Scenarios and items in this section reflect the legal dimensions of professional nursing practice in the perianesthesia environment. These issues represent only a small portion of the diverse situations encountered by the nurse in clinical practice and are important because:
• Each nurse is responsible for practicing in accordance with recognized standards of professional nursing practice and professional performance.
• Professional practice reflects the application of knowledge of current practice standards, guidelines, statutes, rules, and regulations.
• Professional growth and delivery of high-quality patient care preserve and protect patient autonomy, dignity, rights, and confidentiality within legal and regulatory parameters.
| Essential Core Concepts | Affiliated Core Curriculum Chapters |
|---|---|
| Legal Concepts | Chapter 6 |
| Liability Issues | |
| The Legal Process | |
| Issues of Consent | |
| Ethical Standards | Chapter 2 |
| Ethical Principles | |
| Ethical Decision Making | |
| Competency-based Practice |
ETHICAL DILEMMAS IN CLINICAL PRACTICE
Question Set 3
Scenarios and items in this section reflect the ethical dilemmas encountered in professional nursing practice in the perianesthesia environment. This is only a small sampling of the many ethical situations and dilemmas that the perianesthesia nurse may encounter in daily practice. The perianesthesia nurse practices by providing nursing care to preanesthesia and postanesthesia patients. The perianesthesia nurse accepts the responsibility bestowed upon him or her by the state, the profession, and society. Standards for ethical practice demonstrate accountability to the public and to the profession and are important because:
• They assist the perianesthesia nurse to relate the American Nurses Association (ANA) Code of Ethics to his or her own practice.
• They identify the use of appropriate mechanisms to resolve ethical dilemmas.
• They provide a specific context for applying the Code of Ethics to perianesthesia practice and serve as a resource to develop ethically sound practices.
ITEMS 2.1–2.31
2.1. The type of law associated with medical malpractice is:
a. criminal law.
b. common law.
c. procedural law.
d. civil law.
2.2. To proceed with a claim of medical malpractice, it is necessary to have which of the following four key elements?
a. Policy, breach of duty, complaint, and filing
b. Breach of duty, damages, causation, and duty
c. Competency, failure of competency, damages, and incident report
d. Damages, incident report, duty, and loss of work
2.3. An 86-year-old man was admitted to an outpatient facility for a minor urology procedure. After signing his hospital consent form, he proceeded to the preoperative holding area. After his procedure and initial recovery, the patient was moved to the post anesthesia care unit (PACU) Phase II. While moving from the stretcher to the chair, he fell and suffered a fractured right hip. The patient’s family is considering a malpractice claim. The patient established a relationship (duty) with the outpatient facility by:
a. agreeing to the procedure with his doctor.
b. choosing a specific outpatient facility.
c. arriving and signing his hospital consent form.
d. arriving on time for his scheduled procedure.
2.4. Standards of care are:
a. the highest degree of professional behavior.
b. the minimum requirement of acceptable level of care.
c. established professional requirements by the state.
d. policies required by the hospital.
2.5. Professional standards of care are established to provide:
a. an example of provided care for legal purposes.
b. a basis or framework for quality nursing care.
c. a comparison between intended care and established policy.
d. an orientation guide for new nurses.
NOTE: Consider the scenario and items 2.6-2.7 together.
The American Society of PeriAnesthesia Nurses (ASPAN) 2006-2008 Standards of Perianesthesia Nursing Practice states that two licensed nurses, one of whom is a RN competent in Phase II postanesthesia nursing, are present whenever a patient is receiving Phase II level of care. A registered nurse (RN) must be present at all times during Phase II.
2.6. ASPAN defines “present” as meaning:
a. available within 5 minutes of the PACU.
b. present in the physical surgical suite area.
c. present in the place where the patient is receiving care.
d. present in the operating room (OR) as part of the surgical team.
2.7. Examples of patients who may be cared for in this phase include all of the following except:
a. patient awaiting discharge instructions and transportation home with family.
b. patient requiring extended observation/interventions but is stable hemodynamically.
c. patient who is extremely sleepy, has a 92% SaO2, and must be encouraged to take deep breaths.
d. patient without a companion present who no longer needs airway management.
