Ethical/Legal Practice Exam: Unit 1

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Questions and Answers

Which action should be taken when documenting patient information according to HIPAA regulations?

  • Avoid documenting sensitive information
  • Secure electronic records and limit access (correct)
  • Use patient names freely in public areas
  • Include personal opinions about patient behavior

Which of the following should be included in a change-of-shift report?

  • Complete patient medical history
  • Family's opinion on care
  • Patient's current status and plan of care (correct)
  • Any changes or updates in the patient's condition (correct)

What does the SBAR communication tool stand for?

  • Situation, Background, Analysis, Recommendation
  • Systematic, Brief, Analysis, Reporting
  • Symptoms, Background, Assessment, Response
  • Situation, Background, Assessment, Recommendation (correct)

Which statement is true regarding ISBARR?

<p>It is a variant of SBAR that includes 'Identification.' (D)</p> Signup and view all the answers

What is the most appropriate action a nurse should take if they realize they made an error in documentation?

<p>Draw a single line through the error, initial it, and add correct information (C)</p> Signup and view all the answers

What is the nurse's most appropriate response when a family member asks to view the electronic health record (EHR)?

<p>Verify if the patient has given permission for family to access the EHR (D)</p> Signup and view all the answers

Which of the following statements about unauthorized abbreviations in documentation is true?

<p>They could lead to misinterpretation and errors in patient care (A)</p> Signup and view all the answers

Which of the following considerations are appropriate uses of technology in documenting client information?

<p>Storing detailed patient records in a secure electronic system (B), Employing electronic health records to facilitate real-time updates (C)</p> Signup and view all the answers

Which type of bath is most appropriate for patients with mobility limitations who wish to bathe independently?

<p>Partial bath (D)</p> Signup and view all the answers

Is it true that oral care for a patient with a nasogastric (NG) tube can be performed only once daily?

<p>False (B)</p> Signup and view all the answers

What precaution should be taken when providing hygiene care for a patient with an oxygen mask?

<p>Monitor for dryness around the nasal area (C), Cleanse the area around the mask every shift (D)</p> Signup and view all the answers

What is the best approach for a nurse giving a bed bath to a culturally modest patient?

<p>Limit the bath to only exposed areas of the patient's body (B)</p> Signup and view all the answers

Which description accurately defines a closed bed?

<p>Ready for a new patient admission (B)</p> Signup and view all the answers

Which action demonstrates correct procedure when making an occupied bed?

<p>Roll the patient from side to side (A)</p> Signup and view all the answers

What should a nurse consider before providing foot care to a patient with calluses?

<p>The patient’s diabetes status (A)</p> Signup and view all the answers

When providing eye care for a comatose patient, which of the following is a proper action?

<p>Only use saline solution for eye care (D)</p> Signup and view all the answers

What is the best way a nurse can support a patient with impaired mobility in performing personal hygiene?

<p>Allowing the patient to do as much as possible independently (B)</p> Signup and view all the answers

Which hygiene intervention is appropriate for a patient with sensory deficits?

<p>Provide a well-lit environment to promote self-care (A), Speak clearly and face the patient when communicating (B), Ensure the patient is positioned comfortably for self-care (C)</p> Signup and view all the answers

What should a nurse do regarding a patient's decision to wear dentures at night?

<p>Respect the patient's decision to wear dentures at night (B)</p> Signup and view all the answers

When teaching about personal hygiene practices, which of the following should be included?

<p>Apply lotion between toes to prevent dryness (C), Wash hands before eating and after bathroom use (D)</p> Signup and view all the answers

What is the correct approach to performing a back rub on a frail elderly patient?

<p>Use soft, gentle strokes to avoid discomfort (B)</p> Signup and view all the answers

Which statement is true regarding the care of patients with dentures?

<p>Dentures can remain in overnight if the patient prefers (C)</p> Signup and view all the answers

Which hygiene intervention should a nurse NOT assume when caring for patients with sensory deficits?

<p>The patient does not need a well-lit environment (B)</p> Signup and view all the answers

Which practice is considered effective when communicating with a sensory-impaired patient?

<p>Positioning oneself at the patient's eye level for better engagement (B)</p> Signup and view all the answers

Which factor would facilitate learning for a patient?

<p>Quiet, well-lit environment (C)</p> Signup and view all the answers

What is a common principle of effective teaching that a nurse should follow?

