Nokea
Which components are used in determining the standards of professional nursing practice? Select all that apply.
- A. Care given with good intention to the best of one’s ability
- B. Clinical practice statements of professional organizations
- C. Health care institution’s policies and procedures
- D. Nurse Practice Act of the state or province/territory
- E. Nurse’s usual custom and practice
Correct Answer: B,C,D
Rationale: Standards are set by professional organizations, institutional policies, and state Nurse Practice Acts. Good intentions and personal customs do not define professional standards.
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A practical nurse (PN) is assigned to care for a newborn with a neural tube defect. Which dressing, if applied by the PN, would need no further intervention by the charge nurse?
- A. Telfa dressing with antibiotic ointment
- B. Moist sterile nonadherent dressing
- C. Dry sterile dressing that is occlusive
- D. Sterile occlusive pressure dressing
Correct Answer: B
Rationale: Before surgical closure, the sac is prevented from drying by the application of a sterile, moist, nonadherent dressing over the defect. Dressings are changed frequently to keep them moist.
What information would be most important for the nurse to obtain from a client with suspected bladder cancer who reports blood in the urine but no associated pain?
- A. Family history
- B. Industrial chemical exposure
- C. Tobacco use
- D. Usual diet
Correct Answer: C
Rationale: Tobacco use is the strongest risk factor for bladder cancer, strongly linked to painless hematuria. Chemical exposure is relevant but less common, family history is weak, and diet is not a primary factor.
The client has an IV in place when he returns for surgery. While examining the IV site, the licensed practical nurse notices pallor, coolness, and edema. The nurse is aware that these are signs of:
- A. Infiltration
- B. Infection
- C. Thrombus formation
- D. Sclerosing of the vein
Correct Answer: A
Rationale: Pallor, coolness, and edema at an IV site indicate infiltration, where IV fluid leaks into surrounding tissue. Infection shows redness and warmth, thrombus formation may cause pain and redness, and sclerosing involves vein hardening, not edema.
Magnetic resonance imaging has been ordered for a client. Which factor should the nurse report to the physician?
- A. The client states she had an allergic reaction to iodine.
- B. The client has a pacemaker.
- C. The client wears a hearing aid.
- D. The client takes digoxin.
Correct Answer: B
Rationale: A pacemaker is a contraindication for MRI due to magnetic interference, requiring immediate physician notification to ensure safety.
A client started a 24-hour urine collection test at 6:00 AM. The unlicensed assistive personnel (UAP) reports discarding a urine specimen of 250 mL at 10:00 AM by mistake but adding all specimens to the collection container before and after that time. What action should the nurse take?
- A. Add 250 mL to the total output after the 24-hour urine collection is complete tomorrow morning
- B. Discard urine and container, and restart the 24-hour urine collection tomorrow morning
- C. Discard urine and container, have client void, add urine to new container, and then restart test
- D. Relabel the same collection container, and change the start time from 6:00 AM to 10:00 AM
Correct Answer: B
Rationale: Discarding a specimen invalidates the 24-hour collection, requiring a restart to ensure accurate results. Adding volume, restarting mid-collection, or relabeling compromise test integrity.