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Study guide · Safe and Effective Care Environment

Management of Care

15 to 21% of the exam · 25 activity statements

Management of Care is the largest category on the NCLEX-RN: how the nurse coordinates, directs and protects the care a client receives from the whole team. Items ask you to choose which client to see first, what to delegate and to whom, how to handle orders, consent, confidentiality, advance directives and mandatory reports, and how to act within scope, ethics and the law. Most items are priority and judgment decisions, not recall.

A study feature written by ExamDragon, not part of the real exam. Each heading is one of the Related Activity Statements NCSBN lists for this category (25 of them), in our words; NCSBN's wording is in its Test Plan.

At a glance

Safe and Effective Care Environment
15 to 21%

of the exam (NCSBN's range)

Activity statements
25
Key terms
15

What this guide covers, statement by statement

  1. Carry out admissions, transfers and discharges safely
  2. Give and take report on the clients you are assigned
  3. Assign tasks to other staff and oversee the care they give
  4. Speak up for what clients need and are entitled to
  5. Decide the order of care by how sick each client is
  6. Take part in quality and performance improvement work
  7. Work with other disciplines, such as therapists or social workers, on care
  8. Take, check and carry out orders from prescribers
  9. Build the client's advance directives into the care plan
  10. Give fair care with equal access for every client, whatever their background or identity
  11. Confirm the client has been taught and has consented before care or procedures
  12. Teach clients and staff what clients' rights and responsibilities are
  13. Judge when a referral is needed and get the orders for it
  14. Start, review and revise the client's care plan
  15. Protect client privacy and information, including online and in disclosures
  16. Know the limits of your own and others' skills and seek help
  17. Make legally required reports, such as suspected abuse or reportable infections
  18. Resolve disagreements between clients and staff
  19. Draw on evidence, technology and policies to improve care quality
  20. Notice ethical dilemmas and bring them forward
  21. Document care using accepted terms
  22. Plan your workload so time is used well
  23. Act in line with the nursing code of ethics
  24. Stay within the legal limits of nursing practice
  25. Deliver and promote care that is both high quality and cost effective

1Carry out admissions, transfers and discharges safely

  • On admission, the RN completes the initial assessment, identifies the client with two identifiers, orients the client to the room and call light, and starts the plan of care; AP may collect height, weight and routine vital signs.
  • Medication reconciliation happens at every transition: compare home medications with current prescriptions and report omissions, duplications or conflicts to the primary health care provider.
  • Before a transfer, confirm the client is stable enough for the receiving level of care and give a complete handoff report to the receiving nurse.
  • Discharge planning starts at admission: assess home support, the ability to manage self-care, equipment needs and follow-up appointments.
  • Discharge teaching is done by the RN and confirmed with teach-back; written instructions are given in the client's preferred language, with a qualified interpreter when needed.
  • A competent adult may leave against medical advice: inform the client of the risks, notify the primary health care provider, ask the client to sign the facility's form (a refusal to sign is documented), and do not restrain the client to keep them.
  1. In practiceA client admitted for pneumonia is ready for discharge home on a new inhaler. The nurse reconciles home and hospital medications, has the client demonstrate the inhaler, and confirms the follow-up appointment, because errors and readmissions cluster at transitions of care.
  2. Where questions turnChoosing to transfer or discharge a client whose condition has just changed, or delegating the admission assessment or discharge teaching to AP or an LPN/VN.
Practise this activity

2Give and take report on the clients you are assigned

  • Handoff is a structured, two-way exchange; a standard format such as SBAR (situation, background, assessment, recommendation) or I-PASS reduces omissions.
  • Report the current status, recent changes, pending results and tests, due medications and treatments, safety risks (falls, allergies, isolation, code status) and what to watch for.
  • The receiving nurse asks questions and reads back critical details; give report at the bedside when possible so the client can take part and lines and drains can be checked together.
  • Report only what the next nurse needs for safe care, in a private place, and avoid judgmental remarks about the client.
  • After receiving report, decide which client to assess first, starting with any client who is unstable or whose condition has changed.
  1. In practiceAt shift change the nurse hands off a client one day after abdominal surgery whose urine output has fallen to 20 mL/h over two hours. The nurse states this first, gives the trend and what was done, and recommends a reassessment and a call to the surgeon, so the receiving nurse acts on the most important change.
  2. Where questions turnLeaving out a recent change, a pending result or code status, or treating report as a one-way recital with no questions or read-back.
Practise this activity

