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
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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Related Questions
Correct Answer is B
Explanation
A. Remind the client to eat scheduled meals daily: At the end of life, appetite often decreases, and forcing scheduled meals can cause discomfort. Encouraging small, preferred foods as tolerated is more appropriate.
B. Offer the client a blanket to keep warm: Clients nearing end of life often experience cold intolerance due to decreased circulation and metabolism. Providing warmth helps maintain comfort and dignity.
C. Speak in a loud tone when addressing the client: Speaking loudly can be perceived as disrespectful or frightening, especially if the client is confused or hearing impaired. A calm, gentle tone is more supportive.
D. Place the client in a supine position: The supine position may increase discomfort or breathing difficulties in some terminal clients; positioning should focus on comfort and ease of breathing, often semi-Fowler’s or side-lying
Correct Answer is C
Explanation
A. Metabolic acidosis: Small bowel obstructions are more commonly associated with metabolic alkalosis due to loss of gastric contents from vomiting. Acidosis is less typical in the early stages of obstruction.
B. Hyperactive bowel sounds: In nonmechanical (paralytic ileus) obstruction, bowel sounds are usually absent or hypoactive, not hyperactive, due to lack of peristalsis. Hyperactive sounds are more typical in early mechanical obstruction.
C. Distended abdomen: Abdominal distention is a classic sign of bowel obstruction, resulting from gas and fluid accumulation above the site of obstruction. It is expected in both mechanical and nonmechanical types.
D. Passing flatus: The absence of flatus is common in bowel obstruction, as bowel movement is halted. Continued passage of flatus would suggest partial or resolving obstruction, not a typical finding in active nonmechanical obstruction.
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