HESI Comprehensive Review for the NCLEX-RN® Examination PDF

HESI Comprehensive Review for the NCLEX-RN® Examination SIXTH EDITION E. Tina Cuellar, PhD, WHNP, PMHCNS, BC Director of Live Review, Elsevier/HESI, Houston, Texas 2 Table of Contents Cover image Title page Copyright Contributing Authors Preface 1. Introduction to Test-Taking Strategies and the NCLEX-RN® Test-Taking Strategies The NCLEX-RN Job Analysis Studies The NCLEX-RN Computer Adaptive Testing Gentle Reminders of General Principles 2. Leadership and Management: Legal Aspects of Nursing Legal Aspects of Nursing Prescriptions and Health Care Providers Review of Legal Aspects of Nursing Leadership and Management Maintaining a Safe Work Environment Communication Skills 3 Review of Leadership and Management Disaster Nursing Ebola Review of Disaster Nursing 3. Advanced Clinical Concepts Respiratory Failure Respiratory Failure in Children Review of Respiratory Failure Shock Disseminated Intravascular Coagulation (DIC) Review of Shock and DIC Resuscitation Management of Foreign Body Airway Obstruction (FBAO) Review of Resuscitation Fluid and Electrolyte Balance Review of Fluid and Electrolyte Balance Electrocardiogram (ECG) Review of Electrocardiogram (ECG) Perioperative Care Review of Perioperative Care HIV Infection Pediatric HIV Infection Review of HIV Infection Pain: Fifth Vital Sign Review of Pain 4 Death and Grief Review of Death and Grief 4. Medical-Surgical Nursing Communication Health Promotion and Disease Prevention Teaching/Learning Spiritual Assessment Cultural Diversity Complementary and Alternative Interventions Respiratory System Review of Respiratory System Renal System Review of Renal System Cardiovascular System Review of Cardiovascular System Gastrointestinal (GI) System Review of Gastrointestinal System Endocrine System Review of Endocrine System Musculoskeletal System Review of Musculoskeletal System Neurologic System Review of Neurologic System Hematology and Oncology Review of Hematology and Oncology 5 Reproductive System Review of Reproductive System Burns Review of Burns 5. Pediatric Nursing Growth and Development Pain Assessment and Management in the Pediatric Client Review of Child Health Promotion Respiratory Disorders Review of Respiratory Disorders Cardiovascular Disorders Review of Cardiovascular Disorders Neuromuscular Disorders Review of Neuromuscular Disorders Renal Disorders Review of Renal Disorders Gastrointestinal Disorders Review of Gastrointestinal Disorders Hematologic Disorders Review of Hematologic Disorders Metabolic and Endocrine Disorders Review of Metabolic and Endocrine Disorders Skeletal Disorders Review of Skeletal Disorders 6. Maternity Nursing 6 Anatomy and Physiology of Reproduction Antepartum Nursing Care Review of Anatomy and Physiology of Reproduction and Antepartum Nursing Care Fetal and Maternal Assessment Techniques Review of Fetal and Maternal Assessment Techniques Intrapartum Nursing Care Review of Intrapartum Nursing Care Normal Puerperium (Postpartum) Review of Normal Puerperium (Postpartum) The Normal Newborn Review of the Normal Newborn High-Risk Disorders Review of High-Risk Disorders Postpartum High-Risk Disorders Review of Postpartum High-Risk Disorders Newborn High-Risk Disorders Effects on the Neonate of Substance Abuse 7. Psychiatric Nursing Therapeutic Communication Coping Styles (Defense Mechanisms) Treatment Modalities Review of Therapeutic Communication and Treatment Modalities Anxiety and Related Disorders Anxiety Disorders, Obsessive-Compulsive and Related Disorders, and Traumatic and Stressor Related Disorders Review of Anxiety Disorders, Obsessive-Compulsive and Related Disorders, and 7 Traumatic and Stressor Related Disorders Somatic Symptom Disorder and Related Disorders Review of Somatic Symptom Disorder and Related Disorders Dissociative Disorders Review of Dissociative Disorders Personality Disorders (DSM-5 Criteria) Review of Personality Disorders Eating Disorders Review of Eating Disorders Mood Disorders Review of Mood Disorders Schizophrenia Spectrum and Other Psychotic Disorders Review of Thought Disorders Substance Abuse Disorder Substance Use Disorder Review of Substance Abuse Disorder Abuse Review of Abuse Neurocognitive Disorder (DSM-5) Review of Neurocognitive Disorders Childhood and Adolescent Disorders Review of Childhood and Adolescent Disorders 8. Gerontologic Nursing Theories of Aging Neurocognitive Disorder (NCD): Dementia 8 Psychosocial Changes Health Maintenance and Preventive Care Review of Gerontologic Nursing Answer Key to Review Questions APPENDIX. Common Laboratory Tests Index 9 Contributing Authors Safa’a Al-Arabi, PhD, RN, MSN, MPH , Associate Professor and Master’s Track Administrator, University of Texas Medical Branch, Galveston, Texas Karen Alexander, PhD, RN , Program Director at University of Houston Clear Lake, Pearland, Texas Joanna Cain, BSN, BA, RN , President and Founder, Auctorial Pursuits, Inc., Austin, Texas Lucindra Campbell-Law, PhD, ANP, PMHNP, BC , Professor, Carol and Odis Peavy School of Nursing, University of St. Thomas, Houston, Texas E. Tina Cuellar, PhD, WHNP, PMHCNS, BC , Director of Live Review, Elsevier/Education/HESI, Houston, Texas Claudine Dufrene, PhD, RN-BC, GNP-BC, CNE , Assistant Professor, Carol and Odis Peavy School of Nursing, University of St. Thomas, Houston, Texas Sandra Jenkins, PhD, RN , Visiting Professor, University of Houston Clear Lake, Pearland, Texas Shatoi King, MSN, RN , Instructor, University of Houston Clear Lake, Pearland, Texas Necole Leland, MSN, RN, PNP, CPN , Instructor, School of Nursing, University of Nevada, Las Vegas, Las Vegas, Nevada Katherine Ralph, EdD, RN , Nurse Manager Curriculum, Review and Testing, Elsevier/Education/HESI, Houston, Texas 12 Preface Welcome to HESI Comprehensive Review for the NCLEX-RN ® Examination with online study exams by HESI. Congratulations! This outstanding review manual with online study exams is designed to prepare nursing students for what is very likely the most important examination they will ever take—the NCLEX-RN Licensing Examination. HESI Comprehensive Review for the NCLEX-RN ® Examination allows the nursing student to prepare for the NCLEX-RN licensure examination in a structured way. Organize previously learned basic nursing knowledge. Review content learned during basic nursing curriculum. Identify deficits in content knowledge so that study effort can be focused appropriately. Develop test-taking skills to demonstrate application of safe nursing practice. Reduce anxiety level by increasing predictability of ability to correctly answer NCLEX-type questions. Boost test-taking confidence by being well prepared and knowing what to expect. 13 Organization AND PREPARING TO TAKE TESTS Chapter 1 , Introduction to Test-Taking Strategies and the NCLEX-RN ® , gives an overview of the NCLEX-RN Licensing Examination history and test plan for the examination. Reviews of the nursing process, client needs, and strategies for employing clinical judgement to prioritize nursing care are also presented. Chapter 2 , Leadership and Management, reviews the legal aspects of nursing, leadership and management, and disaster nursing. Chapter 3 , Advanced Clinical Concepts, presents nursing assessment, analysis, and planning and intervention, using clinical judgment at the highest level of practice. Topics reviewed include respiratory failure, shock, disseminated intravascular coagulation, resuscitation, fluid and electrolyte balance, intravenous therapy, acid–base balance, electrocardiogram, perioperative care, HIV, pain, and death and grief. Chapters 4 through 8 , Medical-Surgical Nursing, Pediatric Nursing, Maternity Nursing, Psychiatric Nursing, and Gerontologic Nursing, are presented in traditional clinical areas. Each clinical area is divided into physiologic components, with essential knowledge about basic anatomy, growth and development, pharmacology and medication calculation, nutrition, communication, client and family education, acute and chronic care, leadership and management, complementary and alternative interventions, cultural and spiritual diversity, and clinical decision making threaded throughout the different components. Open-ended questions with the answers appear at the end of each chapter, which encourage the student to think in depth about the content that is presented throughout the particular chapter. When a variety of learning mechanisms are used, students have the opportunity to comprehensively prepare for the NCLEX exam; these strategies include: Reading the manual Discussing content with others Answering open-ended questions Practicing with study exams that simulate the licensure examination These learning experiences are all different ways that students should use to prepare for the NCLEX-RN exam. The purpose of the open-ended questions appearing at the end of the chapter is not a focused practice session on managing NCLEX-style questions, but rather a learning approach that allows for more in-depth thinking about specific topics in the chapter. Practice with multiple-choice questions alone cannot provide the depth of critical thinking and analysis that is made possible by the short-answer questions at the end of the chapter. In addition, the open-ended questions presented at the end of the chapter provide a summary experience that helps students focus on the main topics that were covered in the chapter. Teachers use open-ended questions to stimulate the critical-thinking process, and HESI Comprehensive Review for the NCLEX-RN ® Examination facilitates the critical-thinking process by posing the same type of questions the teacher might ask. When students need to practice multiple-choice questions, the online study exams on 14 Evolve offer extensive opportunities for practice and skill building to improve their test- taking abilities. The online study exams include six content-specific exams (Medical- Surgical