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NCLEX REVIEW NOTES NCLEX Review Notes The information contained within these notes is based on NCSBN published NCLEX Test Plan Concepts at the time of review (see below). For full NCLEX preparation to be successf ...

NCLEX REVIEW NOTES NCLEX Review Notes The information contained within these notes is based on NCSBN published NCLEX Test Plan Concepts at the time of review (see below). For full NCLEX preparation to be successful, students should not depend on only the information within these review notes Other sources of information are recommended based on nursing education guidelines within the course of study in which the student is enrolled. These notes contain some key concepts useful for study. Priority Maslow’s Hierarchy of Needs (prioritize from the lowest level upwards) 5th level-Self-actualization: This is a state of being or growth; when you meet a need it expands. These needs are not transitional; these needs are met based on achievements and reflections in life. The specific need is replaced with a new need that follows the continuum of growth and development. 3rd & 4th levels-Psychosocial, (3) love & belonging & (4) self-esteem/other- esteem: Whether fulfilling personal emotional satisfaction or feeling part of a group, how we view ourselves and out relationships guide behavior. These are needs that are transitional; when you meet a need it ends and can reappear. These needs are third/fourth highest priority to satisfy. 2nd level-Safety & Security: Personal, familial, environmental, economic, etc…. These are needs that are transitional; when you meet a need it ends and can reappear. These needs are second highest priority to satisfy. 1st level-Physiological: This is about survival, physiological function, necessary components of living. This is a need that is transitional; when you meet a need it ends and can reappear. These needs are highest priority to satisfy. Safety Topics Fire Safety reminders: RACE • R: rescue (the patient and others at risk; remove from possible harm) • A: (sound the; pull the) alarm • C: contain (the fire if possible; e.g., close fire doors) • E: extinguish (the fire if possible) Pass • P: Pull (the pin from the fire extinguisher) • A: Aim (the device nozzle at the base of the flames) Page 1 of 42 Reviewed: September-December 2021 Downloaded by Morris Muthii ([email protected]) NCLEX REVIEW NOTES • S: Squeeze (the trigger to activate the extinguisher suppressant) • S: Sweep (the flames with suppressant agent) Health Promotion Prevention *Primary Prevention– (i.e., prevention education) actions that prevent the onset of a condition *Secondary Prevention– (i.e., diagnostic screening such as mammograms, diet modifications) actions to determine pathologies or conditions and determine care or decrease risk factors *Tertiary Prevention- (i.e., management of an established condition, pathology, or injury) actions that promote improvement and stabilize conditions/pathologies and/or prevent worsening. Legal Issues • Crimes are acts or behaviors that endanger or damage the well-being of the state and its people. Some include: o False Imprisonment (may also be a intentional tort) (e.g., preventing departure or freedom of movement by choice) using restraints to limit freedom of movement can cause this to occur. o Theft o Diversion of funds, goods, services, or resources o Diversion of pharmacological substances or medications from intended or ordered use o Privacy Violation (HIPPA, etc) • Legal Torts (Intentional & Unintentional) are distinguished from crimes and are acts or omissions that give rise to injury or harm to another which amounts to civil wrongs for which courts impose liability. In that context o Injury is invasion of any legal right o Harm is a loss or detriment in fact that an individual suffers • Liability, when established, can result in court awarded damages (typically awarded as monetary compensation), while less common remedies include restitution and injunction • Torts can include: o Common Types ▪ Assault – Verbal threat ▪ Battery – Physical harm Page 2 of 42 Downloaded by Morris Muthii ([email protected]) Reviewed: September-December 2021 NCLEX REVIEW NOTES ▪ Infliction of Emotional Distress ▪ False Imprisonment (keeping someone in an environment) preventing departure when not authorized by legal authority to do so ▪ Trespass (entering personal residence/property without permission) ▪ Negligence (may lead to malpractice) • Failure to take proper care in doing something • Failure to use reasonable care, resulting in damage or injury to another o Other Types of Torts ▪ Defamation (i.e., …of character by gossip, social