2.8. In addition to caring for an adult male patient, the Phase II PACU nurse was also caring for a very sleepy 10-year-old whose mother was at his side and an adult who had just been transferred from Phase I. The nurse was just asked to admit and care for an endoscopy patient. After reviewing ASPAN’s recommended patient classification staffing guidelines, it is determined that the nurse’s assignment was:
a. appropriate if the unlicensed assistive personnel assigned to Phase II admits the new patient.
b. inappropriate because there is a one-nurse-to-three-patient ratio in Phase II at all times.
c. inappropriate because the 10-year-old patient requires a one-to-one patient ratio at all times.
d. appropriate for the condition of the patients described and necessary level of care.
2.9. Two clinical RNs working in the Phase I PACU already have the following assignments: Nurse One has an adult, conscious, stable, and free of complications; nurse Two has a 9-year-old conscious patient who is stable, and free of complications. The operating room (OR) wants to send a 7-year-old tonsillectomy patient who still has an oral airway in place. Which nurse should receive this assignment?
a. Neither one; the child should remain in the OR until the oral airway is removed and then proceed to Phase II.
b. Nurse One; the patient he or she has is an adult and can be watched easily while caring for an additional patient, making the assignment a one-nurse-to-two-patient ratio.
c. Nurse Two; the 10-year-old patient is already awake and a parent should be called in to sit at the bedside so that the nurse can care for the unconscious child.
d. The two patients already admitted should be combined into one assignment, freeing one nurse to take the new patient, which is a one-to-one patient ratio.
2.10. Privacy, informed consent, confidentiality of communications, and continuity of care are expectations mandated by:
a. The Joint Commission.
b. the Patient Self-Determination Act.
c. the Patient’s Bill of Rights.
d. Health Insurance Portability and Accountability Act (HIPAA).
2.11. To maintain confidentiality in a busy Phase I PACU with two patients next to each other, the nurse should:
a. move one patient to the end of the room when discussing specific information.
b. ask the patient not being spoken to to please not listen to the adjacent conversation.
c. pull the curtain around the patient being spoken to and lower your voice.
d. write everything down and do not speak aloud.
2.12. A hospital is located in an area with diverse multicultural populations. The staff demonstrates competency in:
a. an additional language besides English.
b. communicating by using a sign board.
c. transcultural nursing issues.
d. gender differences.
2.13. As patients are discharged from the Phase I area, monitors are cleared of memory, strips are discarded, and cubicles are cleaned. With regard to patient information, which important regulations went into effect in 2004 that increased sensitivity to all patient information?
a. The Joint Commission sentinel alert
b. HIPAA regulations
c. Hospital department policies
d. Occupational Safety and Health Administration (OSHA) standards
2.14. The staffing and personnel management standard of ASPAN’s 2006-2008 Standards of Perianesthesia Nursing Practice indicates that the professional perianesthesia nurse providing Phase I level of care will maintain certain competencies concerning Advanced Cardiac Life Support (ACLS) and Pediatric Advanced Life Support (PALS), and the expectation is:
a. an equivalent course of ACLS/PALS is provided and maintained by each individual facility.
b. current ACLS and/or PALS provider status is maintained appropriate to the patient population served.
c. current ACLS provider status is maintained and PALS offered when pediatric population exceeds 10 pediatric cases/day.
d. current Basic Life Support (BLS) provider status and be encouraged to seek ACLS/PALS.
2.15. A normally busy Phase II PACU is starting to discharge patients for the day. At 3 pm only two patients are remaining in the Phase II area. The normal staffing at this time if patient census is three or fewer is one licensed practical nurse/licensed vocational nurse (LPN/LVN) and one certified nursing assistant. After reviewing Standard III, the staff determines that this staffing assignment is:
a. appropriate only for one or two patients.
b. inappropriate; one more nursing assistant should be available.
c. appropriate as suggested.
d. inappropriate because one of the personnel must always be an RN.