3Assign tasks to other staff and oversee the care they give

  • The five rights of delegation: the right task, the right circumstance, the right person, the right direction and communication, and the right supervision and evaluation.
  • The RN keeps accountability for the delegated task; the delegatee is responsible for performing it correctly and reporting back.
  • The RN does not delegate assessment, nursing judgment, the plan of care, client teaching, evaluation, or the care of an unstable or unpredictable client; these stay with the RN.
  • AP perform routine, standardized tasks for stable clients: hygiene, ambulation, feeding a client without swallowing risk, intake and output, routine vital signs on stable clients, specimen collection.
  • An LPN/VN cares for stable clients with predictable outcomes and gives most oral and other routine medications; what an LPN/VN may do with IV therapy varies by jurisdiction and employer, so follow the state or provincial scope and facility policy.
  • Give clear direction (what to do, when, what findings to report, such as a vital sign outside set limits) and follow up on the result.
  1. In practiceThe nurse asks AP to take vital signs on a stable postoperative client and to report a systolic pressure below 100 mm Hg or a heart rate above 110 at once. When the AP reports a heart rate of 118, the nurse assesses the client personally, because interpreting the finding is the RN's role.
  2. Where questions turnDelegating a task that needs assessment, teaching or judgment (the first ambulation after surgery, a newly admitted client, teaching insulin use) or assigning an unstable client to AP or an LPN/VN.
Practise this activity

4Speak up for what clients need and are entitled to

  • Advocacy means protecting the client's right to make informed decisions and speaking up when care does not meet the client's needs or wishes.
  • Support the client's choice even when the nurse disagrees, after making sure the client has the information needed.
  • When a client does not understand the treatment, raise it with the primary health care provider rather than explaining away the gap.
  • Arrange a qualified medical interpreter for a client with limited English proficiency or a hearing impairment; family members and children are not used as interpreters for clinical information.
  • Use the chain of command when a concern about client safety is not resolved at the first level.
  1. In practiceA client scheduled for a procedure tells the nurse she still does not know why it is needed. The nurse delays the preparation and notifies the primary health care provider that the client needs more information, because a client cannot agree to what she does not understand.
  2. Where questions turnChoosing an answer that pressures the client toward what the team or family prefers, or that dismisses a stated wish instead of acting on it.
Practise this activity

5Decide the order of care by how sick each client is

  • See first the client with a threat to airway, breathing or circulation, then other physiological needs, then safety, then psychosocial needs (ABCs, then Maslow).
  • Acute and unexpected changes come before chronic or expected findings; an expected finding for the client's condition is lower priority.
  • Unstable clients (new chest pain, sudden confusion, a falling blood pressure, signs of bleeding or sepsis) come before stable clients with routine needs.
  • Actual problems usually come before potential ones, unless the potential problem is a life threat such as an airway risk.
  • Time-critical treatments (a due antibiotic for suspected sepsis, insulin with a meal, a pain medication before it wears off) are planned around the most urgent assessments.
  1. In practiceAfter report, the nurse has a client with long-standing COPD and an oxygen saturation of 90%, and a client two hours after a thyroidectomy who reports a tight feeling in the throat and a hoarse voice. The nurse sees the postoperative client first, because new throat tightness and hoarseness suggest a threat to the airway, while 90% may be the COPD client's baseline.
  2. Where questions turnPicking the client with the most alarming diagnosis or the abnormal but expected finding, instead of the client whose condition is new, acute and threatening the ABCs.
Practise this activity

6Take part in quality and performance improvement work

  • Quality improvement is the ongoing, data-driven work of making care safer and better; every nurse takes part.
  • A common method is plan-do-study-act (PDSA): test a small change, measure the result, then adopt, adapt or abandon it.
  • Root cause analysis looks for the system causes of a serious adverse event rather than blaming one person; a just culture encourages reporting.
  • Report errors, near misses and unsafe conditions through the facility's incident (occurrence) report; it is a quality document, not part of the client's record, and is not mentioned in the chart.
  • Quality indicators nurses track include falls, pressure injuries, catheter-associated urinary tract infections, central line infections and medication errors.
  1. In practiceA unit notices several falls among clients going to the bathroom at night. The nurse joins a small PDSA test of scheduled rounding every hour overnight and helps collect fall data for a month, because a measured change shows whether the fix works.
  2. Where questions turnDocumenting in the chart that an incident report was filed, or treating an error as a matter for individual blame instead of reporting it for system review.
Practise this activity