<p>Encourage patient questions to gauge understanding (A), Tailor information to the patient's educational level (C)</p> Signup and view all the answers

Which characteristic is essential for a good learning environment?

<p>Comfortable temperature (C)</p> Signup and view all the answers

The affective domain of learning primarily involves which of the following?

<p>Attitudes, values, and emotions (B)</p> Signup and view all the answers

When educating a patient from a different cultural background, what should a nurse do?

<p>Use interpreters or culturally appropriate materials if needed (B)</p> Signup and view all the answers

Which domain of learning is primarily addressed when a nurse demonstrates insulin injection techniques?

<p>Psychomotor (D)</p> Signup and view all the answers

Which nursing intervention can improve patient compliance with their care plan?

<p>Simplifying instructions (A), Involving family members in education (B), Using visual aids when explaining complex concepts (D)</p> Signup and view all the answers

True or False: The nursing process and the teaching-learning process share similar steps including assessment, planning, intervention, and evaluation.

<p>True (B)</p> Signup and view all the answers

What best describes surgical asepsis?

<p>A sterile technique used only in surgical procedures (A), A set of practices to maintain a completely sterile environment (D)</p> Signup and view all the answers

Is it true that surgical asepsis is necessary for any procedure that involves contact with mucous membranes?

<p>True (A)</p> Signup and view all the answers

What is the correct order of the infection cycle?

<p>Infectious Agent, Reservoir, Portal of Exit, Mode of Transmission, Portal of Entry, Susceptible Host (B)</p> Signup and view all the answers

Which organism is known for being resistant to methicillin and often associated with healthcare-acquired infections?

<p>Methicillin-resistant Staphylococcus aureus (MRSA) (C)</p> Signup and view all the answers

Which of the following are considered standard precautions to prevent infection?

<p>Hand hygiene before and after patient contact (B), Disposing of needles and sharps in appropriate containers (C), Wearing gloves when touching blood or body fluids (D)</p> Signup and view all the answers

Are redness, swelling, and warmth at the site indicative of local signs of infection?

<p>True (A)</p> Signup and view all the answers

What is the primary nursing action to differentiate between a local and systemic infection in a patient with high fever and elevated WBC count?

<p>Inspect for localized signs such as redness and swelling (A)</p> Signup and view all the answers

What best describes droplet precautions?

<p>Required for patients with infections that spread through large respiratory droplets, usually requiring a mask within three feet (B)</p> Signup and view all the answers

What is the role of narrative documentation in electronic health records (EHR)?

<p>To offer context and clarity to patient information (A)</p> Signup and view all the answers

What does the acronym SBAR stand for in patient communication?

<p>Situation, Background, Assessment, Recommendation (B)</p> Signup and view all the answers

Which of the following practices can enhance documentation accuracy?

<p>Adopting approved abbreviations consistently (C)</p> Signup and view all the answers

How does technology impact the accuracy of documentation in nursing?

<p>It reduces the risk of manual errors, improving overall accuracy (B)</p> Signup and view all the answers

What is the significance of HIPAA in the context of electronic health records?

<p>It mandates both property security and restricted access to patient data (C)</p> Signup and view all the answers

Which statement best describes the documentation responsibilities in nursing?

<p>Accurate documentation is a legal responsibility to protect against liability (D)</p> Signup and view all the answers

In what situation is it appropriate to share patient updates on social media?

<p>Only with the explicit consent of the patient (A)</p> Signup and view all the answers

What does the abbreviation BID signify in medical documentation?

<p>Twice a day (A)</p> Signup and view all the answers

Flashcards

HIPAA Documentation

HIPAA regulations require protecting patient information by securing electronic records and limiting access, avoiding sensitive information, and avoiding using patient names in public areas.

Change-of-shift report

Includes patient status, plan of care, and recent changes in the patient's condition. It excludes complete medical history and opinions of family members.

SBAR

A communication tool in healthcare: Situation, Background, Assessment, Recommendation

Correcting Documentation Errors

Use a single line through the error, initial it, and write the correct information. Never use white-out or tear out pages.

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Unauthorized Abbreviations

Avoid using abbreviations that could mislead or cause errors in patient care.

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EHR Access

Verify patient consent before allowing family members to access the electronic health record (EHR).

