Autonomy
Freedom to make decisions that affect self and to take action for self; is self-governing; includes four basic elements: Respect for others, Ability to determine personal goals, Complete understanding of choice, Freedom to implement plan or choice
The four basic elements of Autonomy
-Respect for others
-Ability to determine personal goals
-Complete understanding of choice
-Freedom to implement plan or choice
Nonmaleficence
To do no harm, either intentional or unintentional
Beneficence
To act in the best interest of others; to contribute to the well being of others; includes client advocacy; has three major components: To promote good, prevent harm or evil, and remove harm or evil
Three major components of Beneficence
1. Promote good
2. Prevent harm and evil
3. Remove harm or evil
Justice
Fair, equitable, and appropriate treatment; resources are distributed equally to all.
Fidelity
Remaining faithful to ethical principles and ANA Code of Ethics for Nurses; keeping commitments and promises
Veracity
To tell the truth, which has an added benefit of promoting trust between client an nurse.
Accountability
Being answerable to self and other for one's actions; incudes the concept of responsibility, a specific type of accountability for duties performed within a specific role.
Ethics
A branch of philosophy that seeks to utilize a body of knowledge to determine what is right or wrong
ANA Code of Ethics for Nurses
A. Developed by American Nurses Association (ANA)to provide guidance to nurses and protection for clients and families.
B. Guidelines delineate values and standards for professional practice.
C. Key elements include compassion and respect, commitment, advocacy, and accountability when working with clients, families, and communities, as well as responsibility to the profession.
Definition:
Morals
Personal philosophy based on what is right or wrong, good or bad.
Morals:
A. Applying ethics is a practical way of putting morals into practice; it aids decision making and problem solving.
B. Ethical considerations define morals essential to practice.
Definition:
Values
Are personally and professionally developed and based on philosophy and principles
Values
-Define actions & reactions to issues and problems
-Provide guidance in determining actions; socialization and experiences help mold personal value system.
A client is referred to a surgeon by the general practitioner. After meeting the surgeon, the client decides to find a different surgeon to continue treatment. The nurse supports the client's action, utilizing which ethical principle?
1. Beneficence
2.Veracity
3. Autonomy
4. Privacy
3. Autonomy
A nurse forgets to administer a client's diuretic and the client experiences an episode of pulmonary edema. The charge nurse would consider the medication error to constitute negligence because the situation contains which element?
1. Purposeful failure to perform a health care procedure.
2. Unintentional failure to perform a health care procedure.
3.Act of substituting a different medication for the one ordered.
4. Failure to follow a direct order by a physician.
2. Unintentional failure to perform a health care procedure.
A client asks why a diagnostic test has been ordered and the nurse replies, "I'm unsure but will find out for you." When the nurse later returns an provides an explanation, the nurse is acting under which principle?
1. Nonmaleficence
2. Veracity
3. Beneficence
4. Fidelity
4. Fidelity
An individual has a seizure while walking down the street. During the seizure, a nurse from a physician's office is noticed driving past without stopping to assist. The individual sues the nurse for negligence but fails to win a judgment for which reason?
1. The nurse had no duty to the individual.
2. The nurse did what most nurses would do in the same circumstance.
3. The did not cause the client's injuries.
4. The nurse was off-duty at the time.
1. The nurse had no duty to the individual
An adult female ambulatory care client receiving an oral anticoagulant is given aspirin for a headache while visiting a neighbor, who is a nurse. The client subsequently has a bleeding episode because of a drug interaction. The legal nurse consultant interprets that which necessary elements of malpractice are missing from this case? Select all that apply.
1. Breech of duty
2. Duty owed
3. Injury experienced
4. Causation between nurse's action and injury
5. Intent to cause harm or injury
2 & 5
2. Duty owed
5. Intent to cause harm or injury
A client with cancer has decided to discontinue further treatment. Although the nurse would like the client to continue treatment, the nurse recognizes the client is competent and supports the client's decision using which ethical principle?
1. Justice
2. Fidelity
3. Autonomy
4. Confidentiality
3. Autonomy
The health care provider orders a medication in a dose that is considered toxic. The nurse administers the medication to the client, who later suffers a cardiac arrest and dies. What consequence can the nurse expect from this situation? Select all that apply.
