NCLEX Cram Module I

Safe and Effective Care

Environment

Prepared by

Lori Baker, RN, BSN

2013

Management of Care (16-22% of NCLEX)

Consents
Nurse responsibility
Obtain consent form and ensure
completed consent forms are on the
chart
Witness clients signature
NOT nurse responsibility
Obtaining the consent signature
Explaining the procedure along with
all risks and benefits
3

Management of Care

(16-22% of NCLEX)

Informed Consent
Consent obtained after the risks and
benefits of having or not having the
procedure or treatment to be performed
are explained by the person performing
the procedure
Written Consent
Not required for all medical treatment if
Client has been fully informed
Client voluntarily consents
Immediate treatment is necessary to
save life or limb
Pregnant minor can sign for herself AND her
fetus

Management of Care

(16-22% of NCLEX)

Verbal Consent
Requires documentation in medical
record
Describe in detail how and why it was
obtained
Identify and record the signatures of
two witnesses to the consent who are
not directly related to the treatment or
procedure

Management of Care

(16-22% of NCLEX)

Written Consent
Requires that the person giving
consent, usually the client, be
Alert, coherent, and an otherwise
competent adult
Parent or legal guardian
Loco parentis (person standing in for
parent or legal guardian
(Note: consent of minor client 14 years of age
and older must agree to treatment along with
parent. Competent, emancipated minors can
consent for treatment without the consent of a
parent or guardian)
6

Management of Care

(16-22% of NCLEX)

Surgical Consent
Obtained prior to any surgical procedure
Consent must be
Written
Explained to the client and parent/guardian by
person performing procedure to include
Possible complications and
disfigurements
Removal of any organs or body parts

Witnessed
Signed by a competent adult,
emancipated minor, or competent
parent/guardian
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Management of Care

(16-22% of NCLEX)

Good Samaritan Act

Protects healthcare practitioner against
malpractice claims for emergency care
provided in good faith
Healthcare personnel are required to
deliver care in a reasonable and
prudent manner

Management of Care

(16-22% of NCLEX)

Right to Refuse Treatment

The patient may always do this,
however, it must be WELL
DOCUMENTED that the patient is well
aware of problems that could arise from
refusal of any treatment/procedure

Management of Care

(16-22% of NCLEX)

Nursing Responsibilities regarding

Advance Directives
To deliver nursing care in a way that
meets the needs of the individual
To deliver care that is consistent with
the goals of the individual with respect
to level of health and quality of life
To educate and advocate for patients,
ensuring that they are fully aware of all
options and their consequences and
can make informed choices about their
healthcare
Adopted from the ANA
10

Management of Care

(16-22% of NCLEX)

Restraint reminders
Restrain only under the following
circumstances
In an emergency
For a limited time
For the limited purpose of client
safety or the safety of others

11

Management of Care

(16-22% of NCLEX)

Restraints (contd)
Nursing responsibilities
Notify healthcare provider immediately
that the client has been restrained and
obtain an order to continue use
Document facts regarding the rationale
for restraining patient
Physician must examine patient and write
the order for type and duration of use
Restraint order must be renewed every
24 hours
(Note: restraints of any kind may constitute false
imprisonment if not treated appropriately and the
patient is protected by law)
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Management of Care

(16-22% of NCLEX)

Legal Terms
Negligence
performing an act that a reasonable
and prudent person would not
perform under similar conditions.
Includes:
Lack of skill
Errors
Professional misconduct
Failure to act
13

Management of Care

(16-22% of NCLEX)

Malpractice
Equates to professional negligence. The
plaintiff must prove all four of the following
elements to prove malpractice:
Duty
obligation to maintain a nursing standard,
i.e. what a reasonable and prudent nurse
would do (a nurse is expected to anticipate
foreseeable risk
Breach of duty
failure to maintain the nursing standard. A
reasonable and prudent nurse in the same
situation would not have performed this act
14
or in this manner. (continued)

Management of Care (16-22% of NCLEX)

Malpractice (contd)
Injury/damages
failure to meet the standard of practice
caused mental or physical injury or
damage to the plaintiff
Proximate cause (causation)
the breach of duty caused the harm
and the nurses action or lack of action
caused harm to the plaintiff. A
connection exists between conduct and
the resulting injury referred to as
proximate cause or remoteness of
damage
15

Management of Care

(16-22% of NCLEX)

Legal terms (contd)

Assault
mental or physical threat to touch
without permission (i.e. forcing a
client to take medication or
treatments)
Battery
touching without permission, with or
without the intent to do harm (i.e.
hitting or striking a client
16

Management of Care

(16-22% of NCLEX)