Nursing, Pharmacology, Pediatrics, Fundamentals, Maternity, and Psychiatric- Mental Health Nursing) and two comprehensive exams patterned after categories on the NCLEX-RN exam. The online study exams on Evolve can be accessed as many times as necessary, and the questions from one study exam are not contained on another study exam. For instance, the Medical-Surgical study exam does not contain questions that are on the Pediatrics study exam. The purpose of the study exams is to provide practice and exposure to the critical thinking–style questions that students will encounter on the NCLEX-RN exam. However, the study exams should not be used to predict performance on the actual NCLEX-RN exam. Only the HESI Exit Exam, a secure, computerized exam that simulates the NCLEX-RN test plan and has evidence-based results from numerous research studies indicating a high level of accuracy in predicting NCLEX success, is offered as a true predictor exam. Students are allowed unlimited practice on each online study exam so that they can be sure to have the opportunity to review all of the rationales for the questions. Here is a plan for a student to use with the online study exams: Step 1: Take the RN study exam without studying for it to see where your strengths and weaknesses are. Step 2: After going over the content that relates to the study questions in a particular clinical area (e.g., Pediatrics, Medical-Surgical, or Maternity), review that section of the manual and take the test again to determine whether you have been able to improve your scores. Step 3: Purposely miss every question on the exam so that you can view the rationales for every question. Step 4: Take the exam again under timed conditions at the pace that you would have to progress in order to complete the NCLEX-RN exam in the time allowed (approximately 1 minute per question). See if being placed under time constraints affects your performance. Step 5: Put the exam away for a while and continue review and remediation with other textbooks, resources, and results of any HESI secure exams that you have taken at your school. Then, take the study exams again to see if your performance improves after in-depth study and following a few weeks’ break from these questions. Step 5 represents a good activity in preparation for the HESI Exit Exam presented in your final semester of the nursing program, especially if you have not used the online study exams for several weeks. Repeated exposure to the questions, however, will make them less useful over time because students tend to memorize the answers. For this reason, these tests are useful only for practice and not for prediction of NCLEX-RN success. The tendency to memorize the questions after viewing them multiple times falsely elevates a student’s score on the study exams. Additional assistance for students studying for the NCLEX-RN Licensing Examination can be obtained from a variety of online products in the Elsevier family. Many nursing schools have also adopted the following: 15 HESI Examinations—A comprehensive set of examinations designed to prepare nursing students for the NCLEX exam. They include customized electronic remediation from current Elsevier textbooks and multimedia, as well as additional practice questions. Each student is given an individualized report detailing exam results and is allowed to view questions and rationales for items that were answered incorrectly. The electronic remediation, a complementary feature of the specialty and exit exams, can be filed by the student for later study. HESI Practice Test—This is the ideal way to practice for the NCLEX exam. With more than 1200 practice questions included in this online test bank, nursing students can access practice exams 24 hours a day, 7 days a week. HESI Practice Test questions are written at the critical-thinking level so that students are tested not for memorization but for their skills in clinical application. Students select a test option (either a clinical specialty or a comprehensive exam), and HESI Practice Test automatically supplies a series of critical-thinking practice questions. NCLEX exam–style questions include multiple-choice and alternate-item formats and are accompanied by correct answers and rationales. HESI RN Case Studies—These prepare students to manage complex patient conditions and make sound clinical judgments. These online case studies cover a broad range of physiologic and psychosocial alterations, plus related management, pharmacology, and therapeutic concepts. HESI Patient Reviews—These are designed to teach and assess students’ retention of core nursing content. These online interactive reviews provide a firsthand look at safe and effective nursing care. HESI Live Review—A live review course is presented by an expert faculty member who has additional instruction in working with students who are preparing to take the NCLEX exam. Students are presented with a workbook and practice NCLEX-style questions that are used during the course. Evolve eBooks—Online versions of all of the Mosby, Saunders, and Elsevier textbooks used in the student’s nursing curriculum are presented. Search across titles, highlight, make notes, and more—all on your computer. Elsevier Simulations—Virtual versions simulate the clinical environment. These multilayered, complex, supplemental simulations enable students to experience clinical assignments without the need for actual clinical space. Elsevier Courses—These are created by experts using instructional design principles. This interactive content engages students with reading, animation, video, audio, interactive exercises, and assessments. 16 Next Generation NCLEX and Clinical Judgment Starting in July of 2017, the National Council of State Boards of Nursing (NCSBN) began including a special research section to select candidates after they complete the exam. The data collected from this section is used to help determine new item types that may be included in a future version of the NCLEX, known as Next Generation NCLEX (NGN). (More information can be found at ( http://www.ncsbn.org/next-generation- nclex.htm. ) An important piece of the NGN is the clinical judgment model. Clinical judgment is important for all nurses, and this book helps nursing students by reviewing information and skills that nurses must master to practice clinical judgment. Additionally, NCLEX practice questions on the Evolve website written at higher levels of Bloom’s taxonomy help students practice applying their clinical judgment knowledge. Finally, a Clinical Judgment Scenario with practice NGN questions is included in Chapter 4 to familiarize students with these types of questions. 17 Introduction to Test-Taking Strategies and the NCLEX-RN® Congratulations! You have made the wise decision to prepare, in a structured way, for the NCLEX-RN®. A. Since you have successfully completed a basic nursing program and are well acquainted with your test-taking skills and ability to apply your clinical knowledge, you already have the basic knowledge required to pass the licensing examination. B. However, following these general guidelines will help ensure your success. 1. Organize your knowledge. 2. Identify weaknesses in content knowledge to help focus your study time appropriately. 3. Review the need-to-know content learned in nursing school. 4. Develop strong test-taking skills to demonstrate your knowledge. 5. Reduce your level of anxiety by dissecting test questions and using your foundational knowledge to arrive at the correct answer. 6. Know what to expect. Remember that knowledge is power. You are powerful when you are well prepared and know what to expect. 18 Test-Taking Strategies These test-taking strategies help you focus your study so that you can concentrate on what the exam questions are asking instead of being distracted by extraneous information that is not needed to answer the questions. A. The NCLEX-RN tests your knowledge about several core concepts and the ability to synthesize information to effectively apply, analyze, or evaluate a client’s needs to provide safe and effective care. For example, a question may appear to be a medical-surgical or pediatric question, but the question can also cover such topics as communication, nutrition, growth and development, medication, client and family education, and safety. HESI Hint The most essential element of nursing care is client safety. B. Understand the question. 1. Determine whether the question is written in a positive or negative style. a. A positive style question may ask what the nurse should do or ask for the best or first nursing intervention to implement. HESI Hint Most questions are written in a positive style. b. A negative style question may ask what the nurse should avoid, which prescription the nurse should question, or which behavior indicates the need for reteaching the client. HESI Hint Negative style questions contain key words that denote the negative style. Examples 1. “Which response indicates to the nurse a need to reteach the client about heart disease?” (Which information or understanding by the client is incorrect?) 2. “Which medication order should the nurse question?” (Which prescription is unsafe, not beneficial, inappropriate to this client situation?) C. Identify key words. 19 1. Ask yourself which words or phrases provide the critical information. 2. This information may include the age of the client, the setting, the timing, a set of symptoms or behaviors, or any number of other factors. a. For example, the nursing actions for a 10-year-old postop client are different from those for a 70-year-old postop client. D. Rephrase the question. 1. Rephrasing the question helps eliminate nonessential information in the question to help you determine the correct answer. a. Ask yourself, “What is this question really asking?” b. While keeping the options covered, rephrase the question in your own words. 