1. The health care provider can be charged w/negligence, being the person who ordered the dose.
2. As the employing agency, only the hospital can be charged w/negligence.
3. The nurse and physician may be terminated from employment to prevent a charge of negligence to the hospital.
4. Negligence will not be charged, as this event could happen to any reasonable person.
5. The nurse can be charged w/negligence for administering the toxic dose.
1 & 5
1. The health care provider can be charged w/negligence, being the person who ordered the dose.
5. The nurse can be charged w/negligence for administering the toxic dose.
A nurse & teacher are discussing legal issues related to the practice of their professions. The teacher asks what the functions are of the Nurse Practice Act (NPA) in that state. The nurse would include which thoughts in a response? Select all that apply.
1. Accredit schools of nursing
2. Enforce ethical standards of behavior
3. Protect the public
4. Define the scope of nursing practice
5. Determine liability insurance rates
3 & 4
3. Protect the public
4. Define the scope of nursing practice
A staff nurse concerned about maintaining client confidentiality would take which action while carrying out assigned duties?
1. Read the records of clients not assigned to the nurse to become more familiar with disease processes.
2. Share information about a client with nurses from the unit to which the client may eventually be transferred.
3. Allow the client's family to review the medical record to obtain answers to their questions.
4. Share information about the client w/those involved in planning nursing care.
4. Share information about the client w/those involved in planning nursing care.
The nurse working in an acute care environment would utilize which strategies to reduce the risk of malpractice litigation? Select all that apply.
1. Discuss any errors w/the client and family in detail.
2. Keep incident reports on file
3. Maintain expertise in practice
4. Offer opinions to client when the situation warrants
5. Report unsafe staffing levels to supervisor
3 & 5
3. Maintain expertise in practice
5. Report unsafe staffing levels to supervisor
Preoperative phase
1. Preoperative phase begins w/decision to have surgery & ends w/ transport of client to operating room (OR); general nursing activities include client identification, client assessment, identifying potential or actual health problems, and beginning teaching about postoperative self care
Intraoperative
Intraoperative phase (surgical period) begins when client transferred to operating table & ends w/admission to postanesthesia care unit (PACU); general nursing activities include
a. Preparing client for induction of anesthesia
b. Maintaining homeostasis & asepsis throughout procedure
c. Assisting surgeon & team as needed by providing an aseptic, hazard-free environment & necessary supplies in a timely manner
Postoperative phase
begins w/client's admission to PACU & ends w/ a follow-up evaluation in either a clinical setting or home; general nursing activities include
a. Assessing for physical adaptation following aesthesia & surgical intervention
b. Assisting in orienting client back to consciousness
c. Providing continuity of information between nursing units about client progress & adaptation following procedure
SUMMARY OF NURSING RESPONSIBILITES DURING PREOPERATIVE PERIOD
1. INTERVIEW: current health status, allergies, medication currently taking, previous surgical experiences, mental status, understanding of surgical, procedure & anesthesia, smoking habit, alcohol & drug use, coping strategies, social resources, and cultural considerations
SUMMARY OF NURSING RESPONSIBILITES DURING PREOPERATIVE PERIOD
2. Arranging for preadmission testing, consultations & education about recovering from surgery & anesthesia
a. Scheduling appropriate ordered laboratory tests, electrocardiogram, x-rays
b. Ensuring reports are available on chart
c. Reporting to surgeon or anesthesiologist any pertinent abnormalities
d. Asking client if arrangements for autologous or directed blood donation (family/friends) have been made; if so, attach pertinent lab requisitions
SUMMARY OF NURSING RESPONSIBILITES DURING PREOPERATIVE PERIOD
Day of surgery; after appropriate identification of client, verify completion of paperwork & secure valuables; if procedures is being performed on an outpatient basis, verify transportation home; then complete these activities:
a. Determine client's cognitive understanding of procedure & obtain signed informed consent form; ensure consent is obtained before administering premedication w/sedative effects; some agencies have client mark limb that will be operated on, if appropriate.