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Technology in Documentation

Technology in nursing helps with the efficiency of documentation, but doesn't replace the need for thorough and accurate patient documentation.

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ISBARR

A communication tool that extends SBAR to include "Identification".

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EHR Documentation

Using an Electronic Health Record (EHR) to record patient information.

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Accuracy of Documentation

The correctness and completeness of recorded information in patient care.

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Narrative Documentation

Detailed written descriptions of patient care and conditions.

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HIPAA Compliance

Adhering to regulations that protect patient privacy and security.

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Shift Report

Information passed from one shift of healthcare personnel to another.

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Correcting Errors

The approved method to correct mistakes in documentation.

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Normal Adult Resting Pulse Rate

The average pulse rate for a resting adult, which ranges from 60 to 100 beats per minute.

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Surgical Asepsis

A sterile technique used in surgical procedures to prevent contamination. It aims to maintain a completely sterile environment to minimize the risk of infection.

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Infection Cycle: Order

The chain of events leading to infection: Infectious Agent, Reservoir, Portal of Exit, Mode of Transmission, Portal of Entry, Susceptible Host.

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MRSA

Methicillin-resistant Staphylococcus aureus. A bacteria commonly found in healthcare settings and resistant to many antibiotics.

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Standard Precautions

Practices designed to prevent infection transmission. They include hand hygiene, glove use, safe handling of sharps, and appropriate disposal of waste.

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Local Infection Signs

Symptoms that appear at the site of infection, such as redness, swelling, warmth, and pain.

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Systemic Infection Indicator

A high fever indicates a possible systemic infection, as the body's immune system is fighting the infection throughout the body.

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Droplet Precautions

Specific procedures like wearing masks within 3 feet of a patient to prevent the spread of infections through large respiratory droplets released through coughing and sneezing.

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Culture and Sensitivity

A lab test that identifies the type of bacteria causing an infection and determines its susceptibility to specific antibiotics.

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Best bath for limited mobility

A sponge bath allows independent bathing with assistance, suitable for patients with mobility limitations.

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Oral care with NG tube

Oral care for patients with a nasogastric tube should be performed regularly, not just once daily, to prevent oral hygiene issues.

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Oxygen mask hygiene

When caring for a patient with an oxygen mask, monitor for dryness around the nose, cleanse the area, and apply petroleum jelly to prevent skin breakdown.

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Bed bath for modesty

When providing a bed bath for a culturally modest patient, respect their preferences and offer options to ensure comfort and dignity.

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Closed bed

A closed bed is made with the sheets turned down and ready for a new patient admission.

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Occupied bed procedure

When making an occupied bed, roll the patient to change linens side by side, keeping the bed in a safe position and leaving sheets on to keep the patient warm.

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Perineal care

Perineal care should be performed respectfully, considering patient dignity and cultural preferences.

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Foot care for diabetic patients

Before providing foot care, check if the patient has diabetes, as this will influence the approach to foot care due to potential complications.

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Eye Cleansing

Using saline solution on a cotton ball to clean the eye.

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Supporting Impaired Mobility

Helping a patient with limited mobility perform personal hygiene tasks while encouraging independence.

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Hygiene for Sensory Deficits

Adapt hygiene care for patients with sensory challenges. Provide clear communication, comfortable positioning, and a well-lit environment.

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Back Rub for Frail Elderly

Use gentle strokes with light pressure when giving a back rub to a fragile elderly patient.

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Dentures at Night

Respect a patient's choice to wear dentures at night. However, educate them on risks and alternative practices.

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Home Hygiene Teaching

Instructing patients on personal hygiene practices to maintain health at home.

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Denture Care

Cleaning dentures regularly and storing them in water to keep them clean and prevent damage.

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Foot Lotion

Apply lotion to feet, especially between toes, to prevent dryness and cracking.

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Learning Environment Factor

A quiet, well-lit environment can facilitate learning by minimizing distractions and providing a comfortable setting for focus.

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Nursing & Teaching Processes

The nursing process and the teaching-learning process share similarities, both involving assessment, planning, intervention, and evaluation.

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Effective Teaching Principles

Tailoring information to the patient's educational level is essential for effective teaching. Encourage questions to gauge understanding, and avoid using complex medical jargon.

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Good Learning Environment

A good learning environment should be comfortable with a suitable temperature and adequate lighting, minimizing distractions and noise.