2. Rule out options. a. Based on your knowledge, you can most likely identify one or two options that are clearly incorrect. b. Physically mark through those options on the test booklet if allowed. Mentally mark through those options in your head if using a computer. c. Differentiate between the remaining options, considering your knowledge of the subject and related nursing principles, such as roles of the nurse, nursing process, ABCs (airway, breathing, circulation), CAB (circulation, airway, breathing for cardiopulmonary resuscitation [CPR]), and Maslow’s hierarchy of needs. E. Implement these guidelines. 1. Consider the content of the question and what specifically the question is asking. 2. Generally, an assessment of the client occurs before an action is taken, except in the case of an emergency, for example, if a client is bleeding profusely, stop the bleeding. Or, if a client is having difficulty breathing, open the airway then assess the client. 3. Identify the least invasive intervention before taking action. 4. Gather all of the necessary information and complete the necessary assessments before calling the healthcare provider. 5. Determine which client to assess first (e.g., most at risk, most physiologically unstable). 6. Identify opposites in the answers. a. Example: prone versus supine; elevated versus decreased. b. Read VERY carefully; one opposite is likely to be the answer, but not always. c. If you do not know the answer, choose the most likely of the “opposites” and move on. 7. Take into account a client’s lifestyle, culture, and spiritual beliefs when answering a question. F. Use your critical thinking skills. 1. Respond to questions based on a. Client safety 20 b. ABCs c. CAB for CPR d. Caring e. Incorporation of culture and spiritual practices f. Scientific, behavioral, and sociologic principles g. Communication (spoken and written [documentation]) with client, family, colleagues, and other members of the healthcare team h. Principles of teaching and learning i. Maslow’s hierarchy of needs j. Nursing process k. Focus on what information is in the stem. Do not focus on information not included in the question. Do not read more into the question than is already there. 1. NCLEX-RN ideal hospital 2. Basic anatomy and physiology 2. Do not respond to questions based on a. YOUR past client care experiences or your employer’s policies b. A familiar phrase or term c. “Of course, I would have already” d. What you think is realistic; perceptions of realism are subjective e. Your children, pregnancies, parents, personal response to a drug, etc. f. The “what-ifs” HESI Hint As soon as you are seated in the testing area, use the erasable noteboard to write down information you’ve memorized (a brain dump). That’s a resource you may use while testing if you become too stressed to recall information you memorized. G. Keep memorization to a minimum. 1. Don’t try to memorize all of the material found in your textbooks because it isn’t possible. Only memorize core concepts. a. Growth and developmental milestones b. Death and dying stages c. Crisis intervention d. Immunization schedules e. Principles of teaching and learning f. Stages of pregnancy and fetal growth g. Nurse Practice Act: Standards of Practice and Delegation h. Ethical practices and standards i. Commonly used laboratory test values: 1. Review Appendix A. 2. Hemoglobin and hematocrit (H&H) 21 3. White blood cells (WBCs), red blood cells (RBCs), platelets 4. Electrolytes: K+, Na+, Ca++, Mg++, Cl − , 5. Blood urea nitrogen (BUN) and creatinine 6. Relationship of Ca++ and 7. Arterial blood gases (ABGs) 8. SED rate, erythrocyte sedimentation rate (ESR), prothrombin time (PT), international normalized ratio (INR), partial thromboplastin time (PTT), activated partial thromboplastin time (aPTT) HESI Hint Remember not to confuse PT, PTT, and aPTT. j. Nutrition 1. High or low Na+ 2. High or low K+ 3. High 4. Iron 5. Vitamin K 6. Proteins 7. Carbohydrates 8. Fats k. Foods and diets related to 1. Body system disturbances (cardiac, endocrine, gastrointestinal) 2. Chemotherapy, radiation, surgery 3. Pregnancy and fetal growth needs 4. Dialysis 5. Burns l. Nutrition concepts 1. Introduce one food at a time for infants and clients with allergies. 2. Progression to “as tolerated” foods and diets H. Understand medication administration. 1. Safe medication administration requires more than knowing the name, classification, and action of the medication. a. The Six Rights, including techniques of skill execution b. Drug interactions c. Vulnerable organs to medication effects 1. Know what to assess (kidney function, vital signs). 22 2. Know which laboratory values relate to specific organs and their functions. d. Client allergies e. Presence of infections and superinfections f. Concepts of peak and trough levels g. How you would know if 1. The drug is working. 2. There is a problem. h. Nursing actions i. Client education 1. Safety 2. Empowerment 3. Compliance 23 The NCLEX-RN A. The main purpose of the NCLEX-RN is to protect the public. B. The NCLEX-RN 1. Was developed by the National Council of State Boards of Nursing (referred to as “the Council” throughout this book) 2. Is administered by the State Board of Nurse Examiners 3. Is designed to test candidates’ a. Capabilities for safe and effective nursing practice b. Essential entry-level nursing knowledge c. Ability to problem solve by applying critical thinking skills 24 Job Analysis Studies A. Essential knowledge that new nurses should know is determined by job analysis studies. B. Job analysis studies indicate that newly licensed registered nurses are using all five categories of the nursing process and that such use is evenly distributed throughout the nursing process areas. Therefore, equal attention is given to each part of the nursing process in selecting NCLEX-RN items (Table 1.1). TABLE 1.1 The Nursing Process HESI Hint The Council wants to ensure that the licensing examination measures current entry-level nursing behaviors. For this reason, job analysis studies are conducted every 3 years. These studies determine how frequently various types of nursing activities are performed, how often they are delegated, and how critical they are to client safety, with criticality given more value than frequency. Nursing Diagnoses A. Nursing diagnoses are formulated during the analysis portion of the nursing process. They give form and direction to the nursing process, promote priority setting, and guide nursing actions (Table 1.2). B. To qualify as a nursing diagnosis, the primary responsibility and accountability for recognition and treatment rest with the nurse. 25 C. NCLEX-RN questions regarding nursing diagnosis can take several forms. 1. You may be given the nursing diagnosis in the stem and asked to select an appropriate nursing intervention based on the stated nursing diagnosis. 2. You may be asked to select, from among the choices provided, the most appropriate nursing diagnosis(es) for the described case. 3. You may be asked to choose, from four nursing diagnoses, the one that should have priority based on the data in the stem. D. For further information about nursing diagnoses, review a fundamentals text, a medical-surgical nursing text, or a nursing diagnosis handbook. HESI Hint A nursing diagnosis must be subject to oversight by nursing management. It is not a medical diagnosis. The cause may or may not arise from a medical diagnosis. Client Needs A. Job analysis studies have identified categories of care provided by nurses called client needs. The test plan is structured according to these categories (Table 1.3). Prioritizing Nursing Care A. Many NCLEX-RN items are designed to test your ability to set priorities. 1. Identify the most important client needs. 2. Which nursing intervention is most important? TABLE 1.2 Components of a Nursing Diagnosis TABLE 1.3 Components of the NCLEX-RN Test Plan 26 27 28 3. Which nursing action should be performed first? 4. Which response is best? B. Setting priorities 1. Which action should be performed first or next? Remember, client safety is paramount. 2. Remember Maslow (Table 1.4). 3. The Five Rights of Delegation (see Chapter 2, p. 16) HESI Hint Answering NCLEX-RN questions often depends on setting priorities, making judgments about priorities, and analyzing the data and formulating a decision about care based on 29 priorities. Using Maslow’s hierarchy of needs can help you set nursing priorities. 30 The NCLEX-RN Computer Adaptive Testing A. Computer adaptive testing (CAT) is used for implementation of the NCLEX-RN. B. The CAT is administered at a testing center selected by the Council. C. Pearson VUE is responsible for adapting the NCLEX-RN to the CAT format, processing candidate applications, and transmitting test results to its data center for scoring. D. The testing centers are located throughout the United States. E. The Council generates the NCLEX-RN questions. TABLE 1.4 Maslow’s Hierarchy of Needs Need Definition Nursing Implications Physiologic Biologic needs for The priority biologic need is breathing (i.e., an open airway). Review Table food, shelter, water,1.3, which lists activities associated with physiologic integrity. If asked to sleep, oxygen, identify the most important action, identify needs associated with sexual expression physiologic integrity (e.g., providing an open airway) as the most important nursing action. Safety Avoiding harm; Review Table 1.3, which lists the activities associated with a safe and attaining security, effective care environment. Ensuring that the client’s environment is safe is order, and physical a priority (e.g., teaching an older client to remove throw rugs that pose a safety safety hazard when ambulating has a greater priority than teaching the client how to use a walker). The first priority is safety, followed by coping skills. Love and Giving and Although these needs are important (described in Table 1.3), they are less Belonging receiving important than