2.16. It is an extremely busy day in the preanesthesia unit. There have been three staffing call-ins and four emergency cases added to the surgical schedule. Eight patients are already admitted to the unit, you have two RNs, one LPN, one certified nursing assistant, and one transporter. A new patient needs to be admitted, and you assign the LPN to this patient. This staffing assignment is:
a. inappropriate because the LPN is already watching two other patients.
b. appropriate because the RN is needed to administer medication.
c. inappropriate because the preanesthesia assessment is performed by an RN competent in preanesthesia nursing.
d. appropriate because the unit is short-staffed.
NOTE: Consider the scenario and items 2.17-2.21 together.
A 19-year-old patient is scheduled for a laminectomy. The doctor explained the procedure to the patient, explained alternatives to the proposed surgery, and then said “That’s it.” The patient had the surgery and suffered paralysis, a devastating complication.
2.17. Using the information given in the scenario just described, identify an important aspect that is missing when referring to “informed consent.”
a. Length of time of proposed surgery
b. Rehabilitation time after surgery
c. Risks and benefits of proposed surgery
d. Choice of anesthesia for proposed surgery
2.18. In a medical malpractice case, the court imposes the liability and responsibility for informed consent on:
a. the hospital and the physician.
b. solely the physician.
c. the preadmission nurse admitting the patient.
d. solely the patient.
2.19. Informed consent consists of:
a. the written document, signed by the patient explaining the proposed procedure.
b. explanation by preadmission nurse about procedure and what to expect.
c. explanation by physician about diagnosis, significant complications, benefits, and alternatives of surgery.
d. a written document detailing the surgical procedure and the proposed anesthetic plan.
2.20. The young patient in this scenario became paralyzed as a result of the laminectomy. There was considerable dispute in the resulting medical malpractice testimony as to what the patient was told. The patient stated he was not told about any possible complications or specifically about the risk of paralysis. The court held the:
a. nurses in the preadmission holding unit liable for not explaining possible postoperative complications.
b. physician liable for lack of an informed consent based on what a reasonable person would want to know.
c. hospital liable for failure to obtain an informed consent.
d. hospital and the physician liable for failure to obtain a written consent form detailing possible complications.
2.21. A patient must consent to being touched; otherwise a patient can claim:
a. breach of confidentiality.
b. battery.
c. assault and battery.
d. invasion of privacy.
NOTE: Consider the scenario and items 2.22-2.25 together.
A group of PACU nurses are eating together in the cafeteria. They begin talking about several of the young teenage girls they took care of that morning and accidentally interchange names and diagnoses. One of the nurses incorrectly identified the wrong girl as having been pregnant.
2.22. This discussion involves a quasi-intentional tort called:
a. invasion of privacy.
b. defamation of character.
c. disclosure of confidential information.
d. misrepresentation and fraud.
2.23. The nurses continue discussing these young patients they have been caring for, commenting on information the girls relayed to them during the admission process. Discussing this information in the cafeteria involves a quasi-intentional tort called:
a. breach of confidentiality.
b. disclosure of confidential information.
c. defamation of character.
d. invasion of privacy.
2.24. One of the visitors sitting in the cafeteria overheard the conversation. He was a school teacher at the incorrectly identified teenager’s school. He shared the information he had heard with the school principal. This resulting tort is called:
a. a HIPAA violation.
b. fraud.
c. invasion of privacy.
d. misrepresentation.
2.25. The majority of lawsuits brought against nurses are based on negligence; a significant number involve an area of law known as intentional and quasi-intentional torts. Intentional torts most often seen in health care are:
a. breach of duty, unprofessional conduct, and defamation of character.
b. assault and battery, false imprisonment, and conversion of property.
c. breach of confidentiality, professional incompetence, and invasion of privacy.
d. misrepresentation, fraud, slander, and libel.
NOTE: Consider the scenario and items 2.26-2.28 together.