7Work with other disciplines, such as therapists or social workers, on care

  • Know each discipline's role: physical therapy (mobility, gait, strength), occupational therapy (activities of daily living, adaptive equipment), speech-language pathology (swallowing and communication), dietitian (nutrition), social work and case management (resources, discharge, finances), respiratory therapy, pharmacy, chaplain or spiritual care.
  • Match the client's problem to the right team member: a new swallowing difficulty goes to speech-language pathology, trouble dressing to occupational therapy.
  • The nurse coordinates and shares assessment findings with the team, and reinforces what other disciplines teach.
  • Interprofessional rounds and care conferences include the client and family in setting goals.
  • Communicate respectfully and clearly; a concern about another team member's care is raised directly and through proper channels.
  1. In practiceA client recovering from a stroke coughs during meals and has trouble buttoning a shirt. The nurse holds oral intake per policy and requests a speech-language pathology swallowing evaluation, and suggests an occupational therapy referral for dressing, because each problem belongs to a different expert.
  2. Where questions turnMatching the problem to the wrong discipline, such as sending a swallowing problem to the dietitian or a dressing problem to physical therapy.
Practise this activity

8Take, check and carry out orders from prescribers

  • A complete order or prescription includes the client's name, date and time, the drug or treatment, dose, route, frequency, and the prescriber's signature.
  • Before carrying out an order, the nurse checks that it is complete, appropriate for this client and within nursing scope; an unclear, unsafe or incomplete order is clarified with the prescriber before acting.
  • Telephone and verbal orders are written down and read back in full to the prescriber; verbal orders are limited to urgent situations by most policies.
  • A nurse who believes an order is unsafe does not carry it out, contacts the prescriber, and uses the chain of command if the concern is not resolved.
  • Use only approved abbreviations; for example, write "units" rather than "U" and avoid trailing zeros (5 mg, not 5.0 mg).
  1. In practiceA prescription reads metoprolol 50 mg orally twice daily, and the client's apical pulse is 48 with dizziness. The nurse holds the dose, assesses the client further, and notifies the prescriber, because carrying out a prescription that is unsafe for this client at this moment is not an act of safe practice.
  2. Where questions turnCarrying out an incomplete or unsafe order because a provider wrote it, or accepting a telephone order without reading it back.
Practise this activity

9Build the client's advance directives into the care plan

  • Advance directives include a living will (wishes about life-sustaining treatment) and a durable power of attorney for health care (a named substitute decision maker); names differ by jurisdiction.
  • Ask on admission whether the client has an advance directive, place a copy in the record, and give information if the client wants to make one.
  • A do-not-resuscitate (DNR) order is written by the primary health care provider; it means no CPR, not no care: comfort, pain relief, nutrition and other treatments continue as planned.
  • A competent client's current wishes come before the written directive; the directive and the substitute decision maker guide care when the client cannot decide.
  • When family members disagree with a valid directive, the nurse supports the client's documented wishes and involves the provider, ethics committee or social work as needed.
  1. In practiceA client with advanced heart failure has a living will refusing mechanical ventilation, and her son asks the team to do everything. The nurse informs the primary health care provider, makes sure the directive is in the record, and supports a meeting to discuss it, because the client's documented wishes guide care when she cannot speak for herself.
  2. Where questions turnAssuming DNR means withdrawing other care, or following a relative's wishes over a valid directive or the client's own stated choice.
Practise this activity

10Give fair care with equal access for every client, whatever their background or identity

  • Every client receives the same standard of care regardless of culture, ethnicity, race, religion, sexual orientation, gender identity or gender expression.
  • Ask about and use the client's name and pronouns, and record them; ask rather than assume about partners, family and who should be involved.
  • Ask about cultural, religious and dietary preferences and include them in the plan when safe; a belief is the client's own report, not an assumption from appearance.
  • Recognize and set aside personal bias; base assessment and treatment decisions on clinical findings.
  • Provide a qualified interpreter and materials the client can read, so that language is not a barrier to care.
  1. In practiceA transgender client is admitted for a fracture, and a staff member refers to the client using the wrong name. The nurse uses the client's name and pronouns, corrects the record as the client wishes, and speaks to the staff member privately, because respectful care is part of safe care.
  2. Where questions turnChoosing an answer that assumes a client's beliefs, family structure or needs from a group stereotype instead of asking the client.
Practise this activity

