A newly licensed nurse is unsure if an assigned task is within their scope Of practice. Which Of the following resources should the nurse consult?

Institutional policies and procedures

Verbal direction from the nurse manager

State Nurse Practice Act

Written prescription from the provider

Answer and Explanation

The Correct Answer is C

A. Institutional policies and procedures: While institutional policies provide guidance on how tasks are performed within a facility, they cannot legally expand or limit a nurse’s scope of practice. Nurses must always ensure tasks are permitted by state law first.
B. Verbal direction from the nurse manager: Managers may offer direction, but their guidance should not override legal regulations. Relying solely on verbal instructions risks performing tasks outside the legal scope of practice, which can lead to liability issues.
C. State Nurse Practice Act: The Nurse Practice Act is a legal document specific to each state that defines the scope of practice for nurses. It outlines what tasks are legally permissible and serves as the most authoritative reference for professional responsibilities.
D. Written prescription from the provider: Although a provider can order treatments or procedures, nurses are still responsible for ensuring those actions fall within their legal scope. Following a prescription without verifying legality may result in practicing beyond licensure.

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Free Nursing Study Resources

Correct Answer is D

Explanation

A. Warm the irrigation solution: While warming may enhance comfort, it does not impact the color of urine or address post-procedure bleeding. It is not a necessary intervention in this situation.
B. Perform the Credé's maneuver: This technique, which involves manual pressure over the bladder, is used for clients with neurogenic bladder or urinary retention. It is not appropriate during continuous bladder irrigation.
C. Replace the indwelling urinary catheter: Catheter replacement would only be considered if there was a complete blockage that couldn't be cleared, severe kinking, or signs of infection, none of which are indicated here. Replacing the catheter unnecessarily increases the risk of trauma and infection.
D. Maintain the irrigation solution rate: Pink-tinged urine is expected within the first few hours following TURP as a result of minor bleeding. Continuing irrigation at the current rate helps prevent clot formation and maintains catheter patency.

A. “I can start the medication 30 minutes earlier.” B. “I have up to 2 hours after the usual scheduled time to give you this medication." C. “I can adjust the time and schedule for when it's convenient for you." D. “I can infuse the medication at a faster rate.”

Correct Answer is A

Explanation

A. “I can start the medication 30 minutes earlier.”: Most facilities allow a 30-minute window before or after the scheduled administration time for IV antibiotics like vancomycin. Administering it more than 30 minutes early may interfere with therapeutic drug levels and proper dosing intervals.
B. “I have up to 2 hours after the usual scheduled time to give you this medication.”: While some medications may allow a late administration window, vancomycin requires precise timing to maintain therapeutic levels and prevent resistance. Delays beyond 30 minutes are generally not appropriate.
C. “I can adjust the time and schedule for when it's convenient for you.”: Medication schedules, especially for antibiotics, are based on pharmacokinetics and infection control. Altering times for convenience can compromise treatment effectiveness and safety.
D. “I can infuse the medication at a faster rate.”: Infusing vancomycin too quickly increases the risk of adverse reactions such as Red Man Syndrome. It must be administered over a prescribed minimum time to reduce complications.

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A newly licensed nurse is unsure if an assigned task is within their scope Of practice. Which Of the following resources should the nurse consult?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who is receiving continuous bladder irrigation following a transurethral resection of the prostate 4 hr ago. The nurse notes pink-tinged urine in the drainage bag. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is preparing to administer vancomycin IV to an adult client. The client asks the nurse if the medication can be given 2 hr earlier. Which of the following statements should the nurse make?

Correct Answer is A

Explanation

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