Chapter 09 Legal And Ethical Issues in Nursing 6th Edition by Ginny Wacker Guido

Chapter 09 Legal And Ethical Issues in Nursing 6th Edition by Ginny Wacker Guido

Complete Chapter Questions With Answers

Sample Questions Are Posted Below

Question 1

Type: MCSA

A newly licensed nurse complains to the preceptor about the amount of time spent documenting in the medical record. What is the preceptor’s best response?

1. “The most important reason we document is to help us communicate the patient’s condition to the rest of the health care team.”
2. “Since you just took a course in nursing research, you should realize the value of accurate documentation as a source of research data.”
3. “We have to document so that charges are clear to third-party payers.”
4. “The medical record protects us if a lawsuit is filed.”

Correct Answer: 1

Rationale 1: The primary reason for documentation is to communicate the patient’s condition to others on the health care team. The preceptor should remind the newly licensed nurse of this fact.

Rationale 2: Information from the medical record can be used for research with the patient’s permission, but this is not the primary reason it is important.

Rationale 3: It is true that accurate documentation supports third-party reimbursement, but this is not the most important use of this information.

Rationale 4: The medical record may or may not offer information that would protect the nurse in case of a lawsuit. This is not the primary reason for documentation.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 9.1 Discuss purposes of the medical record.

Question 2

Type: MCSA

The nurse manager is aware that several patients will be admitted to the unit today. Today’s staff includes three registered nurses, two licensed practical nurses, and three unlicensed nursing assistants. Who should the manager expect to assess and document the admitted patient’s nursing needs?

1. The nursing assistant
2. The admitting physician
3. A registered nurse
4. A licensed practical or vocational nurse

Correct Answer: 3

Rationale 1: The nursing assistant may collect data such as vital signs, but cannot use the data to plan care.

Rationale 2: The physician plans medical care, not nursing care.

Rationale 3: Documentation of admission assessment and nursing needs is the role of the registered nurse.

Rationale 4: The LPN or LVN can collect data, but does not use the data to plan care.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 9.2 Define and describe basic information to be included in the medical record.

Question 3

Type: MCSA

Nursing home policy states that a registered nurse must cosign all charts that licensed practical nurses complete. What is the effect of this policy on the registered nurse?

1. It places the RN in the position of endorsing and authenticating the entries made in the charts cosigned.
2. It gives legal proof that the RN was in the facility.
3. It has no legal effect on the RN.
4. It makes the RN personally liable for any subsequent harm that befalls the patient.

Correct Answer: 1

Rationale 1: Cosigning is a practice that is becoming less frequent. It does place the nurse potentially liable for care, observations, or omissions as charted.

Rationale 2: The RN may have cosigned at a date other than that of the event, so it does not give absolute proof that the RN was in the facility.

Rationale 3: There are legal implications for endorsing or authenticating entries by cosigning.

Rationale 4: The person delivering the care is also liable for any harm that may occur due to malpractice. Liability does not lie exclusively with the person who cosigned.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 9.3 List and give examples of guidelines for accurate documentation.