Advance directives- teaching - ANSCommunicates the client wishes regarding end of life care;
are written before a client becomes ill
Nurses role is to provide info about advance directives
Document client's advance directive status
Ensure advance directives reflects clients current decision
Inform all members of the healthcare team of the client's advanced directives
Culture (client who speaks a different language) - ANSUse an interpreter always; try to get
someone around same age and gender as client
Delegation to UAP - ANSStable/chronic clients; post-mortem care; they cannot teach, assessed,
or evaluate
Ethical (client need for information about treatment) - ANSProvide client with truthful information
so they can make an informed decision about their own health and well-being
Discharge planning - ANSDetermine ability to afford insulin and supplies
Make sure he has transportation to follow up appointments
Informed consent - ANSNurses role is to witness the client signature and ensure that the
provider has obtained the informed consent responsibly
Greater than 18 years of age or if the mother or father is a teenage parent they have the right to
sign the consent form
Client inquiry about surgery - ANSConsult health care provider/surgeon for procedures/informed
consent questions
Telephone prescriptions are - ANSMust write the order down before reading it back to the
provider
Identify Improper documentation - ANSDocumenting should be factual
Subjective data documentation - ANSQuotes with quotation marks- what the client states to the
nurse
, Objective data documentation - ANSWhat the nurses, smells, osculates do not use derogatory
words, judgment, or opinions
Intentional tort - ANSDoing harm (The act must be intentional, not merely reckless or careless)
Assault, battery, false imprisonment, invasion of privacy, slander
Interprofessional team member consult - ANSPT- consulted for mobility issues
OT- assist clients to regain ADL skills
ST- Deals with speech and language disorders
Coordinated client care among healthcare team - ANSSocial worker- Coordinates care and
community resources
Demonstrating client advocacy - ANSNurses role is to provide support of the clients health,
wellness, safety, and personal rights, including privacy
Nursing role- client observation - ANSShare appropriate information among team members
Prioritizing client care - ANSFollow ABC's (airway, breathing, circulation)
Unstable are seen before stable clients
Acute clients are seen before chronic clients
Disposition of valuables
(Admit/transfer/DC) - ANSPersonal items include clothing, jewelry, money, credit cards, hearing
aides, eyeglasses, dentures, etc
Discourage the client from keeping valuables at bedside
Document communication with the client related to items left within the room
Valuables should be locked in the facilities safe
Identify negligence - ANSFailure to provide care as defined by a standard
Breach of duty
Foreseeability of harm
Caused harm
Latex allergy - ANSSchedule first on the morning operating list (OR must be free from powdered
latex gloves for at least 3 hours prior to surgery)
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