A nurse is planning care for four clients. Which of the following tasks are within the nurse's scope of practice?
Teach a client about hemodialysis.
Create a plan of care for a client's discharge.
Assist in checking a unit of packed RBCs to administer to a client.
Regulate the client's infusion pump after initiating a heparin drip infusion
Correct Answer : C,D
A. Teach a client about hemodialysis:
Educating clients about hemodialysis may require specialized knowledge that might exceed the standard nursing scope. However, nurses may provide basic information and support related to the procedure.
B. Create a plan of care for a client's discharge:
Although nurses often contribute to discharge planning by providing input, assessing needs, and communicating with the care team, the creation of a complete discharge plan may involve multidisciplinary collaboration, including social workers, case managers, and physicians.
C. Assist in checking a unit of packed RBCs to administer to a client:
Nurses are often responsible for verifying blood components (like packed red blood cells) before administration, ensuring proper patient identification, compatibility, and correct handling of the blood product.
D. Regulate the client's infusion pump after initiating a heparin drip infusion:
Nurses frequently regulate and monitor infusion pumps after starting medication infusions, ensuring the correct rate of administration according to the prescribed dosage.
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Related Questions
Correct Answer is B
Explanation
A. Flush the tube with 5 mL of water:
Explanation: Flushing the tube with water is a routine practice before and after administering medications or feedings to maintain tube patency. However, it is not the primary action to confirm tube placement.
B. Test the pH of fluid aspirated from the tube (Correct Answer):
Explanation: Testing the pH of aspirated fluid helps confirm that the tube is in the stomach. A pH between 1 and 5 is generally indicative of gastric placement.
C. Inject air through the tubing and auscultate for gurgling sounds:
Explanation: This method is an older practice and is not recommended as a reliable method for verifying tube placement. Testing the pH is a more accurate and preferred method.
D. Change the bag and tubing system every 12 hr:
Explanation: Changing the bag and tubing system every 12 hours is a routine practice to maintain the integrity of the enteral feeding system. However, it is not specifically related to the initial steps in verifying tube placement.
Correct Answer is A
Explanation
A. Instruct the client to limit flexion of the hips no further than 100°.For a client who is postoperative following a total hip arthroplasty, hip flexion should generally be limited to 90° or less to avoid dislocation of the hip prosthesis. The instruction to limit flexion to 100° could potentially put the client at risk for dislocation and should be clarified.
B. Perform range-of-motion exercises every 2 hr.This helps prevent stiffness and promotes circulation, although passive range of motion should be performed carefully to avoid excessive hip flexion.
C. Reposition the client every 2 hr.Regular repositioning helps prevent pressure ulcers and other complications, and is a standard postoperative practice.
D. Place an abduction pillow between the legs.An abduction pillow is used to keep the legs apart and prevent dislocation of the hip joint, which is essential after a hip arthroplasty.
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