media, written word, etc….) • Libel-Written • Slander-Verbal ▪ Nuisance ▪ Invasion of Privacy (i.e., photographing, viewing possessions, etc….) o As well as ▪ Economic Torts • Malpractice – occurs when a Nurse had a duty (a professional relationship established with a client), was negligent (by action or omission) in that duty and did not meet established standards of practice (judgement or actions which another professional would do or not do in similar or identical circumstances) which resulted in harm to the client (i.e., a patient, family, group, or population). • Breach of Contract — One party fails to honor the contracted performs wrong to the other party. This is not a tort, rather it is a Civil Wrong with awardable compensation award possible in a court of law • 72-hour Hold — A legally ordered medical process for preventing departure from an environment with subsequent observation and limitations of free choice and behaviors due to intent that is indicated or actual to harm self or others. • Good Samaritan Law — A law enacted within a civic and legal system in which a licensed professional or other person who is acting within a legal scope of practice but not in a professional capacity (i.e., no duty is established, and the person stops to help at the scene of a MVC) may not be held to legal liability for injuries to a person when rendering aid in emergent circumstances Page 3 of 42 Reviewed: September-December 2021 Downloaded by Morris Muthii ([email protected]) NCLEX REVIEW NOTES • Jurisprudence – Application and interpretation of regulation, laws, and principles in the nursing profession. • Incident Reports or Occurrence Reports — are internal tools to assist in determining the facts of an occurrence and initiating investigations to decrease risk to clients and help prevent future occurrences. These documents are NOT PART OF THE MEDICAL RECORD and ARE NIETHER MENTIONED IN CHARTING, NOR ARE PLACED IN A MEDICAL RECORD (this is related to legal protection). Examples include: o Medication errors o Procedure/Treatment errors – IV causes infection – needs Abx o Needle stick injury’s o Volunteer/Visitor injury o Reports if losses occur- dentures, money, items. o Patient fights with MD. NOTE: The incident or occurrence report does not speculate or judge, assign guilt, contain defensive language, rather it reports only the facts of the case as observed, communicated, and acted upon. NOTE: The medical record will contain a non-judgmental, specific, accurate, concise description of the nurses observations, communications, and related actions in event of such occurrences. Advanced Directives • Can be changed at any time by the patient, the legally appointed health surrogate, the client’s power of attorney or court- appointed guardian (documentation of changed status may be facilitated by nurses using available resources) • Are legal documents assigned by clients to the medical record which provide guidance on decisions relating to the action of others in the absence of the client’s ability to do so of the wishes of the client for response to specific circumstances (i.e., nutrition, hydration, pain control, and life support measures) • Are reported to the healthcare team as needed within privacy guidelines • The nurse’s role is to: o Ask the client about the status of advanced directives on admission and document o Place advance directives in the health record upon receipt from the client Page 4 of 42 Downloaded by Morris Muthii ([email protected]) Reviewed: September-December 2021 NCLEX REVIEW NOTES DNR (Do Not Resuscitate) • DNR ONLY MEANS you DON’T do Compressions • If pt. becomes SOA, put o2 on for comfort • If choking, Perform Heimlich maneuver • CODE status is provided by medical order • When no advance directives are present, and the code status has not been limited by medical order, the healthcare team is legally bound to provide all available life-sustaining measures in the event of an emergent condition. Restraints • Require medical orders or emergent use under standing orders o Prescription within specific time frame (facility protocol) • Must be documented per policy and procedure guidelines (minimum times or more frequent per environment of use and type of use) • Least restrictive measure needs to be used first.(music on to distract pt prior to applying) • Last resort • Distractions used before restraints • Tie to an immovable part of bed • Assess skin integrity and neurovascular checks every 30 minutes • Release q 2 hours for ROM, toileting, and intake of food/liquids • 2 fingers should be able to put between the restraint and the pt’s limb Priority • Sheets can be pulled up to hide tube that pt’s attempting to pull out