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Affective Domain of Learning

The affective domain of learning focuses on attitudes, values, and emotions, influencing how individuals perceive and respond to information.

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Teaching Patients with Cultural Beliefs

When educating patients with diverse cultural beliefs, use interpreters or culturally appropriate materials if needed to ensure effective communication and understanding.

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Effective Teaching Principle

Avoiding overwhelming patients with too much information at once is an essential principle in effective teaching.

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Psychomotor Learning

Demonstrating a skill first, then asking the patient to perform it focuses on the psychomotor domain of learning, which involves physical skills and coordination.

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Study Notes

Final Exam Al Practice Questions

  • Ethical/Legal Practice Exam: Unit 1

  • Mission Statement of PRCC ADN: To provide innovative, patient-centered care and prepare students for professional nursing practice with a strong foundation in ethics.

  • Accrediting bodies recognized: The Joint Commission, Accreditation Commission for Education in Nursing (ACEN), American Nurses Credentialing Center (ANCC), Centers for Medicare & Medicaid Services (CMS)

  • Purpose of the American Nurses Association (ANA) Code of Ethics for Nurses: To provide nurses with ethical guidelines to support ethical decision-making.

  • Ethical conflicts in healthcare: Can arise from differing values among healthcare professionals.

  • Ethical decision-making when confronted with dilemmas of patient autonomy versus beneficence: Consulting hospital ethics committees, considering patient values, and discussing options with the healthcare team are critical elements.

  • Actions that can lead to suspension or revocation of a nursing license in Mississippi according to the Nurse Practice Act: Administering prescribed medication without documenting the dose.

  • Other actions that could lead to violations of patient rights: Documenting patient information inaccurately, violating patient confidentiality, and taking a day off without prior notice.

  • Scope and Standards of Practice: Establish guidelines for professional accountability and quality of nursing care.

  • Intentional vs. unintentional torts: Intentional torts are deliberate actions causing harm—unintentional torts are accidents causing harm.

  • Malpractice: A nurse ignores patient requests for assistance, causing a fall; a nurse misses vital signs due to a computer malfunction.

  • HIPAA Regulations: Govern the confidentiality of all Protected Health Information (PHI).

  • Good Samaritan Act: Provides legal protection in emergency situations outside of a hospital.

  • Essential elements for carrying out healthcare providers' orders: Checking order for completeness and clarity; consulting a senior nurse; ensuring the order is appropriate for the patient; documenting actions.

  • Informed consent: Nurses are responsible for obtaining it from patients before surgical procedures.

  • Incident report: Include objective information about the incident and share with the healthcare team. Do not include it in the patient's chart

  • Essential elements for carrying out healthcare providers' orders: Checking orders for completeness, consulting a senior nurse, ensuring the order is appropriate for the patient, documenting all actions.

  • Medical documentation: Accurate records are crucial to meet legal standards and reduce liability. Types of documentation include narrative, source oriented, charting by exception, and verbal communication.

  • **Electronic health records (EHR):**Benefits include enhanced data security, reduction in errors, and immediate access to patient information.

  • Abbreviations: Familiarize yourself with common abbreviations used in documentation. BID, QD, PRN, TID.

  • Documentation vs. reimbursement: Accurate documentation directly affects reimbursement of services, which may explain some documentation guidelines.

  • JCAHO (now ACHC): Standards require healthcare documentation to be complete, accurate, and timely

  • HIPAA Regulations: Immediate access to patient information is not always permissible

  • Communication/Teamwork Practice Exam: Effective communication is crucial for patient outcomes and team coordination in nursing.

  • Therapeutic communication: Includes Orientation, working, and termination phases (or Establishment, interaction, and evaluation); consider the patient's feelings and experiences. Avoid offering advice or personal opinions when discussing the patient's concerns, using silence is not a good strategy.

  • Ethical communication: Involves self-reflection, collaboration with interdisciplinary teams, and patient's family input. Relying on ethical guidelines can support ethical decision-making.

  • Unprofessional behavior: Avoiding sharing patient information with unauthorized personnel, provide constructive feedback during team meetings, and engaging in appropriate delegation are key characteristics of professional behavior.

  • Assertiveness: Expressing your needs and opinions respectfully without aggression. It is a crucial skill in health care.

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