Five Rights of Delegation

Right task? Can be delegated by RN or PN
Right situation? Consider the setting and
available resources, and the appropriateness of
the delegated task
Right person? Delegation by the proper person
and to the proper person
Right communication? Provide expectations,
complete instructions, and well-defined limits.
Ensure understanding by the delegate
Right supervision? Delegatee receives the
proper guidance, evaluation, and follow-up

17

Management of Care

(16-22% of NCLEX)

PN Duties

Data collection
Focused assessments
Participate in planning nursing care needs
Participate in modifying nursing care plan
Implement care within scope of practice rather than
legal, ethical, and educational parameters
Implement teaching plan for common health
problems and well-defined learning needs
Provide direct basic care to assigned multiple
clients in structured settings
Assist in evaluation of clients responses and
outcomes to therapeutic interventions
Use a problem-solving approach as the basis for
decision making in practice
18

Management of Care

(16-22% of NCLEX)

RN Duties

Perform initial assessment

Perform comprehensive assessments
Determine nursing diagnoses
Formulate nursing care plan
Implement nursing care
Develop and implement teaching plans rather that
promotion, maintenance, and restoration of health
Provide for care of multiple clients either through
direct care or assignment and-or delegation of
care to other members of the healthcare team
Evaluate clients responses and outcomes to
therapeutic interventions

19

Management of Care

(16-22% of NCLEX)

RN Duties (contd)
Use critical thinking approach to analyze clinical
data and current literature as a basis for
decision making in nursing practice
Evaluate impact of care
Make independent decisions
Communicate and consult with other health
team members

20

Management of Care

(16-22% of NCLEX)

Delegation Dos and Don'ts

Do
Always use the 5 rights of delegation
Provide adequate supervision of delegated
tasks
Guidance and direction
Evaluation and monitoring
Follow-up
Understand the qualifications of each
delegatee
Appropriate education, training,
experience, skills
Demonstrated and documented
competence
(continued)
21

Management of Care

(16-22% of NCLEX)

Dont
Delegate tasks that require nursing
judgment
Assessment
Diagnosis
Planning
Evaluation
Delegate invasive or sterile procedures

22

Management of Care

(16-22% of NCLEX)

Float Assignments
Include only those duties and
responsibilities for which competency
has been validated
Someone familiar with the unit must
oversee all patient care and shall act as
a resource nurse
Refusing to float is not an option and
may be viewed as insubordination,
subject to discipline

23

Management of Care

(16-22% of NCLEX)

Incident Reports
These are internal institutional documentation of an
event NOT A PART OF THE CHART
Never make reference in the nurses notes that an
incident report has been filed document only the
facts of the event itself
File an incident any time an incident or event occurs
that is not within institutional guidelines or the
practice of nursing or medicine
They are NOT for tattling they are to inform the
facility administrators of incidents that allow the risk
management team to consider changes that might
prevent similar incidents
They alert administration and the facility insurance
company of potential claims or need for further
investigation

24

Infection Control

(8-14% of NCLEX)

What are transmission-based precautions?

As easy as A D C
A= airborne
D= droplet
C= contact

25

Infection Control

(8-14% of NCLEX)

Who goes in airborne precautions?

My Chicken Haz TB!
Measles
Chickenpox
Herpes Zoster
Tuberculosis

26

Infection Control

(8-14% of NCLEX)

Private Room for Airborne includes

Pretty Nasty Ninny Muggins.
Private room
Negative pressure
N95 filtration mask

27

Infection Control
Droplet precautions
Spiderman
drops from
building
Private room
Mask

(8-14% of NCLEX)

Sepsis
Scarlet fever
Streptococcal pharyngitis
Parvovirus b19
Pertussis
Pneumonia
Influenza
Diphtheria
Epiglottitis
Rubella
Mumps
Meningitis
Mycoplasma or
meningeal pneumonia
Adenovirus
28

Infection Control

(8-14% of NCLEX)

Contact Precautions contact Mrs. Wee

Multidrug resistant organisms

Respiratory infection (RSV)
Skin infections
Wound infections
Enteric infections (c. diff)
Eye infections

29

Infection Control

(8-14% of NCLEX)

Skin infections requiring contact

precautions
Vicarious CHIPS
Varicella zoster
Cutaneous diphtheria
Herpes simplex
Impetigo
Pediculosis
Scabies and staph
30

Infection Control

(8-14% of NCLEX)

Know about Hepatitis A, B, and C

Source of infection
Route of infection
Incubation period
Onset
Seasonal variation
Age group
Vaccine
Inoculation
Potential for chronic liver disease
Immunity
See next slides
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Infection Control

(8-14% of NCLEX)

Hepatitis A

Source of infectioncontaminated food/water

Route of infection-oral, fecal, parenteral
Incubation period-2-6 weeks
Onset-abrupt
Seasonal variation-autumn, winter
Age group-children, young adults
Vaccine-yes
Inoculation-yes
Potential for chronic liver disease-no
Immunity-yes