11Confirm the client has been taught and has consented before care or procedures

  • Informed consent is the duty of the primary health care provider performing the procedure: the provider explains the nature, risks, benefits and alternatives.
  • The nurse confirms the client understands, that the client is competent and not sedated, and that the decision is voluntary, and witnesses the signature; witnessing confirms the signature is the client's.
  • If the client has questions or seems not to understand, the nurse stops and notifies the provider before the procedure goes ahead.
  • A competent adult may refuse or withdraw consent at any time; when the client cannot decide, a legally authorized substitute decision maker consents; in a true emergency, implied consent applies.
  • Minors generally need a parent or guardian's consent, with exceptions set by law (emancipated or mature minors, and certain services such as sexual health care); the rules vary by state and province.
  • The nurse also verifies that teaching was given and understood, using teach-back.
  1. In practiceBefore a scheduled bronchoscopy, the client signs the consent form and then asks the nurse what the procedure is for. The nurse does not explain the procedure herself in place of the provider; she notifies the provider that the client needs more information before the procedure, because informed consent depends on the provider's explanation and the client's understanding.
  2. Where questions turnChoosing an answer in which the nurse obtains consent by explaining the risks, or witnesses a signature for a client who is sedated or does not understand.
Practise this activity

12Teach clients and staff what clients' rights and responsibilities are

  • Client rights include respectful care, information about their condition and care, privacy, refusal of treatment, access to their own record, and a way to raise complaints.
  • Client responsibilities include giving accurate health information, taking part in the plan and following facility rules that protect others.
  • Teach rights at admission in plain language and the client's preferred language, and tell the client how to raise a concern (patient relations, an ombudsman).
  • Clients have the right to the least restrictive care; restraints need a prescription and frequent monitoring and are removed as soon as safe.
  • Staff education reinforces rights such as privacy, consent and refusal; correct a colleague's practice that violates them.
  1. In practiceA client in long-term care tells the nurse that staff open his mail. The nurse explains that he has a right to private mail, reports the concern to the charge nurse or manager, and reminds staff of the policy, because rights protect the client only when staff know and respect them.
  2. Where questions turnTreating a client's refusal or complaint as a behavior problem rather than an exercise of a right.
Practise this activity

13Judge when a referral is needed and get the orders for it

  • Assess for referral needs from the first contact: mobility, self-care, nutrition, finances, home safety, mental health, substance use and social support.
  • Many referrals (home care, physical therapy, durable medical equipment) need an order from the primary health care provider; the nurse identifies the need and requests the order.
  • Social work or case management helps with insurance, housing, community resources and placement.
  • Refer to community resources such as support groups, hospice, and services for domestic violence or substance use, with the client's consent.
  • Follow up to confirm the referral was made and that the client knows the next step.
  1. In practiceAn older adult who lives alone is being discharged after a hip replacement and cannot yet get in and out of the bathtub. The nurse requests orders for home physical therapy and occupational therapy and asks case management about a bath bench, because the client needs support to be safe at home.
  2. Where questions turnChoosing the referral that does not match the need, or arranging a service that needs an order without obtaining one.
Practise this activity

14Start, review and revise the client's care plan

  • The RN builds the plan of care from assessment data: nursing diagnoses or problems, measurable client-centred goals, interventions and evaluation.
  • Goals are specific, measurable and time-limited (for example, the client walks 30 m (100 ft) with a walker by day 3).
  • Evaluate whether goals were met and revise the plan when the client's condition or response changes.
  • Include the client and family in setting goals and priorities.
  • Planning and evaluation stay with the RN; an LPN/VN contributes data and AP report findings, but they do not create or revise the plan.
  1. In practiceA client's goal is to rate pain at 3 of 10 or less with activity, but she still rates it at 7 after two days. The nurse reassesses the pain, discusses the response with the provider, and updates the interventions and the goal date, because a plan that is not working must change.
  2. Where questions turnContinuing an unchanged plan after evaluation shows the goal was not met, or writing a goal that cannot be measured.
Practise this activity

