in front of a peer group is using which of the following types of communication? A. Intrapersonal B. Interpersonal C. Group D. Organizational A. Intrapersonal True/False: Touch is a personal behavior that means the same thing to all persons. A. True B. False B. False Which activity generally occurs during the orientation phase of the helping relationship? A. An agreement or contract about the relationship is established. B. The nurse provides any assistance needed to achieve patient goals. C. The nurse provides patient counseling and teaching. D. The patient and nurse examine the goals of the helping relationship for indications of attainment. A. An agreement or contract about the relationship is established. TRUE/FALSE: An open-ended question or comment serves to validate what the nurse believes is heard or observed. A. True B. False B. False True/False: A nurse who fails to log off a computer after documenting patient care has breached patient confidentiality. A. True B. False A. True True/False: A patient has the right to obtain, review, and revise the patient information in his or her health record. A. True B. False B. False True/False: One of the purposes of creating a patient record is to evaluate the quality of care patients have received and the competence of the nurses providing that care. A. True B. False A. True Which method of documentation is unique in that it does not develop a separate care plan but instead incorporates the care plan into the progress notes? A. Source-oriented records B. Problem-oriented records C. PIE (problem, intervention, evaluation) D. Focus charting C. PIE (problem, intervention, evaluation) The role of the nurse in hospitals includes managing other members of the healthcare team. A. True B. False A. True Which of the following is designed to provide palliative and supportive care services for dying persons? A. Respite care B. Parish nursing C. Voluntary agencies D. Hospice services D. Hospice services Among older adults, fires are the leading cause of injury fatality. A. True B. False B. False Which of the following is the most significant and commonly found infection-causing agent in health care institutions? A. Bacteria B. Fungi C. Viruses D. Mold A. Bacteria Which infection or disease may be spread by touching a contaminated inanimate article? A. Rabies B. Giardia C. E. coli D. Influenza D. Influenza SBAR stands for? Situation Background Assessment Recommendation What is the order for putting on personal protective gear? 1. Gown 2. Mask 3. Goggles 4. Gloves How would you take off Personal protective gear? 1. Gloves 2. Goggles 3. Gown 4. Mask Phases of the Nursing Process Assessment Diagnosis Planning Implementation Evaluation Explain the overall goal of Quality and Safety Education for Nurses (QSEN). Initiative to address the challenge of preparing future nurses with the knowledge, skills, and attitudes (KSAs) necessary to continuously improve the quality and safety of the healthcare systems in which they work. List the six QSEN competencies. - Patient-Centered Care - Teamwork and Collaboration - Evidenced-Based Practice - Quality Improvement - Safety - Informatics Define the concept of safety. - Minimization of risk of harm - Culture of safety - System effectiveness - Individual performance Describe hazards that could cause a health care safety risk. - developmental considerations - lifestyle (occupation and social behavior) - Environment - Mobility - Sensory perception - Knowledge - Ability to communicate - Physical and psychological health state Discuss methods to reduce the risk of harm to patients. Education - Car seat safety - Motor Vehicle Safety - Seat belts - Motorcycle/bicycle helmets - Orientation - Surroundings - Adjustments for sensory perception changes Prevention - Infections - Falls - Home - Hospital - Fire Safety - Firearm safety - Procedural-related accidents - Equipment-related errors Discuss the application of QSEN competencies to ensure the delivery of safe client care. - Teamwork & Collaboration - Evidence-based Practice (hourly rounding) - Quality Improvement (review and assess) - Safety (follow safety measures) - Informatics (documentation) List the 5 elements of the SMART method for short-term and long-term patient goals. Specific Measurable Attainable Relevant Time-based Discuss the chain of infection transmission. Infectious Agent Susceptible Host Portal of Entry Mode of Transmission Portal of Exit Reservoir Explain the body's natural defenses against infection. Saliva - antibacterial enzymes Tears - antibacterial enzymes Skin - prevents entry Mucus Linings - linings trap dirt and microbes Stomach Acid - low pH kills harmful microbes "Good" Gut Bacteria - out complete bad Discuss infection prevention related to nursing care in a variety of settings. Primary Prevention (vaccinations, health education, infection control measures) Hand Hygiene PPE (gloves, gown, mask, protective eyewear) Standard Precautions (used for all patients regardless of diagnosis or infection status) Transmission-Based Precautions (Airborne, Droplet, Contact) Contrast medical and surgical asepsis. Medical Clean technique Surgical Sterile technique Differentiate the types of infection precaution categories. Droplet Used on patients with suspected infections that spread through large-particle droplets (ex. Mumps) Private Room (door can be open) PPE Keep visitor 3 ft away from patient Airborne Used on patients with suspected infections that spread through the air (ex. TB or Chicken Pox) Private Room (door closed) Negative air pressure Respirator Contact Used on patients infected by a multidrug-resistant organism (ex. C. Diff.) Private Room (door can be open) Wash