b. Perform a physical assessment & record vital signs
c. Implement preoperative teaching for postoperative care
d. Physical preparation: may include skin preparation, antiembolism stockings, catheterization, & starting an intravenous (IV) infusion
e. Complete preoperative checklist; note client status & pertinent recent lab results; assist client
f. If client refuses to remove wedding band, tape in place & notify operating room personnel; leave eyeglasses in place if consistent w/hospital policy; keep hearing aid(s) in place; remove dentures
SUMMARY OF NURSING RESPONSIBILITES DURING INTRAOPERATIVE PERIOD
1. Administer IV infusions & medications as needed
2. Provide safe, effective care
a. Position client to ensure functional alignment & exposure of surgical site
b. apply grounding device
c. Provide emotional & physical support if awake
d. Account for all equipment & supplies
e. Maintain aseptic environment
f. Perform physiologic monitoring
g. Assess fluid loss or gain
h. Monitor cardiac, respiratory, & neurological status
i. Monitor client response to preoperative medications
Nursing roles during surgery
a. Circulating nurse assists scrub nurses & surgeons; sterile scrubbing & gloving not necessary
b. Scrub nurses assist surgeons; maintain sterile gowns, gloves, shoe covers; wear eye protection & caps
c. Circulating nurse and scrub nurse account for used sponges, needles & instruments during case
The nurse has taught the client to perform deep-breathing & coughing exercises. The nurse determines that the client needs more teaching when the client is observed doing what activity? Select all that apply
1. Sitting upright before deep breathing & coughing
2. Taking deep breaths before attempting to cough
3. Placing both hands vertically & lightly on either side of the incision
4. Using a pillow for splinting during coughing
5. Use gentle coughing efforts that sound like clearing the throat
3. Placing both hands vertically & lightly on either side of the incision
5. Use gentle coughing efforts that sound like clearing the throat
A toddler who has not had surgery before is being prepared for a surgical procedure. The child's mother expresses concern about the child's psychological adaptation to surgery. While planning for postoperative care, the nurse recognizes that the child is likely to have which greatest concern based on age?
1. Anticipated pain
2. Body image change
3. Communication difficulties
4. Separation from parents
4. Separation from parents
A female client is being prepared for surgery. When the nurse asks the client to remove her wedding ring, the client refuses. What would be an appropriate response by the nurse? Select all that apply
1. Encourage the client to use soapy water to remove the ring it is tight
2 Explain that the hospital cannot be responsible for jewelry worn during surgery
3. Notify the surgeon's office that the surgeon must see the client in the preoperative holding area
4. Tape the ring in place before the client is transported to the preoperative holding area
5. Make a notation on the preoperative checklist that the ring is in place.
4. Tape the ring in place before the client is transported to the preoperative holding area
5. Make a notation on the preoperative checklist that the ring is in place
The nurse is caring for clients in the preanesthesia room. The nurse notes that one client, who is an older adult, has an increased surgical risk based on which factor?
1. Decreased kidney function leading to potential fluid & electrolyte imbalances
2. Increased hunger sensations leading to post-operative complications from hyperacidity
3. Inability to comprehend the seriousness of surgical interventions, leading to noncompliance
4. Poor cardiovascular status leading to decreased pain sensation
1. Decreased kidney function leading to potential fluid & electrolyte imbalances
A client who takes numerous medications is being prepared for surgery. The nurse reviewing the client medication list is most concerned about which medication that increases surgical risk?
1. An antidysrhythmic
2. A sedative-hypnotic
3. A corticosteroid
4. An oral hypoglycemic
3. A corticosteroid
The following clients are in the preanesthesia holding room. The nurse determines that the client undergoing which procedure is having the most serious or major surgery?
1. Tonsillectomy
2. Biopsy of breast
3. Arthroscopy
4. Nephrectomy
4. Nephrectomy
Rationale:
A nephrectomy is a major type of surgery because the kidney is a major vital organ, loss of blood is likely to be greater than w/the other mentioned surgeries & there is greater likelihood of complications. A tonsillectomy, biopsy, & arthroscopy are all examples of minor surgery because they do not involve a high degree of risk.
Each of the following clients will be having surgery this morning. The nurse concludes that which client is most likely to be a higher overall surgical risk?
1. A client who has dementia
2. A client who is culturally different than the medical personnel
3. A client who has a mild anxiety
4. A client who has had previous surgeries
1. A client who has dementia
Rationale:
Dementia affects the person's understanding of the proposed surgery & ability to cooperate w/the perioperative care; it also affects the medications given. Cultural differences should not pose a risk unless the client's belief are contrary to the proposed measures. Mild anxiety will not create a risk. Previous surgeries do not increase risk & could possibly be helpful for the client, who can then draw on previous experiences.
A nurse is preparing a client for surgery. Prior to completing the skin preparation, the nurse assess the surgical site for which finding?
1. Presence of pustules or abrasions
2. Absence of hair growth
3. Presence of lanugo
4. Absence of pulsation
1. Presence of pustules or abrasions
Rationale:
Abrasions, pustules, or other skin conditions have to be assessed & documented because they can interfere w/wound healing, or increased the risk of infection. Lack of hair growth or presence of lanugo or fine hair will not interfere w/the skin preparation. Pulsation is not always visible or available to assess, depending upon the part the body being operated on.