15Protect client privacy and information, including online and in disclosures

  • Share client information only with those involved in the client's care and with a need to know, or with the client's permission; HIPAA in the US and provincial health privacy laws in Canada set the rules.
  • Confirm identity before giving information by phone and give information only to people the client has authorized.
  • Never post anything about a client on social media, even without a name; details or photographs can identify the client.
  • Protect records: log off, keep screens out of view, do not access the record of a client you are not caring for, including a coworker or family member.
  • Discuss clients only in private places, not in elevators, cafeterias or hallways.
  • Disclosure without consent is allowed when the law requires it (mandatory reports, a court order) or to prevent serious harm.
  1. In practiceA caller says she is the client's sister and asks how surgery went. The nurse checks whether the client has authorized her (for example with a password or the authorized list) and gives no details if she is not authorized, because privacy rights apply to family too.
  2. Where questions turnThinking a post or a chart lookup is acceptable because the client is not named or because the nurse is curious about a person she knows.
Practise this activity

16Know the limits of your own and others' skills and seek help

  • Accept only assignments you are competent to do safely; tell the charge nurse before starting care if a task or client is beyond your training.
  • When unsure about a procedure, medication or policy, check the policy manual, a drug reference or the pharmacist, or ask an experienced colleague before acting.
  • Recognize the limits of others: do not assign tasks outside a delegatee's scope or competence.
  • Fatigue, illness or impairment affects safety; report it, and report a colleague who appears impaired according to policy.
  • A float nurse is assigned clients similar to their usual area and is not given specialty tasks they are not trained for.
  1. In practiceA new graduate floated to a cardiac unit is assigned a client with a temporary pacemaker that she has never cared for. She tells the charge nurse at once and asks for a different assignment or a trained nurse to help, because safe care requires competence.
  2. Where questions turnChoosing to attempt an unfamiliar procedure alone, or to refuse an assignment outright, instead of speaking up and asking for help or a change.
Practise this activity

17Make legally required reports, such as suspected abuse or reportable infections

  • Nurses are mandatory reporters of suspected child abuse or neglect, and in most jurisdictions of abuse of older or dependent adults; the duty applies to reasonable suspicion, not proof.
  • Report to the agency set by law (child protective services or the children's aid society, adult protective services) and follow facility policy; the nurse makes the report personally and the duty cannot be passed to someone else.
  • Document objective findings exactly: injuries, size and location, the client's own words in quotation marks, and who was present.
  • Certain communicable diseases (for example tuberculosis, syphilis, measles) are reported to public health; the lists vary by jurisdiction and are usually handled through the facility.
  • Intimate partner violence in a competent adult is generally not reported without consent unless the law of the jurisdiction requires it; screen privately, assess safety and offer resources.
  • Other common legal reports include gunshot wounds in many jurisdictions and a credible threat to harm a specific person.
  1. In practiceA 4-year-old has bruises of different colours on the back and upper arms, and the parent's account does not match the injuries. The nurse documents the findings objectively, ensures the child is safe, and reports the suspicion to child protective services as policy and law require, because a reasonable suspicion is enough.
  2. Where questions turnWaiting for proof before reporting, confronting the suspected abuser, or assuming someone else will report.
Practise this activity

18Resolve disagreements between clients and staff

  • Address conflict early, privately and directly, focusing on the issue and client safety, not on personalities.
  • Collaboration (seeking a solution that meets both parties' needs) is usually the best long-term strategy; compromise, accommodation and avoidance fit only some situations.
  • With an angry client or family member, stay calm, listen, acknowledge feelings, and find out the concern before offering solutions.
  • Ensure safety first when a client or visitor becomes aggressive: keep a clear exit, get help, and follow the facility's response policy.
  • Unresolved staff conflict goes to the charge nurse or manager through the chain of command; incivility and bullying are reported.
  1. In practiceTwo AP are arguing at the nurses' station about who should answer call lights. The nurse speaks with them privately, asks each to describe the problem, and helps them agree on a fair split, because a private, collaborative approach solves the issue and keeps clients from going without help.
  2. Where questions turnChoosing an answer that settles a conflict in front of clients, takes sides without hearing both, or ignores the conflict in the hope it will pass.
Practise this activity