physiologic or safety needs. For example, it is more Esteem and affection; important for a client to have an open airway and a safe environment for Recognition companionship; ambulating than it is to assist him or her to become part of a support identification group. However, assisting the client in becoming a part of a support group with a group has higher priority than assisting in the development of self-esteem. The Self-esteem and sense of belonging comes first, and such a sense may help in developing respect of self-esteem. others; success in work; prestige Self- Fulfillment of It is important to understand the last two needs in Maslow’s hierarchy. Actualization unique They could deal with client needs associated with health promotion and Aesthetic potentialSearch for maintenance, such as continued growth and development and self-care, as beauty and spiritual well as those associated with psychosocial integrity. However, you will goals probably not be asked to prioritize needs at this level. Remember, it is the goal of the Council to ensure safe nursing practice, and such practice does not usually deal with the client’s self-actualization or aesthetic needs. How CAT Works A. The NCLEX-RN consists of 75 to 265 multiple-choice or alternative-format questions (15 of which are pilot items) presented on a computer screen. B. The candidate is presented with a test item and possible answers. C. If the candidate answers the question correctly, a slightly more difficult item will 31 follow, and the level of difficulty will increase with each item until the candidate misses an item. D. If the candidate misses an item, a slightly less difficult item will follow, and the level of difficulty will decrease with each item until the candidate has answered an item correctly. E. This process will continue until the candidate has achieved a definite pass or a definite fail score. There will be no borderline pass or fail scores because the adaptive testing method determines the candidate’s level of performance before she or he has finished the examination. F. The lowest number of items a candidate can answer to complete the examination is 75; 15 of them will be pilot items and will not count toward the pass or fail score; 60 of them will determine the candidate’s score. G. The number of the item the candidate is currently answering will appear on the upper-right area of the screen. H. When the candidate has answered enough items to determine a definite pass or fail score, a message will appear on the screen notifying the candidate that he or she has completed the examination. I. The greatest number of items a candidate can answer is 265, and the longest amount of time the candidate can take to complete the examination is 6 hours. J. Candidates will have up to 6 hours to complete the NCLEX-RN; total examination time includes a short tutorial, two preprogrammed optional breaks, and any unscheduled breaks the candidate may take. The first optional break is offered after 2 hours of testing. The second optional break is offered after 3.5 hours of testing. The computer will automatically tell candidates when these scheduled breaks begin. 1. All breaks count against testing time. 2. When candidates take breaks, they must leave the testing room, and they will be required to provide a palm vein scan before and after the breaks. K. If a candidate has not obtained a pass or fail score at the end of the 6 hours and has not completed all 265 items in the 6-hour limit, but has answered all of the last 60 questions presented correctly, he or she will pass the examination. L. If a candidate has not obtained a pass or fail score at the end of the 6 hours, has not completed all 265 items in the 6-hour limit, and has not answered correctly all of the last 60 questions presented, he or she will fail the examination. M. A specific passing score is recommended by the Council. All states require the same score to pass, so that if you pass in one state, you are eligible to practice nursing in any other state. However, states do differ in their requirements regarding the number of times a candidate can take the NCLEX-RN. N. Although the Council has the ability to determine a candidate’s score at the time of completion of the examination, it has been decided that it would be best for candidates to receive their scores from their individual Board of Nurse Examiners. The Council does not want the testing center to be in a position of having to deal with candidates’ reactions to scores, nor does the Council want those waiting to take their examinations to be influenced by such reactions. O. The candidate must answer each question in order to proceed. You cannot omit a question or return to an item presented earlier. There is no going back; this works 32 in your favor! P. The examination is written at a tenth-grade reading level. Q. There is no penalty for guessing. R. The NCSBN Candidate Bulletin is available at https://www.ncsbn.org/1213.htm. Then select: Examinations/Candidates/Basic Information/Bulletin. HESI Hint For multiple choice questions, one or more of the answer choices is likely to be very wrong. You usually will be able to rule out two of the four choices rather quickly. Reread the question and choices again if necessary. Ask yourself which choice answers the question being asked. Even if you have absolutely no idea what the correct answer is, you will have a 50/50 chance of guessing the right answer if you follow this process. Your first response will provide an educated guess and will usually be the correct answer. Go with your gut response! Examination Item Formats A. A number of different types of examination items are presented on the NCLEX- RN. Many of the questions are multiple-choice items with four answer choices from which the candidate is asked to choose one correct answer. There are seven alternate format item types of questions. 1. Multiple-response items require the candidate to select one or more responses. The item will instruct the candidate to select all that apply. 2. Fill-in-the-blank questions require the candidate to calculate the answer and type in numbers. A drop-down calculator is provided. 3. Hot-spot items require the candidate to identify an area on a picture or graph and click on the area. 4. Chart or exhibit formats present a chart or exhibit that the candidate must read to be able to solve the problem. 5. Drag-and-drop items require a candidate to rank order or move options to provide the correct order of actions or events. 6. Audio format items require the candidate to listen to an audio clip using headphones and then select the correct option that applies to the audio clip. 7. Graphic format items require the candidate to choose the correct graphic option in response to the question. B. There is no set percentage of alternative items on the NCLEX-RN. All examination items are scored either right or wrong. There is no partial credit in scoring any examination questions. 33 Gentle Reminders of General Principles A. Be sure to take care of yourself. If you don’t, you may be susceptible to illness that can cause you to miss the exam. B. Eat well. Consume lots of fresh fruits, vegetables, and lean protein, and avoid high- fat foods and sugars. Processed sugar can cause blood sugar levels to spike and then plummet, which can cause brain fogginess. C. Get enough sleep. This includes getting enough sleep the week of, not just the night before, the exam. The week of the exam is not the time to cram or to party. D. Eliminate alcohol and other mind-altering drugs. These substances can inhibit your performance on the examination. E. Schedule study times. During the weeks leading up to the examination, review nursing content, focusing on areas that you have identified as your weakest areas. Use a study schedule to block out the time needed for study. F. Be prepared. Assemble all necessary materials the night before the examination (admission ticket, directions to the testing center, identification, money for lunch, glasses or contacts). G. Bring the necessary items to the exam. Candidates are only allowed to bring a form of identification into the testing room. Watches, candy, chewing gum, food, drinks, purses, wallets, pens, pencils, beepers, cellular phones, Post-It notes, study materials or aids, and calculators are not permitted. A test administrator will provide each candidate with an erasable noteboard that may be replaced as needed while testing. Candidates may not take their own noteboards, scratch paper, or writing instruments into the examination. A calculator on the computer screen will be available for use. H. Arrive early. Allow plenty of time to eat breakfast and travel to the testing center. It is better to be early than late. Allow for traffic jams and so forth. The candidate may consider spending the night in a hotel or motel near the testing center the night before the examination. I. Dress comfortably. Dress in layers so that you can put on or take off a sweater or jacket as needed. J. Avoid negative people. During the weeks leading up to the examination, stay away from those who share their anxieties with you or project their insecurities onto you. Sometimes this is a fellow classmate or even your best friend. The person will still be there when the examination is over. Stay focused and positive. K. Do not discuss the exam. Avoid talking about the examination during breaks and while waiting to take the test. L. Avoid distractions. Take earplugs with you and use them if you find that those around you are distracting you. The rattling of paper or a candidate getting up to leave the exam room can be distracting. M. Think positively. Use the affirmation, “I am successful.” Obtain a relaxation and affirmation recording, and use it during rest periods or any time you feel the need to boost your confidence. Think, “I have the knowledge to successfully complete the NCLEX-RN.” 34 HESI Hint The night before the NCLEX-RN, allow only 30 minutes of study time. This 30-minute period should be designated for review of test-taking strategies only. Practice these strategies with various practice test items if you wish (for 30 minutes only; do not take an entire test). Spend the night before the examination doing something that you enjoy. Engage in stress reduction and do not use alcohol or other mind-altering drugs. Only you can identify the special something that will work for you. Remember, you can be successful! For more review, go to http://evolve.elsevier.com/HESI/RN for HESI’s online study examinations. 