Three clinical RNs working in the Phase I PACU anticipate five patient admissions during the next 90 minutes and collaboratively plan nursing care assignments. Patients already in the PACU include a sedated 13-year-old boy whose oral airway was just removed and now has an SpO2 of 98% and respiratory rate of 15 breaths per minute and an awake 9-year-old girl who is accompanied by her mother. The staff intends to provide safe nursing care that aligns with staffing recommendations in ASPAN’s 2006-2008 Standards of Perianesthesia Nursing Practice. One suggested assignment option is to have one nurse care for both children and to admit one adult woman after her cardioversion ends in 5 minutes.
2.26. After reviewing ASPAN’s recommended patient classification guidelines, the staff determines that this assignment option is:
2.27. The nurse to patient ratio changes to a one-on-one ratio with children when the child is:
a. 9 years old, awake, but without a parent to sit with him or her.
b. 13 years old without an artificial airway.
c. younger than 8 years and uncon-scious.
d. 8 years old and conscious with a parent at the bedside.
2.28. ASPAN’s patient classification guidelines give specific criteria for nurse to patient ratios in the Phase I PACU. Ratios include:
a. one nurse to one patient, one nurse to two patients, and two nurses to one patient.
b. one nurse to one patient, two nurses to one patient, and one nurse to three patients.
c. two nurses to one patient, one nurse to two patients, and one nurse to three patients.
d. one nurse to three patients with a second nurse available to assist as necessary.
2.29. Conditions most associated with increased risk of nosocomial infection include all of the following except:
a. broad-spectrum antibiotics.
b. applied asepsis principles.
c. multiple invasive catheters.
d. concurrent multisystem illnesses.
2.30. The nurse obtains the most appropriate supplies, as recommended by the Malignant Hyperthermia Association of the United States, including dantrolene sodium and:
a. bag-valve-mask unit with oxygen, iced crystalloid, and sodium bicarbonate.
b. succinylcholine, ventilator, and renal-dose dopamine.
c. chilled gastric lavage, lidocaine, and pressure monitoring equipment.
d. phenylephrine, cooling blanket, and midazolam.
2.31. To reconstitute dantrolene, you will need:
a. sterile water.
b. normal saline.
c. normal saline without additives.
d. sterile water without preservatives.
ITEMS 2.32–2.51
NOTE: Consider the scenario and items 2.32-2.33 together.
During a postoperative transfusion of banked packed red blood cells through an electrically operated blood warmer, the patient’s temperature increases to 39° C (102.2° F). The nurse observes the color of blood entering the patient is bright red; the blood tubing feels hot. The transfusion is immediately discontinued and returned to the blood bank, where the blood temperature registers 42° C (107.6° F). An “overtemperature” alarm failed to signal increasing blood temperature before cell hemolysis.
2.32. The clinical nurse’s responsibility includes:
a. determining whether long-term patient harm occurred.
b. reporting the incident directly to the manufacturer.
c. informing facility managers of the malfunction.
d. returning the equipment for quick biomedical repair.
2.33. In addition to the reporting process concerning equipment failure, what additional piece of documentation should be completed concerning the patient’s problem?
a. A root cause analysis form
b. A hospital incident report
c. A medical equipment log
d. A biomedical safety alert form
NOTE: Consider the scenario and items 2.34-2.38 together.
The orthopedist orders 5 mg midazolam and 25 mg meperidine intravenously for an adult male patient’s moderate sedation. The orthopedist then gives the nurse a list of supplies, sterile gloves, antibiotics, and additional medications, which are needed from the preanesthesia holding unit.
2.34. In this situation, the PACU nurse’s primary responsibility is to:
a. administer medications as ordered and then obtain the necessary supplies.
b. locate an anesthesia-certified colleague to administer medications as ordered.
c. collaborate with the surgeon to adjust and individualize the medication doses as monitoring of the patient indicates.
d. obtain the supplies while the orthopedist medicates the patient and begins the procedure.
2.35. The PACU nurse reminds the orthopedist that the patient takes phenelzine (Nardil) each day for depression. His last dose was 9 pm last evening. One medication to avoid is:
a. streptomycin.
b. midazolam.
c. ketorolac.
d. meperidine.