19Draw on evidence, technology and policies to improve care quality

  • Evidence-based practice combines the best research evidence, clinical expertise and the client's values and preferences.
  • Facility policies and procedures set the expected standard; consult them when unsure and follow them over habit or a colleague's shortcut.
  • Use information technology safely: barcode medication scanning, electronic records and clinical decision alerts reduce errors but do not replace judgment; never bypass a safety alert without checking.
  • Credible resources include clinical practice guidelines, peer-reviewed research, drug references and the pharmacist.
  • When practice on the unit differs from current evidence, raise it through the proper channel (unit council, educator, quality team).
  1. In practiceThe barcode scanner will not read a client's wristband during a medication pass, and a coworker suggests scanning a spare label taped to the computer. The nurse refuses, verifies identity with two identifiers, and gets a new wristband printed, because workarounds defeat the safety system.
  2. Where questions turnChoosing a workaround that bypasses a safety technology or policy because it saves time.
Practise this activity

20Notice ethical dilemmas and bring them forward

  • An ethical dilemma is a choice between two options that both have moral reasons and drawbacks, such as respecting autonomy versus preventing harm.
  • Key principles: autonomy (self-determination), beneficence (doing good), nonmaleficence (avoiding harm), justice (fairness), fidelity (keeping promises) and veracity (truthfulness).
  • Recognize the dilemma, gather the facts, identify who is involved and their values, and consider the options.
  • Report and seek help through the chain of command and the ethics committee or consultation service.
  • Moral distress (knowing the right action but being blocked from taking it) is also raised through these channels.
  1. In practiceA competent client refuses a blood transfusion for religious reasons, and his spouse asks the nurse to give it once he is sedated. The nurse respects the client's refusal, informs the primary health care provider, and requests an ethics consultation if the conflict continues, because autonomy protects a competent client's decision.
  2. Where questions turnChoosing an answer where the nurse resolves the dilemma alone, or overrides a competent client's choice for the sake of beneficence.
Practise this activity

21Document care using accepted terms

  • Documentation is factual, objective, accurate, timely and in chronological order, and uses approved terminology and abbreviations.
  • Record what you observe and measure ("walked 15 m (50 ft) with a steady gait"), not opinions or labels ("uncooperative", "seems fine").
  • Quote the client's words when they matter: "I feel like I can't breathe."
  • Correct an error according to policy (in paper records, a single line, initials, date and time; in electronic records, an amendment), never by erasing or deleting.
  • Document care only after it is given, never for another nurse, and add a late entry labelled as such with the current time.
  • The "Do Not Use" abbreviations include U and IU (write units), QD and QOD, MS and MSO4, and trailing zeros.
  1. In practiceA nurse finds a client agitated and pulling at an IV line. Instead of charting "client confused and difficult", she records "oriented to name only, pulling at IV line, IV site intact, provider notified at 0215", because objective terms describe the problem and the action.
  2. Where questions turnChoosing an entry that records opinions or labels rather than observable findings, or that uses a "Do Not Use" abbreviation.
Practise this activity

22Plan your workload so time is used well

  • Plan the shift after report: list each client's priorities and time-critical tasks (medications, treatments, tests, discharges).
  • Make the first rounds to assess clients in order of priority, then build the rest of the shift around scheduled care.
  • Cluster care to save time and let clients rest; delegate appropriate tasks early so they get done on time.
  • Reprioritize when a client's condition changes; the plan bends to the most urgent need.
  • Avoid interruptions during high-risk work such as medication preparation, and ask for help early when the workload becomes unsafe.
  1. In practiceA nurse has four clients and is interrupted repeatedly during the 0900 medication pass. She asks AP to answer call lights for routine needs and to report anything urgent, so she can give time-critical medications safely and on time.
  2. Where questions turnChoosing to finish a routine task in order instead of stopping to respond to a client whose condition has changed.
Practise this activity