35 Leadership and Management Legal Aspects of Nursing 36 Legal Aspects of Nursing Laws Governing Nursing A. Nurse Practice Acts provide the laws that control and regulate nursing practice in each state to protect the public from harm. Mandatory Nurse Practice Acts authorize that, under the law, only licensed professionals can practice nursing. All states now have mandatory Nurse Practice Acts. Laws affecting nursing practice vary from state to state. B. Nurse Practice Acts govern the nurse’s responsibility in making assignments. Each state sets its own educational and examination requirements. 1. Client assignments should be commensurate with the nursing personnel’s educational preparation, skills, experience, and knowledge. HESI Hint Assignments are often tested on the NCLEX-RN. The Nurse Practice Acts of each state govern policies related to making assignments. Usually, when determining who should be assigned to do a sterile dressing change, for example, a licensed nurse should be chosen— that is, a registered nurse (RN) or licensed practical nurse (LPN) who has been checked off on this procedure. 2. The nurse should supervise the care provided by unlicensed assistive personnel (UAP) or any individual for which the nurse is administratively responsible. 3. Sterile or invasive procedures should be assigned to or supervised by an RN. 4. Documenting client care is a legal task. Torts (Violation of Client’s Private Right) Unintentional Torts A. Definition: An act involving injury or damage to another (except breach of contract) resulting in civil liability (i.e., the victim can sue) instead of criminal liability (see Crime). B. Negligence and malpractice. 1. Negligence: Performing an act that a reasonable and prudent person would not perform. The measure of negligence is “reasonableness” (i.e., would a reasonable and prudent nurse act in the same manner under the same circumstances?). That is, did the nurse provide care that did not meet the standard? 2. Malpractice: Negligence by professional personnel (e.g., professional misconduct or unreasonable lack of skill in carrying out professional 37 duties). Malpractice is a negligent act performed by an individual in a professional role that results in an injury. C. Four elements are necessary to prove malpractice; if any one element is missing, malpractice cannot be proved. 1. Duty: Obligation to use due care (what a reasonable, prudent nurse would do); failure to care for and/or to protect others against unreasonable risk. The nurse must anticipate foreseeable risks. Example: If a floor has water on it, the nurse is responsible for anticipating the risk of a client fall. 2. Breach of duty: Failure to perform according to the established standard of conduct in providing nursing care. 3. Injury/damages: Failure to meet the standard of care, which causes actual injury or damage to the client (physical injury). Neither emotional nor mental injury is enough to prove malpractice, either physical or mental. 4. Causation: A connection exists between conduct and the resulting injury, referred to as proximate cause or remoteness of damage. D. Hospital policies provide a guide for nursing actions. They are not laws, but courts generally rule against nurses who have violated the employer’s policies. Hospitals can be liable for poorly formulated or poorly implemented policies. HESI Hint Nurses can avoid negligence and malpractice by following their organization’s policies and procedures. E. Incident reports alert the administration to possible liability claims and the need for investigation; they do not protect against legal action being taken for negligence or malpractice. F. Examples of negligence or malpractice: 1. Burning a client with a heating pad 2. Leaving sponges or instruments in a client’s body after surgery 3. Performing incompetent assessments 4. Failing to heed warning signs of shock or impending myocardial infarction 5. Ignoring signs and symptoms of bleeding 6. Forgetting to give a medication or giving the wrong medication Intentional Torts A. Assault and battery 1. Assault: Mental or physical threat (e.g., forcing [without touching] a client to take a medication or treatment) 2. Battery: Actual and intentional touching of one another, with or without the intent to do harm (e.g., hitting or striking a client). If a 38 mentally competent adult is forced to have a treatment he or she has refused, battery occurs. B. Invasion of privacy: Encroachment or trespassing on another’s body or personality 1. False imprisonment: Confinement without authorization 2. Exposure of a person: a. Body: After death, a client has the right to be unobserved, excluded from unwarranted operations, and protected from unauthorized touching of the body. b. Personality: Exposure or discussion of a client’s case or revealing personal information or identity. 3. Defamation: Divulgence of privileged information or communication (e.g., through charts, conversations, or observations) C. Fraud: Illegal activity and willful and purposeful misrepresentation that could cause, or has caused, loss or harm to a person or property. Examples of fraud include 1. Presenting false credentials for the purpose of entering nursing school, obtaining a license, or obtaining employment (e.g., falsification of records). 2. Describing a myth regarding a treatment (e.g., telling a client that a placebo has no side effects and will cure the disease, or telling a client that a treatment or diagnostic test will not hurt, when indeed pain is involved in the procedure). Crime A. An act contrary to a criminal statute. Crimes are wrongs punishable by the state and committed against the state, with intent usually present. The nurse remains bound by all criminal laws. B. Commission of a crime involves the following behaviors: 1. A person commits a deed contrary to criminal law. 2. A person omits an act when there is a legal obligation to perform such an act (e.g., refusing to assist with the birth of a child if such a refusal results in injury to the child). 3. Criminal conspiracy occurs when two or more persons agree to commit a crime. 4. Assisting or giving aid to a person in the commission of a crime makes that person equally guilty of the offense (awareness must be present that the crime is being committed). 5. Ignoring a law is not usually an adequate defense against the commission of a crime (e.g., a nurse who sees another nurse taking narcotics from the unit supply and ignores this observation is not adequately defended against committing a crime). 6. Assault is justified for self-defense. However, to be justified, only enough force can be used to maintain self-protection. 7. Search warrants are required before searching a person’s property. 8. It is a crime not to report suspected child abuse. 39 HESI Hint The nurse has a legal responsibility to report suspected child abuse. Nursing Practice and the Law Psychiatric Nursing A. Civil procedures: Methods used to protect the rights of psychiatric clients B. Voluntary admission: The client admits himself or herself to an institution for treatment and retains civil rights. C. Involuntary admission: Someone other than the client applies for the client’s admission to an institution. 1. This requires certification by a health care provider that the person is a danger to self or others. (Depending on the state, one or two health care provider certifications are required.) 2. Individuals have the right to a legal hearing within a certain number of hours or days. 3. Most states limit commitment to 90 days. 4. Extended commitment is usually no longer than 1 year. D. Emergency admission: Any adult may apply for emergency detention of another. However, medical or judicial approval is required to detain anyone beyond 24 hours. 1. A person held against his or her will can file a writ of habeas corpus to try to get the court to hear the case and release the person. 2. The court determines the sanity and alleged unlawful restraint of a person. E. Legal and civil rights of hospitalized clients 1. The right to wear their own clothes and to keep personal items and a reasonable amount of cash for small purchases 2. The right to have individual storage space for one’s own use 3. The right to see visitors daily 4. The right to have reasonable access to a telephone and the opportunity to have private conversations by telephone 5. The right to receive and send mail (unopened) 6. The right to refuse shock treatments and lobotomy F. Competency hearing: Legal hearing that is held to determine a person’s ability to make responsible decisions about self, dependents, or property 1. Persons declared incompetent have the legal status of a minor—they cannot a. Vote b. Make contracts or wills c. Drive a car d. Sue or be sued e. Hold a professional license 2. A guardian is appointed by the court for an incompetent person. 