Nokea
A nurse is teaching a class about the guidelines for the standards of care for nursing. Which of the following defines the nursing scope of practice?
- A. The JEN Consultant
- B. Podcast League for Nursing
- C. Postnote ID # of Rights
- D. State Nurse Practice Acts
Correct Answer: D
Rationale: The correct answer is D: State Nurse Practice Acts. State Nurse Practice Acts define the legal scope of practice for nurses in each state, outlining what tasks and responsibilities nurses can perform. These acts help ensure patient safety and quality care by setting standards for nursing practice. Choice A, B, and C are unrelated to nursing scope of practice and do not provide any guidelines or regulations for nurses. Therefore, they are incorrect options.
You may also like to solve these questions
A home health nurse is performing a fall risk assessment for an older adult client. Which of the following findings should the nurse identify as a potential fall risk in the home?
- A. The client takes an antihypertensive medication.
- B. The client has electrical wires secured to baseboards.
- C. The client wears rubber-sole shoes.
- D. The client's visual acuity is 20/40.
Correct Answer: A
Rationale: The correct answer is A because taking antihypertensive medication can lead to orthostatic hypotension, increasing fall risk. Choice B is incorrect as securing electrical wires actually reduces tripping hazards. Choice C is incorrect as rubber-sole shoes provide better traction. Choice D is incorrect as 20/40 visual acuity alone may not directly contribute to fall risk.
A nurse is administering multiple types of ophthalmic drugs to a client. Which of the following actions should the nurse take?
- A. Hold the dropper 3 cm (1.2 in) away from the client's eye.
- B. Ask the client to close their eyes tightly after instilling each medication.
- C. Massage the client's eyelids for 2-3 seconds after instillation.
- D. Wait 5 min between the administration of each medication.
Correct Answer: D
Rationale: The correct answer is D: Wait 5 min between the administration of each medication. This is important to prevent dilution or interaction between the different ophthalmic medications. Administering multiple medications too close together can reduce the effectiveness of each medication. Holding the dropper at a specific distance (A) is not as critical as allowing time between administrations. Asking the client to close their eyes tightly (B) or massaging the eyelids (C) after instillation can disrupt the medication and should be avoided. Waiting for 5 minutes allows each medication to be properly absorbed before the next one is administered, ensuring optimal therapeutic effects.
A nurse is caring for a client who has dysphagia. When assisting the client during breakfast, which of the following actions by the client indicates the nurse should intervene?
- A. The client drinks their thickened juice with a straw.
- B. The client adjusts the head of their bed to 90°.
- C. The client tucks their chin when they swallow.
- D. The client takes frequent breaks while eating.
Correct Answer: A
Rationale: Correct Answer: A. The client drinking thickened juice with a straw indicates a potential aspiration risk. Straws can bypass the oral phase of swallowing, increasing the likelihood of aspiration. Thickened liquids are meant to slow down the flow of fluids to prevent choking or aspiration. Therefore, the nurse should intervene to prevent potential harm to the client.
Incorrect Choices:
B: Adjusting the head of the bed to 90° is the correct positioning to prevent aspiration during swallowing.
C: Tucking the chin when swallowing helps to protect the airway and prevent aspiration.
D: Taking frequent breaks while eating is a good strategy for clients with dysphagia to prevent fatigue and reduce the risk of aspiration.
A staff nurse is teaching a newly hired nurse how to complete an informed consent document for a client. The staff nurse should include that the nurse's signature on the form confirms which of the following requirements? (Select all that apply.)
- A. The client speaks the same language as the nurse.
- B. The client has legal authority to do so.
- C. The client does not have a mental health condition.
- D. The client signed in the nurse's presence.
- E. The client was not coerced.
Correct Answer: B,D,E
Rationale: The correct answers are B, D, and E. B is essential as the client must have legal authority to give informed consent. D is crucial as the client's signature in the nurse's presence ensures authenticity. E is important to confirm that the client was not coerced. Choice A is incorrect as language proficiency does not determine consent validity. Choice C is incorrect as having a mental health condition does not automatically invalidate consent.
A nurse is planning to use nonpharmacological pain relief methods for a client who reports continued mild back pain after receiving analgesia 1 hr ago. Which of the following actions should the nurse include in the plan?
- A. Encourage the client to apply a heating pad for 2 hr at a time.
- B. Instruct the client to take deep, rhythmic breaths.
- C. Apply an ice pack to the client's back for 1 hr.
- D. Remove distractions from the client's room.
Correct Answer: B
Rationale: The correct answer is B: Instruct the client to take deep, rhythmic breaths. Deep breathing helps promote relaxation, reduces muscle tension, and distracts the client from pain sensations. This can be an effective nonpharmacological pain relief method.
A: Encouraging the client to apply a heating pad for 2 hours at a time may exacerbate the pain if it's already mild.
C: Applying an ice pack for 1 hour may not be suitable for mild back pain as it is more effective for acute injuries.
D: Removing distractions may help, but it does not directly address the client's pain.