32

Infection Control

(8-14% of NCLEX)

Hepatitis B
Source of infection-contaminated blood,
needles, or surgical instruments
Route of infection-parenteral, oral, fecal, direct
contact, breast milk, sexual contact
Incubation period-6-20 weeks
Onset-insidious
Seasonal variation-all year
Age group-any age
Vaccine-yes
Inoculation-yes
Potential for chronic liver disease-yes
Immunity-yes
33

Infection Control

(8-14% of NCLEX)

Hepatitis C
Source of infection-contaminated blood,
needles, IV drug use, dialysis
Route of infection-parenteral, sexual contact
Incubation period-average 6-7 weeks
Onset-insidious
Seasonal variation-all year
Age group-any age
Vaccine-no
Inoculation-yes
Potential for chronic liver disease-yes
Immunity -no
34

Infection Control

(8-14% of NCLEX)

Liver Problems
Symptoms
Fatigue, malaise, weakness, anorexia, N/V
Jaundice, dark urine, clay-colored stool
Myalgia (muscle aches), joint pain
Dull headaches, irritability, depression
Abdominal tenderness in RUQ
Fever with Hepatitis A
Elevated liver enzymes (ALT, AST,
alkaline Phosphatase), bilirubin
35

Infection Control

(8-14% of NCLEX)

Liver problems cause high ammonia

levels
Give Lactulose
to decrease ammonia levels
This causes diarrhea remind the
patient this is an expected side
effect

36

Infection Control

(8-14% of NCLEX)

Tuberculosis
Symptoms
Fever with night sweats
Anorexia, weight loss
Malaise, fatigue
Cough, hemoptysis
Dyspnea, pleuritic chest pain with
inspiration
Cavitation or calcification as evidenced
on chest x-ray
Positive sputum culture (AFB)
37

Infection Control

(8-14% of NCLEX)

TB planning, intervention and patient

teaching
Take all medications daily for 9-12 months
Hand hygiene often
Return to work after 3 (three) negative
sputum cultures
Respiratory isolation while hospitalizedpersonnel to wear a particulate respirator
mask
38

Infection Control

(8-14% of NCLEX)

Skin Test for TB

Mantoux test with PPD (tuberculin purified protein
derivative) injected intradermally on the forearm;
standard method for identifying infection with M.
tuberculosis
Must be given INTRADERMALLY
If given subcutaneously, the test is invalidated
The common cold is NOT a contraindication for
immunization
Tine test (OT, Old Tuberculin),
consists of four prongs pressed into the forearm;
these multiple puncture tests are unreliable and
should not be used to determine the presence of a
TB infection
39

Infection Control

(8-14% of NCLEX)

Skin Test for TB (contd)

A positive reaction represents exposure to M.
tuberculosis
Screening can be initiated at 12 months of age
Read at 48 to 72 hours (10cm induration is
positive or 5 cm if the client is
Immunocompromised)
Anyone who has received a BCG vaccine
(vaccine against TB) will have a positive skin
test and must be evaluated using a chest x-ray
Once positive, always positive they must
always get a chest x-ray instead of the skin test
40

Infection Control

(8-14% of NCLEX)

TB Therapy points
Rifampin reduces effectiveness of oral
contraceptives; should use other
birth control methods during
treatment
Gives body fluids orange tinge
stains

41

Infection Control

(8-14% of NCLEX)

TB Therapy points ( contd)

Isoniazid (INH)
Increases Dilantin levels
Ethambutol
Vision check before starting therapy and
monthly
May have to take 1-2 years longer
Note: the rationale for combination drug
therapy is to increase compliance.
Resistance develops more slowly if several
anti-TB drugs are given, instead of just one
drug at a time
42

Infection Control

(8-14% of NCLEX)

HIV/AIDS
Risk groups
Homosexual or bisexual males
IV drug abusers or those who have had tattoos or
acupuncture
Heterosexual partner of a risk group member
Recipients of blood products prior to blood product
screening (~1985)
Those taking medications such as steroids or
other agents that cause immunosuppression
Infants born to infected mothers
Breastfeeding infants of infected mothers

43

Infection Control

(8-14% of NCLEX)

HIV/AIDS (contd)
Lab testing
Positive ELISA (enzyme-linked
immunosorbent assay); can be false
positive
Confirmation is by the Western Blot
test
Uses electrophoreses and
evaluates virus specific bands

44

Infection Control

(8-14% of NCLEX)

Stage of HIV

Primary CD4 T- cell counts of at

least 800 cells/mm3

Description/Symptoms

HIV-Asymptomatic (CDC Category A)