40 Declaring a person incompetent can be initiated by the state or the family. G. Insanity: Legal term meaning the accused is not criminally responsible for the unlawful act committed because he or she is mentally ill H. Inability to stand trial: Person accused of committing a crime is not mentally capable of standing trial. He or she 1. Cannot understand the charge against himself or herself 2. Must be sent to the psychiatric unit until legally determined to be competent for trial 3. Once mentally fit, must stand trial and serve any sentence, if convicted Patient Identification A. The Joint Commission has implemented new patient identification requirements to meet safety goals (http://www.jointcommission.org/standards_information/npsgs.aspx). B. Use at least two patient identifiers. Ask the client to tell you his or her name and date of birth (DOB) whenever taking blood samples, administering medications, or administering blood products. C. The patient room number may not be used as a form of identification. Surgical Permit A. Consent to operate (surgical permit) must be obtained before any surgical procedure, however minor it might be. B. Legally, the surgical permit must be 1. Written 2. Obtained voluntarily 3. Explained to the client (i.e., informed consent must be obtained) C. Informed consent means the procedure and treatment or operation has been fully explained to the client, including 1. Possible complications, risks, and disfigurements 2. Removal of any organs or parts of the body 3. Benefits and expected results D. Surgery permits must be obtained as follows: 1. They must be witnessed by an authorized person, such as the health care provider or a nurse. 2. They protect the client against unsanctioned surgery, and they protect the health care provider and surgeon, hospital, and hospital staff against possible claims of unauthorized operations. 3. Adults and emancipated minors may sign their own operative permits if they are mentally competent. 4. Permission to operate on a minor child or an incompetent or unconscious adult must be obtained from a legally responsible parent or guardian. The person granting permission to operate on an adult who lacks capacity to understand information about the proposed 41 treatment (e.g., because of advanced Alzheimer disease or unconscious adult) must be identified in a Durable Power of Attorney or an Advance Health Directive. HESI Hint Often an NCLEX-RN question asks who should explain and describe a surgical procedure to the client, including both complications and the expected results of the procedure. The answer is the health care provider. Remember that it is the nurse’s responsibility to be sure that the operative permit is signed and is in the client’s medical record. It is not the nurse’s responsibility to explain the procedure to the client. The nurse must document that the client was given the information and agreed to it. Consent A. The law does not require written consent to perform medical treatment. 1. Treatment can be performed if the client has been fully informed about the procedure. 2. Treatment can be performed if the client voluntarily consents to the procedure. 3. If informed consent cannot be obtained (e.g., client is unconscious) and immediate treatment is required to save life or limb, the emergency laws can be applied. (See the subsequent section, Emergency Care.) B. Verbal or written consent 1. When verbal consent is obtained, a notation should be made. a. It describes in detail how and why verbal consent was obtained. b. It is placed in the client’s record or chart. c. It is witnessed and signed by two persons. 2. Verbal or written consent can be given by a. Alert, coherent, or otherwise competent adults b. A parent or legal guardian c. A person in loco parentis (a person standing in for a parent with a parent’s rights, duties, and responsibilities) in cases of minors or incompetent adults C. Consent of minors 1. Minors 14 years of age and older must agree to treatment along with their parents or guardians. 2. Emancipated minors can consent to treatment themselves. Be aware that the definition of an emancipated minor may change from state to state. Emergency Care A. Good Samaritan Act: Protects health care providers against malpractice claims for 42 care provided in emergency situations (e.g., the nurse gives aid at the scene to an automobile accident victim). B. A nurse is required to perform in a “reasonable and prudent manner.” HESI Hint Often NCLEX-RN questions address the Good Samaritan Act, which is the means of protecting a nurse when she or he is performing emergency care. 43 Prescriptions and Health Care Providers A. A nurse is required to obtain a prescription (order) to carry out medical procedures from a health care provider. B. Although verbal telephone prescriptions should be avoided, the nurse should follow the agency’s policy and procedures. Failure to follow such rules could be considered negligence. The Joint Commission requires that organizations implement a process for taking verbal or telephone orders that includes a read- back of critical values. The employee receiving the prescription should write the verbal order or critical value on the chart or record it in the computer and then read back the order or value to the health care provider. C. If a nurse questions a health care provider’s (e.g., physician, advanced practice RN, physician’s assistant, dentist) prescription because he or she believes that it is wrong (e.g., the wrong dosage was prescribed for a medication), the nurse should do the following: 1. Inform the health care provider. 2. Record that the health care provider was informed and record the health care provider’s response to such information. 3. Inform the nursing supervisor. 4. Refuse to carry out the prescription. D. If the nurse believes that a health care provider’s prescription was made with poor judgment (e.g., the nurse believes the client does not need as many tranquilizers as the health care provider prescribed), the nurse should 1. Record that the health care provider was notified and that the prescription was questioned 2. Carry out the prescription because nursing judgment cannot be substituted for a health care provider’s judgment E. If a nurse is asked to perform a task for which he or she has not been prepared educationally (e.g., obtain a urine specimen from a premature infant by needle aspiration of the bladder) or does not have the necessary experience (e.g., a nurse who has never worked in labor and delivery is asked to perform a vaginal examination and determine cervical dilation), the nurse should do the following: 1. Inform the health care provider that he or she does not have the education or experience necessary to carry out the prescription. 2. Refuse to carry out the prescription. HESI Hint If the nurse carries out a health care provider’s prescription for which he or she is not prepared and does not inform the health care provider of his or her lack of preparation, the nurse is solely liable for any damages. If the nurse informs the health care provider of his or her lack of preparation in carrying out a prescription and carries out the prescription anyway, the nurse and the health care provider are liable for any damages. 44 F. The nurse cannot, without a health care provider’s prescription, alter the amount of drug given to a client. For example, if a health care provider has prescribed pain medication in a certain amount and the client’s pain is not, in the nurse’s judgment, severe enough to warrant the dosage prescribed, the nurse cannot reduce the amount without first checking with the health care provider. Remember, nursing judgment cannot be substituted for medical judgment. Restraints A. Clients may be restrained only under the following circumstances: 1. In an emergency 2. For a limited time 3. For the purpose of protecting the client from injury or from harm B. Nursing responsibilities with regard to restraints 1. The nurse must notify the health care provider immediately that the client has been restrained. 2. It is required and imperative that the nurse accurately document the facts and the client’s behavior leading to restraint. C. When restraining a client, the nurse should do the following: 1. Use restraints (physical or chemical) after exhausting all reasonable alternatives. 2. Apply the restraints correctly and in accordance with facility policies and procedures. 3. Check frequently to see that the restraints do not impair circulation or cause pressure sores or other injuries. 4. Allow for nutrition, hydration, and stimulation at frequent intervals. 5. Remove restraints as soon as possible. 6. Document the need for and application, monitoring, and removal of restraints. 7. Never leave a restrained person alone. HESI Hint Restraints of any kind may constitute false imprisonment. Freedom from unlawful restraint is a basic human right and is protected by law. Use of restraints must fall within guidelines specified by state law and hospital policy. Health Insurance Portability and Accountability Act of 1996 A. Congress passed the Health Insurance Portability and Accountability Act of 1996 (HIPAA) to create a national patient-record privacy standard. B. HIPAA privacy rules pertain to health care providers, health plans, and health clearinghouses and their business partners who engage in computer-to-computer transmission of health care claims, payment and remittance, benefit information, and health plan eligibility information, and who disclose personal health 45 information that specifically identifies an individual and is transmitted electronically, in writing, or verbally. C. Patient privacy rights are of key importance. Patients must provide written approval of the disclosure of any of their health information for almost any purpose. Health care providers must offer specific information to patients that explains how their personal health information will be used. Patients must have access to their medical records, and they can receive copies of them and request that changes be made if they identify inaccuracies. D. Health care providers who do not comply with HIPAA regulations or make unauthorized disclosures risk civil and criminal liability. E. For further information, use this link to the Department of Health and Human Services (DHHS) website, Office of Civil Rights, which contains frequently asked questions about HIPAA standards for privacy of individually identifiable health information: http://aspe.hhs.gov/admnsimp/final/pvcguide1.htm. 46 Review of Legal Aspects of Nursing 1. What types of procedures should be assigned to professional nurses? 