hands before and after room PPE Do not share equipment Explain the principle behind sterile setting and sterile gloving. Sterile objects only touch sterile objects...unsterile touching sterile means contamination has occurred Discuss the indications for a urinary catheter. - Urinary retention - Obstruction (enlarged prostate, swelling) - Long-Term Use (spinal cord injury) - Medical (sterile urine specimen, ill patients, EOL comfort, immobilization) Explain the nursing care related to urinary catheters. - Hand Hygiene - Clean the perineal area thoroughly, especially around the meatus, daily and after each bowel movement - Cleanse the catheter by cleaning gently from the meatus outward - Use mild soap and water or perineal cleanser to clean the perineal area; rinse the area well. - Do not use powders or lotions after cleaning - Do not use antibiotics or other antimicrobial cleaners or betadine at the urethral meatus - Encourage generous fluid intake to prevent infection and irrigates the catheter naturally by increasing urine output - Encourage patient to be out of bed as ordered - Note volume and character of urine, record observations as noted - Record the amount of urine on the patient's intake-and-output record every 8 hours - Empty urine into a graduated cylinder for an accurately calibrated amount - Do not open the drainage system to obtain urine specimens, utilize the specimen collection access - Educate the client regarding the importance of personal hygiene- especially after bowel movements - Remove the catheter at the earliest time possible, review evidence-based practice and facility policy - Change indwelling catheter only as necessary - Promptly report any signs/symptoms of infection Sentinel Event an unexpected occurrence involving death or serious physical or psychological injury, or the RISK thereof Ex. Falls, unexpected death, foreign body left inside after surgery, etc. Root Cause Analysis Happens after a sentinel event to find the cause of a sentinel event. Quality Assurance Keeps track of sentinel events, and works to educate staff on how to avoid them Mandatory Reporting Child or elder abuse, gun violence or burns, penetration wounds, infectious disease, coworkers under the influence. You have the suspicion of it, but not the evidence to back it up. You are not entitled to do your own investigation Ensure you are following your institution/facility's chain of command when reporting Six Aims of Healthcare (Quality Improvement) Safe, effective, patient-centered, timely, efficient, equitable Pearson, pg 2858 Electronic Medical Record Focuses on diagnosis and treatment. Stays within a clinical setting Electronic Health Record Gives broader view on a patient's health. Designed to be viewed in multiple disciplines, and provides patients with more comprehensive management of health Good Faith Immunity Healthcare workers are protected from civil or criminal liabilities when they report suspected child abuse in good faith. Is mandatory reporting a violation of HIPAA? NO. Mandatory reporting may force the healthcare provider to reveal protected health information to the person doing the investigation (diagnosis, patient's name, age, address, etc.) and is not a considered a violation of HIPAA. Negligence A nurse fails to implement safety measures for a client Ex. A nurse does not follow safety measures for a client at risk for falls, and the patient falls as a result Malpractice Failure by a health professional to meet accepted standards. When a nurse makes errors that is not up to nursing standards Ex. Failing to do the 7 rights of medicine administration and gives the patient the incorrect dose of a med Difference between practicing medicine and nursing? Medicine follows the medical model, while nursing looks at patients as a whole (holistic) and sees how things impact their lives Who gathers the data of the mandatory reporting/sentinel events and puts it into national patient safety goals? The Joint Commission Quality Assurance Nurses Keep track of sentinel events and help build how they are going to educate the staff. Evidence Based Practice Using proven evidence to provide care to a patient Nursing Research Research done to improve patient outcomes and care. Outcomes of this research DRIVES evidence-based practice Evidence Based Practice does what for the standards of nursing care? EBP sets the standards of care through the Joint Commission Benefits of Evidence Based Practice Provide higher quality of care and enhances patient outcomes. Provides and encourages trust in the nursing profession Concepts Related to EBP Accountability; clinical decision making; health, wellness, and illness; legal issues; professional behaviors; quality improvement *Pearson pg. 2763 Barriers to EBP -Work schedule, workload demands; -Client preferences -Lack of access to technology -Limited knowledge -Lack of experience, confidence in development of strategies -Lack of support -Lack of access to continuing education -Attitudes -Resistance to change *Pearson pg. 2773 ANA Code of Ethics Ethical guide by which nurses practice Nurse Practice Acts Differ state to state. The LEGAL way by which nurses practice and by which the scope of nursing professionals can practice Nurses Need To: Practice ETHICALLY and LEGALLY. You can follow the law all day long, but in order to be a good nurse, you need to practice ETHICALLY as well HIPAA The Health Insurance Portability and Accountability Act, a federal law protecting the privacy of patient-specific health care information and providing the patient with control over how this information is used and distributed. Ex. Before talking to patient, verify the correct patient and make