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

Answer and Explanation

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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Correct Answer is C

Explanation

A. Providing the client's breakfast is an essential aspect of diabetes care, but obtaining information about the client's blood glucose level is a priority before administering insulin or making decisions about meal planning.

B. Obtaining the client's capillary blood glucose level is a critical first step. Knowing the current blood glucose level guides the nurse in determining the appropriate insulin dosage, assessing the need for any adjustments in the treatment plan, and planning the client's breakfast based on their current glucose level.

C. Checking the calibration of the glucometer is the first action to ensure the accuracy of the blood glucose measurement. Regular calibration checks help maintain the precision of the glucometer and ensure reliable results.

D. Administering prescribed insulin is an important step in managing type 1 diabetes, but the dosage should be determined based on the client's current blood glucose level. Administering insulin without knowing the current glucose level could lead to inappropriate dosage and potential complications.

A. The client's blood pressure was recorded at 0730 and 1130. B. The client's pain medication was administered twice during this shift. C. The client's enteral feeding bag needs to be changed at 2200. D. The client received a bath and backrub.

Correct Answer is A

Explanation

A. The client's blood pressure was recorded at 0730 and 1130.

In a change-of-shift report, it is important to communicate vital signs, especially changes in the client's condition. Recording the blood pressure at different times during the shift helps the oncoming nurse understand the client's cardiovascular status and identify trends or potential issues.

B. The client's pain medication was administered twice during this shift:

While medication administration is important information, specifying the number of times pain medication was administered may be less relevant in a brief change-of-shift report. It's more critical to communicate the client's pain level, response to medication, or any concerns related to pain management.

C. The client's enteral feeding bag needs to be changed at 2200:

While enteral feeding is an essential aspect of care, the timing of the feeding bag change may not be as crucial in a change-of-shift report. Instead, it would be more pertinent to communicate any issues related to the client's tolerance of feeding, any changes in feeding rate, or signs of intolerance.

D. The client received a bath and backrub:

Personal care activities, such as a bath and backrub, are essential components of nursing care, but they may be less critical in a change-of-shift report unless there are specific concerns related to the client's skin condition or overall well-being. More emphasis should be placed on clinical assessments and changes in the client's condition.

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