2. Negligence is measured by reasonableness. What question might the nurse ask when determining such reasonableness? 3. List the four elements that are necessary to prove malpractice (professional negligence). 4. Define an intentional tort and give one example. 5. Differentiate between voluntary and involuntary admission. 6. List five activities a person who is declared incompetent cannot perform. 7. Name three legal requirements of a surgical permit. 8. Who may give consent for medical treatment? 9. What law protects the nurse who provides care or gives aid in an emergency situation? 10. What actions should the nurse take if the nurse questions a health care provider’s prescription—that is, believes the prescription is wrong? 11. Describe the nurse’s legal responsibility when asked to perform a task for which he or she is unprepared. 12. Describe nursing care of the restrained client. 13. Describe six patient rights guaranteed under HIPAA regulations that nurses must be aware of in practice. See Answer Key at the end of this text for suggested responses. 47 Leadership and Management A. Nurses act in both leadership and management roles. B. A leader is an individual who influences people to accomplish goals. C. A manager is an individual who works to accomplish the goals of the organization. D. A nurse manager acts to achieve the goals of safe, effective client care within the overall goals of a health care facility. Skills of the Nurse Manager Refer to Box 2.1. HESI Hint Motivation comes from within an individual. A nurse leader can provide an environment that will promote motivation through positive feedback, respect, and seeking input. Look for responses that demonstrate these behaviors. HESI Hint NCLEX-RN questions often include examples of nursing interventions that do or do not demonstrate the skills and characteristics of the nurse manager. Box 2.1 Skills and Characteristics of the Nurse Manager 48 LPN, Licensed practical nurse; RN, registered nurse; VN, vocational nurse. 49 Maintaining a Safe Work Environment A. Nurse managers are responsible for addressing 1. Workplace violence 2. Nursing staff substance abuse 3. Incivility and bullying a. Incivility and bullying includes actions taken and not taken. b. Example: Refusing to share pertinent information with another nurse regarding a client’s stats, thus jeopardizing the client’s safety. c. Example: Deliberately withholding information pertinent to the client’s well-being and safety, such as not telling a nurse that the HCP requested that a client’s medication should be held. 4. Inappropriate use of social media 5. Inappropriate nurse-client relationships B. Nurse leaders and staff members must provide systems to educate staff for heightened awareness of common behaviors associated with the items mentioned above, as well as providing mechanisms for reporting. 1. In dire cases, nurse managers must implement remediation and training to protect clients from these egregious behaviors that infringe on patients’ safety. 2. The Joint Commission, the American Nurses Association, and other entities are addressing the dangerous impact of incivility and bullying on patients. 50 Communication Skills A. Assertive communication 1. Includes clearly defined goals and expectations 2. Includes verbal and nonverbal messages that are congruent 3. Is critical to the directing aspect of management HESI Hint Assertive communication starts with “I need” rather than with “You must.” Organizational Skills A. Organizational skills encompass management of 1. People 2. Time 3. Supplies Delegation Skills A. The authority, accountability, and responsibility of the RN are based on the state Nurse Practice Act, standards of professional practice, the policies of the health care organization, and ethical-legal models of behavior. B. Definitions 1. Delegation is the process by which duties, tasks, and coordination of care are transferred to ancillary and assistive personnel, as well as other nurses. The nurse maintains responsibility and accountability for the quality and quantity of supervision in regard to delegated assignments. 2. Responsibility is the obligation to complete a task. 3. Authority is the right to act or command the actions of others. 4. Accountability is the ability and willingness to assume responsibility for actions and related consequences. C. The nurse transfers responsibility and authority for the completion of delegated tasks, but the nurse retains accountability for the delegation process. This accountability involves ensuring that the five rights of delegation have been achieved. D. The five rights of delegation (as defined by the National Council of State Boards of Nursing) 1. Right task: Is this a task that can be delegated by a nurse? 2. Right circumstance: Considering the setting and available resources, should delegation take place? 3. Right person: Is the task being delegated by the right person to the 51 right individual? 4. Right direction/communication: Is the nurse providing a clear, concise description of the task, including limits and expectations? 5. Right supervision: Once the task has been delegated, is appropriate supervision maintained? HESI Hint Delegating to the right person requires that the nurse be aware of the qualifications of the delegatee: appropriate education, training, skills, experience, and demonstrated and documented competence. HESI Hint Remember the nursing process: Assessments, analysis, diagnosis, planning, and evaluation (any activity requiring nursing judgment) may not be delegated to UAP. Delegated activities fall within the implementation phase of the nursing process. HESI Hint UAP generally do not perform invasive or sterile procedures. HESI Hint RNs should give clear instructions—be specific, communicating the objectives of the delegated task and the expected results. Remember that even though a task may be delegated under law and facility policy, you, the nurse, are responsible for its outcome. Supervision Skills A. Direction/guidance 1. Clear, concise, specific directions 2. Expected outcome 3. Time frame 4. Limitations 5. Verification of assignment B. Evaluation/monitoring 1. Frequent check-in 2. Open communication lines 3. Achievement of outcome C. Follow-up 1. Communication of evaluation findings to the LPN or UAP and other 52 appropriate personnel 2. Need for teaching or guidance HESI Hint The RN is accountable for adhering to the three basic aspects of supervision when delegating to other health care personnel, such as LPNs, graduate nurses, inexperienced nurses, student nurses, and UAP. Critical Thinking Skills A. Nurses are accustomed to using the nursing process as the model for problem solving in client care situations. B. Use this model to think critically in leadership and management situations. 1. Assessment: What are the needs or problems? 2. Analysis: What has the highest priority? 3. Planning: a. What outcomes and goals must be accomplished? b. What are the available resources? 1. Nursing staff 2. Interdisciplinary team members 3. Time 4. Equipment and supplies 5. Space (client rooms, home environment, etc.) 4. Implementation a. Communicating expectations b. Is documentation complete? 5. Evaluation a. Were the desired outcomes achieved? b. Was safe, effective care provided? HESI Hint Priorities often center on which client the nurse should assess first. Ask yourself the following questions: Which client is the most critically ill and unstable? Which client is most likely to experience a significant change in condition? Which client requires assessment by an RN? HESI Hint The nurse manager must analyze all the desired outcomes involved when assigning rooms for clients or assigning client care responsibilities. For example, a client with an infection should not be assigned to share a room with a surgical or immunocompromised client. A 53 nurse’s client care management should be based on the nurse’s abilities, the individual client’s needs, and the needs of the entire group of assigned clients. Safety and infection control are high priorities. Skills Needed by Change Agents A. Problem solving B. Decision making C. Interpersonal relationships (Table 2.1) HESI Hint Change causes anxiety. An effective nurse change agent uses problem-solving skills to recognize factors such as anxiety that contribute to resistance to change and uses decision making and interpersonal skills to overcome that resistance. Interventions that demonstrate these skills include seeking input, showing respect, valuing opinions, and building trust. Table 2.1 Nurse Leaders and Managers as Change Agents Lewin’s Change Theory Nurses Act as Change Agents, Which Involves the Following: Unfreezing Initiation of a change Moving Motivation toward a change Refreezing Implementation of a change Nurse Leaders and Managers as Collaborators A. Interprofessional health care teams require 1. Shared goals, commitment, and accountability 2. Open and clear communication 3. Respect for the expertise of all team members B. Critical pathways 1. Are interprofessional plans of care 2. Are used for diagnoses and care that can be standardized 3. Are guides to track client progress 4. Do not replace individualized care C. Case management 1. Coordinates care provided by an interprofessional team 2. Manages resources effectively 3. Uses critical pathways to organize care D. Quality assurance 1. Involves continuous quality improvement/total quality management 2. Is an organized approach to the improvement of 54 a. Outcome achievement b. Quality of care provided HESI Hint The Interprofessional Education Collaborative Expert Panel (IPEC) recommended development of four core competencies for interprofessional collaborative practice. Those competency domains among health care professionals include 1) values/ethics for interprofessional practice; 2) roles/responsibilities; 3) interprofessional communication; and 4) teams and teamwork. 