Scope of Practice
This legal document, which varies by state, defines the legal boundaries of nursing practice and is the "ultimate rulebook" for what an RN or LPN can safely and legally perform.
What is the Nurse Practice Act?
This communication technique focuses on empathy and active listening.
What is therapeutic communication?
This type of documentation records patient information in chronological order throughout the shift.
What is narrative documentation?
These five steps guide nursing care.
Assessment, Diagnosis, Planning, Implementation, and Evaluation?
While the Registered Nurse (RN) is responsible for the entire nursing process, this specific phase—which involves analyzing assessment data to create nursing diagnoses and prioritize hypotheses—falls strictly within the RN's scope of practice and cannot be performed by an LPN or UAP
What nursing diagnosis or data analysis?
When an RN delegates a task like "ambulating a stable patient" to a UAP, the RN transfers the authority to perform the task, and the RN is still legally responsible for the outcome and must follow up to ensure the task was done correctly.
What is Accountability?
This standardized tool is used to communicate patient information.
What is SBAR?
A student charts “patient doing better today.
What is subjective data?
This step involves collecting subjective and objective data.
What is assessment?
A patient refuses a blood transfusion due to religious beliefs. This ethical principle must be respected by the nurse.
What is autonomy?
A nurse discusses a patient's condition in a busy cafeteria.
What is breaking patient confidentiality (HIPAA)?
This communication technique involves restating what the patient has said to ensure understanding.
What is reflection?
This documentation method records only abnormal findings or deviations from established norms.
What is documentation by exception?
A patient reports dizziness and weakness. The nurse notes a blood pressure of 88/54, pale skin, and delayed capillary refill. Which step of the nursing process is demonstrated when the nurse recognizes these findings as concerning?
What is assessment?
A nurse administers an injection after a patient clearly states they do not consent.
What is battery?
You are a student nurse on a clinical floor. A surgeon runs past you and yells, "Hey, student! Give this patient 5mg of Morphine IV, STAT!" Even though you know how to give the med, you must refuse. Why?
What are the ethical and legal boundaries of a student nurse?
A nurse receives a verbal order over the phone. What communication action best ensures accuracy?
What is repeating the order back to the provider for verification?
RN documents BP 120/72, SPO2 98% on room air, HR72 and RR 18.
What is objective data?
Based on assessment findings of unsteady gait, confusion, and recent falls, the nurse identifies “Risk for Falls.
What is nursing diagnosis?
This occurs when a nurse threatens a patient with unwanted treatment, causing fear, even if no physical contact occurs.
What is assault?
An RN considers delegating a task to a student nurse. According to scope of practice, what condition must be met before delegation is appropriate?
What is that the task is within the student nurse’s scope of practice and the patient’s condition is stable
Noise, use of medical jargon, and language differences are examples of these factors that impact communication.
What is barriers to communication?
When a patient falls or a medication error occurs, the nurse completes this confidential document, which is sent to Risk Management rather than being placed in the patient's medical record, to help the facility identify trends and improve safety
What is an incident report?
A nurse is caring for four patients. One reports shortness of breath, one needs pain medication, one is waiting for discharge teaching, and one needs assistance to the bathroom. Which step of the nursing process guides the nurse in deciding who to see first?
What is planning?
This ethical principle guides nurses to act in the patient’s best interest and promote good outcomes.
What is beneficence?