2.36. Physiologic measurements should include but not be limited to:
a. level of consciousness, temperature, pain assessment, and ability to talk.
b. respiratory rate, oxygen saturation, blood pressure, cardiac rate/rhythm, and level of consciousness.
c. respiratory rate, oxygen saturation, blood pressure and pulse, and temperature.
d. blood pressure, pulse, respirations, and oxygen saturation.
2.37. Which of the following emergency equipment must be immediately available during the administration of and recovery from sedation?
b. Oxygen, appropriate airways, reversal agents, and code button to summon emergency cart
c. Emergency cart with defibrillator, respiratory equipment, and all medications
d. Bag-valve-mask devices, oxygen, and emergency plan to transfer patient if needed
NOTE: The scenario continues.
2.38. The nurse assesses that the patient is wincing and is not relaxed; the orthopedist now asks the nurse to administer methohexital 50 mg. When the orthopedist asks the nurse to administer methohexital 50 mg, a legally appropriate response for the PACU nurse to ask the physician is to delay further manipulation and:
a. observe the patient while the nurse obtains methohexital.
b. ask an anesthesia provider to administer methohexital.
c. quickly review the state’s nurse practice act.
d. attach a pulse oximeter and cardiac and blood pressure monitors.
NOTE: Consider the scenario and items 2.39-2.40 together.
A PACU nurse is named in a malpractice lawsuit 6 months after a patient alleges she developed a back wound infection on the day of her L3-L4 hemilaminectomy and microdiskectomy surgery. The complaint states that the PACU was busy and that her nurse care provider improperly changed her bleeding back wound dressing after caring for another patient with hepatitis and then failed to inform the neurosurgeon of bleeding.
2.39. To demonstrate negligence, this patient must prove:
a. legal duty.
b. harmful intent.
c. undesirable outcome.
d. damaging conduct.
2.40. Criteria used to measure this nurse’s clinical performance may include showing that her nursing care aligned with accepted community practice and demonstrating:
a. that a nurse is accountable only to the unit manager.
b. compliance with 2006-2008 Standards of Perianesthesia Nursing Practice.
c. a lack of proximate cause during wound assessment.
d. that her skills equal the performance of a certified colleague.
2.41. A 6-year-old patient is undergoing a tonsillectomy, adenoidectomy, and bilateral myringotomy. At the end of the surgical procedure, the child is still unresponsive, placed on the stretcher, and transferred by the anesthesiologist alone to the PACU. The operating room suite is the last room in a long hallway. The child begins to wake up while en route to the PACU, starts thrashing, and before the anesthesiologist can intercede, has struck his arm on the stretcher rail, resulting in a fracture. Because of this injury, the hospital may have placed itself in jeopardy of a medical malpractice claim. What part of the scenario would be the probable cause based on understanding of the 2006-2008 Standards of Perianesthesia Nursing Practice?
a. Children should not be transported unresponsive.
b. Children should not be transported alone by one person.
c. Appropriate safety features should be used, especially when transporting children.
d. Children should be transferred by carrying them to the PACU.
2.42. When describing something that you observe with a patient, it is very important that you chart:
a. immediately.
b. objectively.
c. sequentially.
d. subjectively.
2.43. A particularly troubling problem in writing orders and in taking both verbal and telephone orders prompted The Joint Commission to put out a list of:
a. grammar mistakes.
b. frequently misspelled medications.
c. abbreviations not to use.
d. incorrect dosages.
2.44. When documenting patient assessments, it is important to:
a. leave several blank lines so that you can be sure to have enough space to finish your narrative charting.
b. date and time each entry and sign your name at the end of the documentation.
c. include every single comment made by the patient.
d. document an assessment every 10 min-utes, even if nothing has changed.