sure the people in the room are able to hear what will be said Florence Nightingale Founder of modern nursing. Dorthea Dix Helped to reform the way people treat the mentally ill Lillian Ward Founder of public health nursing. "Health of the community equals the health of the individual" Clara Barton Founder of the American Red Cross. Mary Mahoney The first African American professional nurse Quality Improvement Seeks to determine weaknesses in procedures and processes, as well as organizational issues that can affect nurses' ability to provide nursing care consistent with established professional standards of care. Breach of Care/Duty When nurses deviate from the standard of care i.e. when the nurse does something they should not have been done (give wrong medication) or when they do NOT do something that should have been done (fails to administer scheduled medication) Blame Free Environment Healthcare providers can report errors or near misses without fear of punishment. Most errors are the result of the system, not individual Just Culture Attempts to balance the blame free environment with appropriate accountability by focusing on correcting problems that lead to people who engage in unsafe behavior. Zero tolerance for reckless behavior. Priorities For Healthcare -Patient Safety -Person and family centered care -Effective prevention and treatment -Healthy living -Affordability Safety Decreasing risks of dangers or hazards to prevent accidents, injuries, mistakes and harm. Quality Level of performance consistent with current evidence that increases efficiency and effectiveness for desired safety outcomes Seven Rights of Drug Administration -Right assessment -Right drug -Right dose -Right patient -Right route -Right time -Right documentation Work Ethic -Attentive and available -Accountable -An advocate for the patient -Punctual -Optimistic -Communication!!! -Time management -Spirit of inquiry -Continuing education *Generational differences Pearson pg. 2658 Elements Necessary to Prove Negligence 1. duty to provide care as defined by standard 2. breach of duty by failure to meet standard 3. foreseeablity of harm 4. breach of duty has potential to cause harm 5. harm/injury occurs Client Responsibilities -Treat care providers with respect and courtesy -Provide accurate complete health info -Follow recommended health care plans -Assume responsibility for personal actions -Follow hospital regulations Basic Principles of Nursing Ethics -Advocacy -Responsibility -Accountability -Confidentiality Ethical Principles for Client Care -Autonomy -Beneficence -Fidelity -Justice -Nonmaleficence -Veracity Advocacy Support and defend clients' health, wellness, safety, wishes, and personal rights, including privacy Responsibility Willingness to respect obligations and follow through on promises Accountability Ability to answer for one's own actions Confidentiality Protection of privacy without diminishing access to high-quality care Autonomy The right to make one's own personal decisions, even when those decisions might not be in that person's best interest. Beneficence Action that promotes good for others, without any self interest. Fidelity Fulfillment of promises Justice Fairness in care delivery and use of resources Nonmaleficience A commitment to do no harm Veracity A commitment to tell the truth Ethical Dilemmas Problems that involve more than one choice and stem from differences in the values and believes of the DECISION MAKERS. A nurses' OWN morals do NOT make an ethical dilemma an ethical dilemma Ethics Committees Address unusual or complex ethical issues Moral Distress When a nurse is placed in a difficult situation where the actions taken are different from what the nurse feels is ethically correct. NOT an ethical dilemma, since it is the NURSE'S own morals Informed Consent An ethical principle requiring that clients be told enough to enable them to choose whether they wish to participate in treatment of care. Client or appointed decision maker must give written consent to a procedure. A PROVIDER must explain the procedure, not the nurse What the Patient Must Understand from Provider for Informed Consent -Reason for treatment -How the procedure will benefit the patient -Risks involved with procedure -Other options, including NOT having procedure Nurse's Role in Informed Consent Witness client's signature and ensure provider has obtained informed consent responsibly Advanced Directives Communicate a client's wishes regarding end-of-life care should the client be unable to do so Ex. Living will, durable power of attorney for health care, provider's order (DNR) Affordable Care Act Increases access to healthcare. Pre-existing conditions do not hinder the person from obtaining health insurance. Medicaid AIDS lower income individuals Medicare For 65 and older, or have chronic illnesses. CHIP (children's health immunization program) Help children get access to immunizations at no cost, even if they are uninsured Federally Qualified Health Center (FQHC) Pay based off income and gives basic preventative care to those who cannot afford it. EMTALA (Emergency Medical Treatment and Active Labor Act) People cannot be turned away if they cannot pay. If someone is in dire need of care or in active labor, they cannot be turned away Primary Prevention Education that helps prevent disease processes and vaccinations Ex. Educational pamphlets, social media, billboards Secondary Prevention Screening and testing for diseases, as well as the treatment of diseases. All testing/screening is a secondary prevention Tertiary Prevention Controlling SYMPTOMS of disease. Restoration and rehabilitation Ex. Treatment of ulcers CAUSED by diabetes is