55 Review of Leadership and Management 1. By what authority may RNs delegate nursing care to others? 2. A UAP may perform care that falls within which component of the nursing process? 3. Which type of communication is necessary to implement a democratic leadership style? 4. What are the five rights of delegation? 5. Which of the following tasks can be delegated to a UAP? A. Inserting a Foley catheter B. Measuring and recording the client’s output through a Foley catheter C. Teaching a client how to care for a catheter after discharge D. Assessing for symptoms of a urinary tract infection 6. What are the essential steps of effective supervision? 7. Which of the following is an example of assertive communication? A. “You need to improve the way you spend your time so that all of your care gets performed.” B. “I’ve noticed that many of your clients did not get their care today.” 8. What are common signs of substance? 9. Describe common characteristics of incivility/bullying among nurses. See Answer Key at the end of this text for suggested responses. 56 Disaster Nursing A. The role of the nurse takes place at all three levels of disaster management: 1. Disaster preparedness 2. Disaster response 3. Disaster recovery B. To achieve effective disaster management, 1. Organization is the key. 2. All personnel must be trained. 3. All personnel must know their roles. Levels of Prevention in Disaster Management A. Primary prevention 1. Participate in the development of a disaster plan. 2. Train rescue workers in triage and basic first aid. 3. Educate personnel about shelter management. 4. Educate the public about the disaster plan and personal preparation for disaster. B. Secondary prevention 1. Triage 2. Treatment of injuries 3. Treatment of other conditions, including mental health 4. Shelter supervision C. Tertiary prevention 1. Follow-up care for injuries 2. Follow-up care for psychological problems 3. Recovery assistance 4. Prevention of future disasters and their consequences Triage A. A French word meaning “to sort or categorize” B. Goal: Maximize the number of survivors by sorting the injured according to treatable and untreatable victims (Table 2.2). C. Primary criteria used: 1. Potential for survival 2. Availability of resources Nursing Interventions and Roles in Triage A. Triage duties using a systematic approach such as the simple triage and rapid treatment (START) method (Fig. 2.1) 57 B. Treatment of injuries 1. Render first aid for injuries. 2. Provide additional treatment as needed in definitive care areas. C. Treatment of other conditions, including mental health 1. Determine health needs other than injury. 2. Refer for medical treatment as required. 3. Provide treatment for other conditions based on medically approved protocols. Shelter Supervision A. Coordinate activities of shelter workers. B. Oversee records of victims admitted and discharged from the shelter. C. Promote effective interpersonal and group interactions among victims in the shelter. D. Promote independence and involvement of victims housed in the shelter. Bioterrorism A. Learn the symptoms of illnesses that are associated with exposure to likely biologic and chemical agents. B. Understand that the symptoms could appear days or weeks after exposure. C. Nurses and other health care providers would be the first responders when victims seek medical evaluation after symptoms manifest. First responders are critical in identifying an outbreak, determining the cause of the outbreak, identifying risk factors, and implementing measures to control and minimize the outbreak. D. Possible agents (Table 2.3) 1. Biologic agents: a. Anthrax b. Pneumonic plague c. Botulism d. Smallpox e. Inhalation tularemia f. Viral hemorrhagic fever 2. Chemical agents: a. Biotoxin agents: ricin b. Nerve agents: sarin 3. Radiation HESI Hint In a disaster the nurse must consider both the individual and the community. Table 2.2 Triage Color Code System 58 Triage Color Code System Nursing Assessment A. Community-disaster risk assessment B. Measures to mitigate disaster effect C. Exposure symptom identification Nursing Plans and Interventions A. Participate in development of a disaster plan. B. Educate the public on the disaster plan and personal preparation for disaster. C. Train rescue workers in triage and basic first aid. D. Educate personnel on shelter management. E. Practice triage. F. Treat injuries and illness. G. Treat other conditions, including mental health. H. Supervise shelters. I. Arrange for follow-up care for injuries. J. Arrange for follow-up care for psychological problems. K. Assist in recovery. L. Work to prevent future disasters and their consequences. 59 Ebola A. The risk of contracting Ebola in the United States is very low, even when working with West African communities in the United States. 60 FIG. 2.1 Simple Triage and Rapid Treatment (START) Method for Triage. Table 2.3 Signs, Symptoms, and Treatments of Biologic and Chemical Agents and Radiation 61 62 63 Note: For further information, go to https://emergency.cdc.gov/agent/agentlist-category.asp. ARS, Acute radiation syndrome; IM, intramuscular; IV, intravenous. B. Ebola is spread by direct contact with blood or body fluids of a person who is ill with Ebola, has died from Ebola, has had contact with objects such as needles that have been contaminated with the virus. 1. It is also possible that Ebola virus can be transmitted through the semen of men who have survived infection. C. The Centers for Disease Control (CDC) implemented entry screening at five U.S. airports for travelers arriving from Guinea, Liberia, and Sierra Leone, as well as other African countries. The CDC strongly recommends that travelers from these countries be actively monitored for symptoms by state or local health departments for 21 days after returning from any of these countries. D. People of West African descent are not at more risk than other Americans if they have not recently traveled to the region. Neither ethnic nor racial backgrounds have anything to do with becoming infected with the Ebola virus. E. Even if travelers were exposed, they are only contagious after they start to have symptoms (e.g., fever, severe headache, muscle pain, diarrhea, vomiting, and 64 unexplained bleeding). F. Symptoms: 1. Fever of greater than 38.6° C or 101.5° F 2. Severe headache 3. Muscle pain 4. Vomiting 5. Diarrhea 6. Abdominal pain 7. Unexplained hemorrhage G. Diagnosis 1. CDC recommends testing for all persons with onset of fever within 21 days of having a high-risk exposure. A high-risk exposure includes any of the following: a. Percutaneous or mucous membrane exposure or direct skin contact with body fluids of a person with a confirmed or suspected case of Ebola without appropriate personal protective equipment (PPE) b. Laboratory processing of body fluids of suspected or confirmed Ebola cases without appropriate PPE or standard biosafety precautions c. Participation in funeral rites or other direct exposure to human remains in the geographic area where the outbreak is occurring without appropriate PPE H. Nursing interventions 1. Obtain a thorough history, including recent travel from areas where the virus is present. 2. Monitor vital signs. 3. Place the client in strict isolation for 21 days using special precautions identified by the CDC and state. 4. Notify the CDC. I. Health care provider protection 1. Health care providers should wear gloves, gown (fluid resistant or impermeable), shoe covers, eye protection (goggles or face shield), and a facemask. 2. Additional PPE might be required in certain situations (e.g., copious amounts of blood, other body fluids, vomit, or feces present in the environment), including but not limited to double gloving, disposable shoe covers, and leg coverings. 3. Avoid aerosol-generating procedures. If performing these procedures, PPE should include respiratory protection (N95 filtering face piece respirator or higher), and the procedure should be performed in an airborne isolation room. 4. Diligent environmental cleaning, disinfection, and safe handling of potentially contaminated materials is paramount because blood, sweat, emesis, feces, and other body secretions represent potentially infectious materials. 65 Review of Disaster Nursing 1. List the three levels of disaster management. 2. List examples of the three levels of prevention in disaster management. 3. Define triage. 4. Identify three bioterrorism agents. 5. Identify three infection control measures for Ebola. 6. Identify the agency to notify when providing care for a client with a suspected diagnosis of Ebola virus. See Answer Key at the end of this text for suggested responses. For more review, go to http://evolve.elsevier.com/HESI/RN for HESI’s online study examinations. 66 Advanced Clinical Concepts 67 Respiratory Failure Acute Respiratory Distress Syndrome (ARDS) A. ARDS is a progressive disorder that leads to acute respiratory failure. ARDS causes an exchange of oxygen (O2) for carbon dioxide (CO2) in the lungs that is inadequate for O2 consumption and CO2 production within the body’s cells. The increased permeability of the alveolar membrane leads to fluid build-up in the alveoli interferes with the exchange of CO2 and O2 at the capillary beds. 1. Clients may be initially be treated for another illness or may present for treatment of ARDS in addition to another illness; the client may develop ARDS as a complication that usually involves mechanical ventilation. Because the manifestations of ARDS are often nonspecific, the diagnosis may initially be missed (Fig. 3.1). B. Causes of ARDS (American Lung Association) 1. Progressive symptoms of dyspnea and diminished arterial O2 saturation an increasing

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