When the nurse asks the client about previous surgeries, the client asks why this information is important. The nurse responds that previous surgeries can have which effect on the client?
1. Interfere w/the absorption of anesthetic agents.
2. Affect the ability of the client to comprehend the instructions prior to surgery.
3. Affect the central nervous system
4. Alter the client's responses to surgery
4. Alter the client's responses to surgery
Rationale:
Previous surgeries can affect the physiological or psychological responses of the client to the planned surgery. Previous surgeries can reveal possible difficulties or problems w/certain anesthetics, hinder comprehension of instructions, or affect the central nervous system.
A male client who arrives for an outpatient surgical procedure has the odor of alcohol on his breath. Before completing the preoperative assessment, the nurse reports this finding to the surgeon, after drawing which conclusion about the significance of this finding?
1. Alcohol can affect the client's response to anesthesia & surgery
2. Alcohol can increase the risk for respiratory complications
3. Alcohol can decrease the effectiveness of preoperative sedatives or hypnotics
4. Physiological & psychological responses are slowed down by recent alcohol intake.
1. Alcohol can affect the client's response to anesthesia & surgery.
Rationale:
Alcohol affects the central nervous system & therefore the client's response to surgery & the anesthetic itself. Smoking, not alcohol (in small amounts), poses respiratory risks. Alcohol could have an addictive or synergistic effect w/any preoperative sedatives or hypnotics, because both depress the central nervous system. Past & recent intake of alcohol can impact responses, which can be either slowed down or escalated.
When the staff nurse asks questions about the preoperative client's vision & hearing, a family member asks the nurse why these questions are important. What information should the nurse provide as the primary reason for seeking this information?
1. "This will help us determine the need for additional resources after discharge."
2. This will help assess the risk of accidents in the home after surgery, which could affect the surgical outcome."
3."This helps identify any unanticipated needs prior to beginning the surgery."
4. "This will help us to individualize how we provide preoperative and postoperative teaching."
4. "This will help us to individualize how we provide preoperative and postoperative teaching."
Rationale: The ability of the client to see & hear could affect the preoperative & postoperative teaching methods used. The need for referrals for post-discharge resources depends not only on the client's vision & hearing, but also on family supports & the client's physical & mental status. Vision & hearing impairments could interfere w/ safety post-discharge, but this is not a primary reason for the assessments at this time. UNANTICIPATED NEEDS is a very general term that can be applied not just to vision & hearing but also to any area of client functioning.
A client is admitted for surgery. During the preoperative assessment, the nurse learns the client was taking warfarin sodium (Coumadin) but stopped it a few days ago per surgeon instructions. The nurse would include assessing for which specific problem when developing the postoperative plan of care?
1. Delirium tremens
2. Respiratory depression
3. Bleeding or oozing at the surgical wound site
4. Hypovolemia
3. Bleeding or oozing at the surgical wound site
Rationale: Anticoagulants inhibit clotting of the blood, putting the client at increased risk for bleeding postoperatively. If the client was abusing alcohol, the nurse would need to assess for onset of delirium tremens caused by alcohol withdrawal. Respiratory compromise might occur if the client takes sedatives or hypnotics. Hypovolemia is a general risk in the intraoperative and post operative period, but this risk would be heightened if the client is taking diuretics.
While planning postoperative care for an obese client prior to surgery, the nurse would develop which nursing diagnosis specific to the effect obesity has on postsurgical recovery?
1. Risk for Ineffective Tissue Perfusion (cardiopulmonary)
2. Excess fluid volume
3. Risk for Impaired skin integrity (Pressure Ulcer)
4. Ineffective Thermoregulation
1. Risk for Ineffective Tissue Perfusion (cardiopulmonary)
Rationale: Wound & cardiovascular complications are more common among clients who are obese. The heart is stressed from its workload & the added stress of surgery could place the client at risk. The client has no risk for excess fluid volume. Pressure ulcers occur more frequently in emaciated clients than in obese clients because of pressure over bony prominences. The obese client has no problem with thermoregulaion.
The postsurgical unit nurse is implementing measures to prevent thrombophlebitis. Which measure would be the priority action by the nurse?
