Nokea
A nurse is asked to perform a task that she believes is outside her scope of practice. What is the appropriate response to this issue?
- A. Contact the state board of nursing licensure to report the offense
- B. Review the state scope of practice standards for nurses
- C. Ask another nurse to perform the task to learn the procedure
- D. Contact the house supervisor to make the decision on whether the nurse should perform the task
Correct Answer: B
Rationale: The correct answer is B: Review the state scope of practice standards for nurses. This is the appropriate response as it allows the nurse to understand her legal boundaries and responsibilities. By reviewing the state scope of practice standards, the nurse can ensure she is acting within the limits of her licensure and avoid potential legal or ethical issues.
Choice A is incorrect because reporting the offense to the state board of nursing licensure should not be the initial response without first verifying the scope of practice standards. Choice C is incorrect as it does not address the issue of the nurse operating outside her scope of practice. Choice D is incorrect as the house supervisor may not have the necessary knowledge of the nurse's scope of practice.
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The charge nurse is notified that the unit will be receiving an admission of a client from another bed in the hospital in order to make room for others being admitted through the emergency room. The unit is the Women's Health Center of the hospital. Which of the following patients would be most appropriate to be transferred to this unit?
- A. A 26-year-old woman who had a bowel resection
- B. A 40-year-old man who underwent a hernia repair
- C. A 31-year-old woman with septicemia and who is on a ventilator
- D. A 91-year-old man with Alzheimer's disease recovering from a fall
Correct Answer: A
Rationale: The correct answer is A: A 26-year-old woman who had a bowel resection. This choice is appropriate for the Women's Health Center as it aligns with the specialization of the unit in women's health. The patient's condition is surgical in nature, which can be managed effectively in a women's health unit that likely has the necessary resources and expertise to care for post-surgical patients.
Choice B: A 40-year-old man who underwent a hernia repair, is incorrect because it is not aligned with the specialization of the Women's Health Center.
Choice C: A 31-year-old woman with septicemia and on a ventilator, is incorrect because this patient requires intensive care and support beyond what a women's health unit can provide.
Choice D: A 91-year-old man with Alzheimer's disease recovering from a fall, is incorrect because this patient's needs are more aligned with geriatric care rather than women's health.
A nurse is required to float to another unit within the hospital where he is asked to care for a client on a ventilator. The nurse is uncomfortable with this assignment, as he has not had a ventilated client since nursing school. What is the nurse's most appropriate response?
- A. Explain to the nursing supervisor the level of discomfort and ask for a different assignment
- B. State that the client's needs are outside the nurse's scope of practice and request a different assignment
- C. Accept the assignment, asking for help when necessary
- D. Request to return to the home unit and send another nurse who can perform the job
Correct Answer: A
Rationale: The correct answer is A: Explain to the nursing supervisor the level of discomfort and ask for a different assignment. This is the most appropriate response because the nurse is being transparent about their discomfort and seeking a solution to ensure quality care for the client. By communicating concerns, the nurse can potentially be given a more suitable assignment or receive additional training. Option B is incorrect as it is important for nurses to continuously learn and adapt to new situations within their scope of practice. Option C is not ideal as the nurse should not take on a task they are uncomfortable with without proper support. Option D is not the best choice as it does not address the issue directly with the supervisor.
A 39-year-old woman presents for treatment of excessive vaginal bleeding after giving birth to twins one week ago. Which nursing diagnosis is most appropriate in this situation?
- A. Knowledge Deficit related to post-partum blood loss
- B. Self-Care Deficit related to post-partum neglect
- C. Fluid Volume Deficit related to post-partum hemorrhage
- D. Body Image Disturbance related to body changes after delivery
Correct Answer: C
Rationale: The correct answer is C: Fluid Volume Deficit related to post-partum hemorrhage. This nursing diagnosis is most appropriate because excessive vaginal bleeding can lead to a significant loss of blood volume, potentially resulting in hypovolemia. It is crucial to address this issue promptly to prevent further complications. Choice A is incorrect as the primary concern is the fluid volume deficit, not knowledge deficit. Choice B is incorrect as self-care deficit is not the priority in this situation. Choice D is incorrect as body image disturbance is not directly related to the excessive bleeding.
Which of the following is an example of the intervention phase of the individualized nursing care plan for a client who receives a colostomy after a bowel resection?
- A. Taking a health history and performing a physical exam prior to the procedure
- B. Instructing the client about how to care for his colostomy stoma
- C. Developing goals that state the client will ambulate three times a day
- D. Determining that the client may need more support at home after dismissal
Correct Answer: B
Rationale: The correct answer is B. Instructing the client about how to care for his colostomy stoma is an example of the intervention phase as it involves providing specific guidance to the client on post-operative care. This intervention directly addresses the client's needs post-colostomy and helps promote optimal healing and adjustment.
Choice A is part of the assessment phase, which occurs before the intervention phase. Choice C involves goal-setting, which is part of the planning phase. Choice D pertains to discharge planning, which is part of the evaluation phase.
In summary, Choice B is the correct answer because it aligns with the intervention phase of the nursing care plan, focusing on providing necessary education and support to the client regarding colostomy care.
At the beginning of her shift in a long-term care facility, which of the following clients should a nurse check on first?
- A. A 91-year-old man who needs help eating breakfast
- B. An 86-year-old man who has been incontinent in his bed
- C. An 82-year-old woman who needs IV antibiotics
- D. A 75-year-old man who is recovering from an injury and needs an ice pack
Correct Answer: C
Rationale: The correct answer is C: An 82-year-old woman who needs IV antibiotics. Checking on this client first is crucial because IV antibiotics are time-sensitive and require proper administration to ensure the effectiveness of treatment. Delaying or missing a dose can have serious consequences for the client's health. The other choices, while important, can be prioritized after attending to the client needing IV antibiotics. A: The 91-year-old man needing help eating breakfast can wait a bit longer. B: The 86-year-old man who has been incontinent can be addressed after the client needing IV antibiotics. D: The 75-year-old man recovering from an injury and needing an ice pack can also be attended to after the client requiring IV antibiotics.