tertiary, because it is controlling the symptoms related to the disease that was diagnosed in secondary prevention Palliative Care Idea of making the time left as comfortable as possible. QUALITY over QUANTITY Incident Reporting -Individual who discovers, should report -Facts, do not speculate -Document the event, but not that a report was MADE -Document how you see the patient -Document if something has the POTENTIAL to do harm as well Informatics use information and technology to communicate, manage knowledge, mitigate error, and support decision making Benefits of Informatics -Efficient -Improve safety (barcodes) -Better documentation -Reduces cost of healthcare -Ease in ordering prescriptions and medication reconciliation -Improves teaching of patient Everyday Information Technology -Glucometers -ECGs -Automatic BP machines -Thermometers Nursing Process (ADPIE) -Assessment -Diagnosis -Planning -Intervention -Evaluation then repeat Assessment Looking at patient OBJECTIVELY and SUBJECTIVELY. Collecting data Nursing Diagnosis (NOT medical diagnosis) Describes a health problem that can be treated by nursing measures Ex. Alteration of mobility related to loss of continuity of metatarsal of foot, as evidenced by visual deformity of right great toe At risk for skin integrity Subjective Data Things a person (SUBJECT) tells you about that you cannot observe through your senses; symptoms (pain, nausea, etc.) Objective Data Information that is seen, heard, felt, or smelled by an observer, or that is measured. (OBSERVE) Planning Planning to educate or provide patient with assistance Ex. Plan to educate to increase fluids to help with constipation Intervention Implement what was planned in previous step. Can also be verbal Ex. "I am concerned for your safety, so please call me on the call light if you need to go to the bathroom" "Increasing your intake of water can help with your risk for constipation" Independent Nursing Action/Interventions Things nurses can do within their scope of practice that do not require authority to do them Dependent Nursing Actions/Interventions Things that the patient/nurse is told to do, or need help doing Ex. Cannot change a patient's diet that has already been prescribed to them by a provider, or give them medication not prescribed to them by a provider Evaluation Determination of if interventions helped. If intervention did not work, go back to assessment step I.e. patient shows no signs or symptoms through the use of data False Imprisionment A person is confined or restrained against their will Ex. Giving patient sedative they do not need, or using restraints on them without an order REAL PROBLEMS TRUMP POTENTIAL PROBLEMS Yes they do Nursing Care plan Initiated when patient is admitted, guide that organizes information about patient care. Updated in response to changes in goals or patient outcomes Goals (part of planning) Need to Be Specific Measurable Achievable Reasonable/Relevant Timely Goal of Evidence Based Practice Improve client care, and the best way to justify care is by evaluating the client's response to care by examining outcomes. Privacy Rule of HIPAA Requires all nurses protect all written and verbal communication about clients Security Rule of HIPAA Establishes a national set of security standards for securing PHI when held or transferred in ELECTRONIC form. Patient Rights from Joint Commission -Right to be informed about the care you receive -Right to important information about your care in your PREFERRED LANGUAGE -Right to get information in a manner that meets your needs (if patient has vision, hearing, or mental impairments) -Right to make decisions about your care -Right to refuse care -Right to safe care -Right to know the names of the caregivers who give you care -Right to have your pain addressed -Right to care that is free from discrimination -Right to know if something goes wrong in your care -Right to get a list of all current medications -Right to be listened to -Right to be treated with courtesy and respect -Right to have a personal representative of your choice (advocate, family member, friend, etc.) present when receiving care *Pearson pg. 2755 Assault Threaten to harm patient Ex. "I'm going to sedate you if you do not comply" Battery Go ahead with the threat and harm patient Ex. Sedates patient that was not complying after threatening them Clinical Decision Support System Computerized programs used within the health care setting to support decision making Who is responsible for quality improvement? Quality improvement is the responsibility of every employee of the agency, not just administration. Steps of Evidence Based Practice - Cultivate a spirit of inquiry. - Ask the burning clinical question in PICOT format. - Search for and collect the most relevant best evidence. (review literature) - Critically appraise the evidence (i.e., rapid critical appraisal, evaluation, and synthesis). - Integrate the best evidence with one's clinical expertise and patient preferences and values in making practice decision or change. - Evaluate outcomes of the practice decision or change based on evidence. - Disseminate the outcomes of the EBP decision or change. Clinical Information System The CIS is used by various medical professionals to input data, such as assessments or treatments, into the client's electronic record Patient Centered Care The provision of caring and compassionate, culturally sensitive care that addresses clients' physiological, psychological, sociological, spiritual, and cultural needs, preferences, and values Incident Report A report documenting an incident and the response to the incident; also known as an occurrence report or event report.