1. Apply ordered pneumatic compression boots.
2. Reinforce importance of smoking cessation.
3. Assess the legs w/each set of vital signs
4. Teach the client to report Homans' sign.
1. Apply ordered pneumatic compression boots.
Rational: Pneumatic compression boos facilitate venous return from the lower extremities by alternately inflating & deflating. Smoking can contribute to cardiovascular events, but cessation will not necessarily lessen the chance of thrombophlebitis in immediate postsurgical period. Assessment of the leg will help w/detection but not prevention thrombophlebitis. Homans' sign is pain on dorsiflexion of the leg, and this assessment is a means of detection but not prevention.
A client has been admitted for surgery for resection of nerve roots. The client, observing the written comment that the surgery is palliative, asks what this means. The nurse would offer which explanation?
1. The surgery schedule is overbooked, so the client's surgery could be delayed.
2. The surgeon is against performing the surgery
3. The exact surgical procedure has not been decided
4. The procedure will be done to relieve pain, but will not cure the problem.
4. The procedure will be done to relieve pain, but will not cure the problem.
Rationale:
A surgical procedure that relieves symptoms of disease or pain but does not cure is described as palliative.
The physician progress note indicated a plan to let a client's wound heal by tertiary intention. The nurse concludes that healing has occurred after making which observation of the wound?
1. The wound is smaller but irregular
2. Very little scarring has occurred
3. Tissue loss prevents the edges from approximating.
4. A wide scar is present over the area of wound closure.
4. A wide scar is present over the area of wound closure.
Rationale:
A wide scar occurs in tertiary intention because the edges are not approximated & they regenerate via granulation. A wound that is smaller but irregular is consistent w/a wound that has healed by secondary intention. Tissue loss that prevents edges from approximating is consistent w/ a wound that is healing by secondary intention.
The nurse assesses the wound of a postoperative client to have moderate drainage with a greenish tinge. The nurse should take which priority action next?
1. Document the expected findings
2. Check for bleeding at the base of the wound
3. Take the pulse an blood pressure, and compare w/previous readings
4. Note the latest temperature & WBC count.
4. Note the latest temperature & WBC count.
Rationale: Purulent drainage, which often indicates wound infection, is make up of tissue debris, WBC's & bacteria and can have different colors, depending upon the type of bacteria. The next action by the nurse would be to gather additional data that could indicate infection, such as elevated temperature & WBC count.
A client is scheduled for surgery & has been placed on NPO status. The client reports thirst & hunger and asks for breakfast. The nurse explains that NPO status has which purpose?
1. To make anesthesia induction easier
2. To avoid the risk of aspiration
3. To prevent excessive bleeding
4. To allow for more rapid wound healing
2. To avoid the risk of aspiration
Rationale:
By keeping stomach empty during surgery, the risk of vomiting & aspiration is decreased. NPO status does not make anesthesia induction easier, prevent excessive bleeding, or allow for more rapid wound healing.
The nurse is teaching a client about wound care in preparation for discharge. How should the nurse evaluate the effectiveness of homecare teaching on wound care? Select all that apply
1. Give a paper & pencil quiz
2. Have the caregiver or client demonstrate the procedure
3. Have the client or caregiver explain the procedure
4. Have the client or caregiver critique a video on the video
5. Ask the client detailed questions while demonstrating the procedure.
2. Have the caregiver or client demonstrate the procedure
3. Have the client or caregiver explain the procedure
Rationale:
Return demonstration is the best way to evaluate teaching of a procedure. Ideally, the teaching is done over a few days & is then evaluated. Having the client explain the procedure is also appropriate, because it indicates that the client has the necessary knowledge to perform the procedure.
A 78 YO client w/chronic obstructive pulmonary disease (COPD) has had abdominal surgery, and suddenly feels something "let go" in the incision underneath the dressing when coughing. What are the nurse's immediate actions? Select all that apply
1. Have someone notify the physician
2. Open the dressing and view the problem
3. Apply pressure over the site
4. Use a sterile dressing and sterile saline to keep the open incision moist.
5. Sit the client upright in bed
1. Have someone notify the physician
2. Open the dressing and view the problem
Rationale:
The nurse should someone else notify the doctor so the nurse can stay w/the patient. The symptoms are of possible dehiscence & evisceration; the nurse needs to assess the problem before taking quick follow-up action. A sterile dressing & sterile normal saline are used to maintain a moist environment until the client goes back to surgery. Applying pressure over the wound will not return the contents into the abdominal cavity if they have eviscerated & pressure could decrease blood flow, causing tissue hypoxia or necrosis or tissue hypoxia if applied for too long. The client should be placed in low Fowler's position w/the knees slightly elevated to reduce tension on the abdomen.