Management of Care – (9)
Advance Directives/Self-Determination/Life Planning – (1)
Professional Responsibilities: Client Teaching About Do-Not-Resuscitate Orders
(Active Learning Template – Basic Concept, RM Leadership 7.0 Chp. 3)
Unless a do not resuscitate (DNR) or allow...
ATI RN COMPREHENSIVE PREDICTOR 2016 REMEDIATION
Management of Care – (9)
Advance Directives/Self-Determination/Life Planning – (1)
Professional Responsibilities: Client Teaching About Do-Not-Resuscitate Orders
(Active Learning Template – Basic Concept, RM Leadership 7.0 Chp. 3)
Unless a do not resuscitate (DNR) or allow natural death (AND) prescription is
written, the nurse should initiate CPR when a client has no pulse or respirations.
The written prescription for a DNR or AND must be placed in the client’s medical
record. The provider consults the client and the family prior to administering a
DNR or AND.
Client Rights – (1)
Coordinating Client Care: Appropriate Action When a Client Leaves Against Medical
Advice (Active Learning Template – Basic Concept, RM Leadership 7.0 Chp. 2)
A client who leaves a facility without a prescription for discharge from the
provider is considered leaving against medical advice (AMA). A client who is
legally competent has the legal right to leave the facility at any time. The nurse
should immediately notify the provider. If the client is at risk for harm, it is
imperative that the nurse explain the risk involved in leaving the facility. The
individual should sign a form relinquishing responsibility for any complications
that arise from discontinuing prescribed care. The nurse should document all
communication, as well as the specific advice that was provided for the client. A
nurse who tries to prevent the client from leaving the facility can face legal
charges of assault, battery, and false imprisonment.
Collaboration with Interdisciplinary Team – (1)
Coordinating Client Care: Information to Report to Occupational Therapist (Active
Learning Template – Basic Concept, RM Leadership 7.0 Chp. 2)
Patient’s condition and current status; any medications the patient is on; patient’s
tolerance level for pain; any assistive devices the patient uses
Confidentiality/Information Security – (1)
Professional Responsibilities: Protecting Confidential Client Information (Active
Learning Template – Basic Concept, RM Leadership 7.0 Chp. 3)
It is essential for nurses to be aware of the rights of clients in regard to privacy
and confidentiality. Facility policies and procedures are established in order to
ensure compliance with HIPAA regulations. It is essential that nurses know and
adhere to the policies and procedures. HIPAA regulations also provide for
penalties in the event of noncompliance with the regulations.
Continuity of Care – (1)
Information Technology: Preparing a Change-of-Shift Report (Active Learning
Template – Basic Concept, RM FUND 9.0 Ch 5)
Nurses give this report at the conclusion of each shift to the nurse assuming
responsibility for the clients. Formats include face to face, audiotaping, or
presentation during walking rounds in each client’s room (unless the client has a
roommate or visitors are present). An effective report should: include significant
, Ariana Melesio 2
objective information about the client’s health problems; proceed in a logical
sequence; include no gossip or personal opinion; relate recent changes in
medications, treatments, procedures, and the discharge plan
Legal Rights and Responsibilities – (1)
Professional Responsibilities: Understanding Regulations for Nursing Scope of
Practice (Active Learning Template – Basic Concept, RM Leadership 7.0 Chp. 3)
Standards of care guide, define, and direct the level of care that should be given
by practicing nurses. They also are used in malpractice lawsuits to determine if
that level was maintained. Nurses should refuse to practice beyond the legal scope
of practice and/or outside of their areas of competence regardless of reason
(staffing shortage, lack of appropriate personnel). Nurses should use the formal
chain of command to verbalize concerns related to assignment in light of current
legal scope of practice, job description, and area of competence.
Performance Improvement (Quality Improvement) – (1)
Maintaining a Safe Environment: Demonstrating Quality and Safety Education for
Nurses Competencies (Active Learning Template – Basic Concept, RM Leadership
7.0 Chp. 4)
Safe use of equipment refers to appropriate operation of health care-related
equipment by trained staff. Equipment-related injuries can occur as a result of
malfunction, disrepair, or mishandling of mechanical equipment. Nurses must
ensure that they have the competence necessary to use equipment for tasks that
fall within their scope of practice. Nurses should use equipment only after
receiving sufficient instruction. Equipment should be regularly inspected by the
engineering or maintenance department and by the user prior to use. Faulty
equipment (frayed cords, disrepair) can start a fire or cause an electrical shock and
should be removed from use and reported immediately per agency policy.
Referrals – (2)
Alzheimer’s Disease: Resources for Home Care (Active Learning Template – System
Disorder, RM AMS RN 10.0 Chp 8)
Refer to social services and case managers for long-term/home management,
Alzheimer’s Association, community outreach programs, and support groups
Nutrition and Oral Hydration: Priority Finding Following an Ischemic Stroke (Active
Learning Template – System Disorder, RM FUND 9.0 Ch 39)
Identify if someone has dysphagia, this patient will need pureed foods; clear and
full liquids plus pureed meats, fruits and scrambled eggs, low residue: low in fiber
Safety and Infection Control – (6)
Accident/Error/Injury Prevention – (2)
Adverse Effects, Interactions, and Contraindications: Priority Action to an Allergic
Response (Active Learning Template – Medication, RM Pharm RN 7.0 Chp 5)
Treat with epinephrine, bronchodilators, and antihistamines. Provide respiratory
support and inform the provider.
Health Promotion of Infants (2 Days to 1 Year): Car Seat Safety (Active Learning
Template – Basic Concept, RM NCC RN 10.0 Chp 3)
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