The nurse graduate is reviewing his scope of practice.
Which of the following does he correctly identify as outlining the legal scope of practice for nursing?

Nurse Practice Act.

Nursing process.

Code of Ethics.

Facility policies and procedures.

Answer and Explanation

The Correct Answer is A

The Nurse Practice Act is a law that outlines the legal scope of practice for nursing in each state. It defines the roles, functions, responsibilities and activities that a nurse is educated, competent and authorized to perform. The Nurse Practice Act also establishes the regulatory bodies that create and implement rules and regulations to protect the public.

Choice B. Nursing process is wrong because it is a systematic method of providing nursing care, not a legal document that defines the scope of practice.

Choice C. Code of Ethics is wrong because it is a set of principles that guide the moral and professional conduct of nurses, not a legal document that defines the scope of practice.

Choice D. Facility policies and procedures are wrong because they are specific guidelines for each healthcare organization, not a legal document that defines the scope of practice.

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Correct Answer is C

Explanation

This nursing diagnosis is typically not associated with anemia because anemia does not cause dehydration or loss of body fluids. Anemia is a condition in which the hemoglobin concentration or the number of red blood cells is lower than normal, resulting in decreased oxygen delivery to the tissues.

Choice A. Ineffective tissue perfusion is wrong because anemia can impair tissue perfusion by reducing the oxygen-carrying capacity of the blood.

Choice B. Activity intolerance is wrong because anemia can cause fatigue, weakness, and dyspnea on exertion due to inadequate oxygen supply to the muscles.

Choice D. Risk for decreased cardiac output is wrong because anemia can increase the risk of cardiac complications such as tachycardia, palpitations, angina, and heart failure due to increased cardiac workload and demand for oxygen.

Normal ranges for hemoglobin are 13.5 to 17.5 g/dL for men and 12 to 15.5 g/dL for women; normal ranges for hematocrit are 38.8 to 50% for men and 34.9 to 44.5% for women; normal ranges for red blood cell count are 4.7 to 6.1 million/mm3 for men and 4.2 to 5.4 million/mm3 for women; normal ranges for reticulocyte count are 0.5 to 1.5% of red blood cells.

A. Encouraging the client to increase intake of foods that contain high fat to increase GI motility. B. Encouraging the client to increase solid food intake to promote peristalsis. C. Encouraging the client to increase intake of foods that contain fiber. D. Withholding food and oral fluids until intestinal mobility has returned.

Correct Answer is D

Explanation

Withholding food and oral fluids until intestinal mobility has returned. This is because the client may have postoperative ileus (POI), which is a reduction of gastrointestinal motility after abdominal surgery. POI is characterized by abdominal distension, lack of bowel sounds, accumulation of gas and fluids in the bowel, and delayed passage of flatus and stools.

Giving food and fluids to a client with POI may worsen the condition and cause complications.

Choice A is wrong because high fat foods may slow down GI motility and increase the risk of constipation.

Choice B is wrong because solid food intake may also aggravate POI and cause abdominal discomfort.

Choice C is wrong because fiber intake may increase gas production and distension in the bowel. The nurse should auscultate the abdomen for bowel sounds, and if they are present, or the client reports passing flatus, clear fluids can commence, and aperients can be administered. However, bowel sounds are not a reliable indicator of the end of POI, as they may not be associated with the time of first flatus.

Therefore, withholding food and oral fluids until intestinal mobility has returned is the most appropriate action by the nurse.

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The nurse graduate is reviewing his scope of practice. Which of the following does he correctly identify as outlining the legal scope of practice for nursing?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which of the following nursing diagnoses would typically NOT be associated with anemia?

Correct Answer is C

Explanation

The nurse is conducting an assessment on a client who is 36 hours postoperative following an appendectomy. During the assessment, the nurse is unable to hear any bowel sounds. The client denies passing flatus (gas). Given this information, which action is most appropriate by the nurse?

Correct Answer is D

Explanation

While preparing a client for surgery, the nurse marks the arm that is to be amputated and participates in a “time-out” procedure before the surgery begins. Which sentinel event is this action intended to prevent?

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The nurse graduate is reviewing his scope of practice.
Which of the following does he correctly identify as outlining the legal scope of practice for nursing?