CD4 T-cell counts more than 500
cells/mm3

Flu-like symptoms, fever, malaise

Mononucleosis-like illness,
lymphadenopathy, rash
Symptoms usually occur within 3
weeks of initial exposure to HIV, afterwhich the person becomes
asymptomatic

No clinical problems
Characterized by continuous viral
replication
Can last for many years (10 years or
longer
45

Infection Control

(8-14% of NCLEX)

Stage of HIV

Description/Symptoms

HIV symptomatic (CDC Category B)

CD4 T-cell counts between 200499 cells/mm3

Persistent generalized
lymphadenopathy
Persistent fever
Weight loss, diarrhea
Peripheral neuropathy
Herpes zoster
Candidiasis
Cervical dysplasia
Hairy leukoplakia, oral

46

Infection Control

(8-14% of NCLEX)

Stages of HIV

Description/Symptoms

AIDS (CDC Category C) - CD4 T-cell

counts less than 200 cells/mm3

Occurs when a variety of bacteria,

parasites, or viruses overwhelm the
bodys immune system
Once classified as category C, the
client remains classified as category C;
this provides eligibility for entitlements
such as health benefits, housing, food
stamps, etc. (if certain financial
requirements exist)

CDC Categories of HIV

A - Mildly symptomatic
B - Moderately symptomatic
C - Severely symptomatic

47

Infection Control

(8-14% of NCLEX)

Treatment

STD/Symptoms
Syphilis

Primary (local); up to 90 days post

exposure
Chancre (red, painless lesions
with indurated border)
Highly infectious

Secondary (systemic); 6 weeks to

6 months post exposure
Influenza type symptoms
Generalized rash that affects
palms of hands and soles of feet
Lesions are contagious

Tertiary; 10-30 years post

exposure

Penicillin G given IM usually 2.4 to 4.8

million units

Any STD in infants and

children usually indicate
sexual abuse and should be
reported. The nurse is legally
responsible to report
suspected cases of child
abuse.

Cardiac and neurologic

destruction
48

Infection Control

(8-14% of NCLEX)

STD/Symptoms

Treatment

Gonorrhea

Females; majority are

asymptomatic
Males; dysuria, yellowish-green
urethral discharge, urinary
frequency

Ceftriaxone sodium plus doxycycline

hyclate
Spectinomycin HCL plus doxycycline
hyclate

49

Infection Control

(8-14% of NCLEX)

STD/Symptoms

Treatment

Chlamydia

Females; many asymptomatic, but

may exhibit dysuria, urgency,
vaginal discharge
Males; leading cause of
nongonococcal urethritis

Doxycycline hyclate or Tetracycline

HCL

Chlamydia is the most

reported communicable
disease in the United States

50

Infection Control

(8-14% of NCLEX)

STD/Symptoms

Treatment

Trichomoniasis

Females; green, yellow, or white

frothy foul-smelling vaginal
discharge with itching
Males; asymptomatic

Metronidazole (Flagyl)
Male partners treated regardless of
symptoms to prevent reinfection

51

Infection Control

(8-14% of NCLEX)

STD/Symptoms

Treatment

Herpes simplex type 2

Vesicles in clusters that rupture

and leave painful erosions that
cause painful urination
Characterized by remissions and
exacerbations
May be contagious even when
asymptomatic

Acyclovir (Zovirax) partially controls

symptoms
Palliative care
Viscous lidocaine topically to ease
pain
Keep lesions clean and dry

52

Infection Control

(8-14% of NCLEX)

STD/Symptoms

Treatment

HPV (Human papillomavirus)

Multiple strains (>70), some of

which are implicated in cervical
cancer
Alarming rate increase in
adolescent population
Lesions may be small, wart-like or
clustered
May be flat or raised

Applied medications such as

podophyllin (contraindicated in
pregnancy)
Trichloroacetic acid (TCA)
Laser
Cryotherapy

53

Infection Control

(8-14% of NCLEX)

Disaster/Bioterrorism
Triage categories
Red
Most urgent, first priority, lifethreatening injuries, cannot delay
treatment
Yellow
Urgent, second priority, injuries with
systemic effects and complications,
may delay treatment 30-60 minutes

54

Infection Control

(8-14% of NCLEX)

Triage (contd)
Green
Third priority
Minimal injuries with no systemic
complications
May wait several hours for treatment
Black
Dying or dead
Catastrophic injuries
No hope for survival even with
treatment
55

Infection Control

(8-14% of NCLEX)

Bioterrorism
Possible agents
Anthrax
Pneumonic plague
Botulism
Smallpox
Inhalation tularemia
Viral hemorrhagic fever
Biotoxin agents (Ricin)
Nerve agents (Sarin)
Radiation
56

End of Module I

Please keep in mind, this is a very brief

overview and should not be used as your
sole source of NCLEX study.

57