2.45. The nurse working 7 am-3:30 pm has left for the day. She calls on her cell phone at 4:15 pm and asks you to chart a medication that was given to a patient who was transferred to Phase II just before she left. What should you do?
a. Take down the exact information (drug, dose, and time given) and chart it on the patient’s chart.
b. File an incident report and ask her to come back to work immediately and chart this information.
c. Report the information to the nurse caring for the patient and save the chart for a late entry to be made.
d. Refer the call to the manager and let him or her decide what to do.
2.46. The purpose of taking a deposition is to:
a. let everyone involved in the care know what to say in case there is a trial.
b. get testimony from anyone thought to have information pertaining to the case.
c. practice the testimony you will actually give in court.
d. allow you to meet the patient’s attorney and learn why they are claiming medical malpractice.
2.47. A deposition is:
a. a friendly gathering to discuss the details of the case.
b. testimony given under oath, recorded by a court reporter.
c. an informal hearing to establish who needs to testify.
d. a formal hearing with judge and witnesses.
2.48. All of the information given during the deposition is:
a. inadmissible during a real medical malpractice trial.
b. can be used in future examination and testimony.
c. used, but only with consent of those at the deposition.
d. admitted into the trial with the judge’s approval.
2.49. A critical element of the perianesthesia nurse’s educational growth is willingness to:
a. work alone to provide care and education for four patients in a Phase II PACU.
b. demonstrate selected PACU competencies each year.
c. delegate mandibular support to the medical aide.
d. attend one educational seminar and adapt content to orient a colleague.
2.50. The PACU nurse reviews literature describing visitation by family members in the PACU for the unit’s monthly journal club meeting. After critiquing several studies that report anxiety reduction among visited patients, the perianesthesia nurse supports incorporating study recommendations into unit practice. When preparing his journal club presentation, this nurse carefully phrases research conclusions as:
a. proof that visited patients have shorter PACU stays.
b. decisive evidence that refutes skepticism of peers.
c. a technique to encourage family bonding.
d. information to support PACU policy for visitation.
2.51. ASPAN’s 2006-2008 Standards of Perianesthesia Nursing Practice recommends current ACLS provider certification for perianesthesia nurses. The American Heart Association (AHA) recommends that ACLS provider status occur:
a. annually.
b. every 2 years.
c. every 3 years.
d. before The Joint Commission visitation.
ITEMS 2.52–2.78
2.52. A 95-year-old resident of a long-term care facility with a “do not resuscitate or intubate” (DNR/DNI) advance directive fell and broke her hip. The physician orders a “no cardiopulmonary resuscitation (CPR)” status for the duration of the hospitalization. Her family signs consent for surgical repair. With regard to the advance directive in the PACU, ethical guidelines as interpreted by recent literature recommend:
a. perioperative continuation of the DNR/DNI directive.
b. automatic revocation until return to long-term care.
c. focused review of intent for perianesthesia period.
d. suspension of the DNI directive and retention of the DNR portion.
2.53. The nurse’s advocacy role to promote patient well-being is predicated on the ethical principle of:
a. beneficence.
b. autonomy.
c. fidelity.
d. justice.
2.54. The word “ethical” is used to refer to:
a. moral principles.
b. reasons for decisions about how one ought to act.
c. nonnegotiable care.
d. explicit primary obligations.
2.55. The next patient admitted to the PACU, Phase I, is a 32-year-old woman who had a breast biopsy. She was extremely anxious in the preoperative holding area. The anesthesiologist tells you that the physician believes the biopsy is definitely positive but wants you to tell the patient that “everything is fine” until he sees her in the office. Which ethical principle does this challenge?
a. Justice
b. Fidelity
c. Double-effect
d. Veracity
2.56. A 17-year-old patient is scheduled for an abortion. Three staff nurses are on duty during the afternoon shift. Two nurses have assignments, and nurse C is free to accept a patient. Nurse C objects to this assignment. Ethical responsibility to patients includes ensuring that all patients are cared for by a professional nurse. This responsibility can be challenged when:
a. there are too many patients and not enough staff, causing an inequity in patient ratios.
b. the perianesthesia nurse’s personal convictions prohibit participation.
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