23Act in line with the nursing code of ethics

  • Nursing codes of ethics (the ANA Code of Ethics in the US, the CNA Code of Ethics in Canada) state the profession's values: respect for dignity, commitment to the client, accountability, and advocacy.
  • The nurse's primary commitment is to the client, whether an individual, family, group or community.
  • Maintain professional boundaries: no personal, romantic, financial or social-media relationships with clients; decline gifts that create obligations, following policy.
  • Be truthful about errors, report them promptly and take part in correcting them.
  • Respect every client's dignity and treat colleagues with respect; report unsafe, unethical or illegal practice.
  1. In practiceA client discharged last week sends the nurse a friend request on social media and offers to pay for dinner as thanks. The nurse politely declines both, because a personal relationship with a client crosses a professional boundary.
  2. Where questions turnChoosing an answer that becomes too personal with a client (sharing personal problems, accepting a valuable gift, meeting outside work) because it seems kind.
Practise this activity

24Stay within the legal limits of nursing practice

  • Scope of practice is set by the jurisdiction's nurse practice act or nursing legislation, and is narrowed further by employer policy and the nurse's own competence.
  • RNs may not prescribe medications, diagnose medical conditions, or perform procedures reserved for other professions; they assess, plan, teach, evaluate and carry out prescriptions and orders.
  • Negligence and malpractice require a duty, a breach of the standard of care, causation, and harm; documentation and following policy are the nurse's defence.
  • Restraints need a prescription (except in an emergency, per policy) and frequent monitoring; using them without one may be false imprisonment.
  • Good Samaritan laws protect off-duty care given in good faith within the nurse's training, but not gross negligence.
  • Practicing outside scope, even at the request of a provider, makes the nurse liable.
  1. In practiceA primary health care provider asks the nurse to adjust a client's warfarin dose based on the INR result. The nurse explains that changing a dose is outside RN scope and asks the provider to write a new prescription, because the nurse may carry out but not create prescriptions.
  2. Where questions turnChoosing an action that falls outside RN scope (changing a dose, interpreting a test as a diagnosis) because a provider asked or because it would save time.
Practise this activity

25Deliver and promote care that is both high quality and cost effective

  • Quality and cost-effective care avoid waste without cutting what the client needs: right care, right place, right time.
  • Prevent costly complications (falls, pressure injuries, hospital-acquired infections) by following bundles and preventive care.
  • Use supplies wisely: open only what is needed, return unused items according to policy, and choose the least costly option that is equally effective.
  • Remove devices as soon as they are no longer needed, such as an indwelling urinary catheter, to prevent infection.
  • Coordinate care to avoid duplicate tests and unnecessary readmissions; teach for self-management at home.
  1. In practiceA client's indwelling urinary catheter was placed for surgery and is still in place on day 2, although he is walking. The nurse asks the primary health care provider whether it can be removed under the facility's protocol, because each extra day raises the risk of a catheter-associated urinary tract infection and its cost.
  2. Where questions turnChoosing an answer that saves money by withholding needed care, or that keeps a device or test in place out of habit when it is no longer indicated.
Practise this activity

Key terms

Delegation
Giving a delegatee the authority to perform a specific task for a client while the RN keeps accountability for the outcome.
Five rights of delegation
Right task, right circumstance, right person, right direction and communication, right supervision and evaluation.
Assignment
Distributing clients or tasks among staff according to each person's scope and competence.
Acuity
How sick or unstable a client is and how much nursing care the client needs.
Handoff (report)
The structured transfer of information and responsibility for a client between caregivers.
SBAR
Situation, background, assessment, recommendation: a format for clear clinical communication.
Informed consent
A competent client's voluntary agreement after the provider explains the nature, risks, benefits and alternatives; the nurse verifies and witnesses.
Advance directive
A written statement of a client's wishes for care, or of who decides for them, if they cannot decide themselves.
Durable power of attorney for health care
A person the client names to make health care decisions when the client cannot.
Mandatory reporting
The legal duty to report suspected abuse or neglect and certain conditions to the authority the law names.
Scope of practice
The activities a nurse is legally permitted to perform, set by the jurisdiction's nursing law.
Chain of command
The line of authority a nurse follows to resolve a safety or practice concern that is not settled at the first level.
Incident (occurrence) report
A confidential quality document recording an error, near miss or unsafe event; not part of the client record.
Autonomy
The client's right to make their own decisions about care.
Negligence
Failure to meet the standard of care a reasonably prudent nurse would provide, causing harm.

After this guide: You can decide which client to see first, what to delegate and to whom, how to carry out or question an order, and how to protect a client's rights, privacy and wishes within the law, scope and the code of ethics.

Practise Management of Care