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Clinical practice guidelines provide a protocol or a set of guidelines to follow for specific health care problems or situations. Clinical practice guidelines are evidence-based recommendations that help healthcare providers make informed decisions in specific clinical situations. While they offer a structured approach to care, they are not directly related to the Board of Nursing's role, which focuses on licensing, regulation, and legal compliance.

Quality and Safety Education for Nurses (QSEN) establishes competencies for nurses before licensure. QSEN focuses on improving the quality and safety of nursing care by incorporating competencies such as patient-centred care, teamwork, and evidence-based practice. However, it does not establish licensing competencies; this responsibility falls under the Board of Nursing and accrediting bodies like the National Council of State Boards of Nursing (NCSBN).

The National League of Nursing (NLN) promotes excellence in nursing education. The NLN's four core values are caring, integrity, diversity, and excellence. The NLN supports nursing education by setting educational standards and advocating for faculty development. While it plays a significant role in nursing education, it does not oversee nursing practice regulations, making it less relevant to the BON's primary function.

Witnessing a client consent for a surgical procedure. The nurse can act as a witness to the client’s signature on the informed consent form. This ensures that the client voluntarily agrees to the procedure without coercion. However, the nurse does not obtain informed consent, as that responsibility belongs to the provider performing the procedure.

Confirming that a client appears competent to consent to a surgical procedure. The nurse plays a role in assessing whether the client appears competent to provide consent. If the client is confused, disoriented, or under the influence of sedating medications, the nurse should notify the provider and ensure that legal and ethical protocols are followed.

Witnessing a client consent for a surgical procedure. The nurse’s role in informed consent includes witnessing the client’s signature, verifying the client's understanding, and ensuring that the client is making an informed, voluntary decision. This is within the scope of professional nursing practice.

Advocacy. Advocacy involves protecting a client’s rights, ensuring informed decision-making, and speaking up for patient safety. While advocating for patient well-being is crucial, this scenario primarily reflects the nurse’s responsibility for their own actions rather than advocating for the client.

Fairness. Fairness involves treating all patients equitably and ensuring unbiased care. While important in nursing, fairness does not directly apply to this situation, which centers on taking responsibility for an error rather than distributing care impartially.

Confidence. Confidence refers to the nurse’s self-assurance in clinical decision-making and skills. While confidence is essential in nursing practice, admitting and reporting an error requires integrity and accountability rather than confidence.

Fairness. Fairness involves providing equitable and unbiased care to all patients. While fairness is a crucial aspect of nursing ethics, checking a client’s response to pain medication is more aligned with the nurse’s duty to follow through on patient care responsibilities.

Confidence. Confidence refers to a nurse’s self-assurance in their clinical skills and decision-making. Although confidence is important in nursing practice, evaluating a medication’s effectiveness is more about fulfilling a professional duty rather than demonstrating confidence.

Advocacy. Advocacy involves speaking up for a patient’s rights, ensuring they receive appropriate care, and supporting their well-being. While assessing pain relief can contribute to advocacy, in this case, the nurse is primarily fulfilling their professional responsibility in medication administration and follow-up.

Decreased peripheral pulses. Fever leads to vasodilation and increased cardiac output, which generally enhances peripheral blood flow. As a result, peripheral pulses are more likely to be strong and bounding rather than decreased.

Dilated pupils. Pupil dilation is associated with sympathetic nervous system activation, often due to stress, fear, or certain medications. Fever alone does not typically cause pupil dilation, making this an unlikely expected finding.

Respiratory rate 10/min. Fever usually increases metabolic demand, leading to a higher respiratory rate (tachypnea) rather than a lower one. A respiratory rate of 10 breaths per minute would be considered bradypnea, which is not a typical response to fever.

Hypoglycemia. Acute pain does not directly cause hypoglycemia. While stress responses can influence blood sugar levels, pain typically triggers the release of catecholamines, which increase glucose levels rather than decrease them.

Bradycardia. Pain activates the sympathetic nervous system, leading to an increase in heart rate (tachycardia) rather than a decrease (bradycardia). Bradycardia is more commonly associated with parasympathetic activation or certain medications.

Decreased respiratory rate. Pain often causes an increase in respiratory rate (tachypnea) due to heightened sympathetic stimulation. A decreased respiratory rate would be more likely in cases of severe sedation or opioid overdose, not in response to acute pain.

TJC is an organization that monitors insurance claims. The Joint Commission does not oversee insurance claims or reimbursement processes. Its primary role is to evaluate and accredit healthcare organizations to ensure they meet safety and quality standards.

TJC provides licensure for health care providers. TJC does not issue professional licenses; this is the responsibility of state licensing boards and regulatory agencies. Instead, TJC focuses on accrediting healthcare organizations to ensure they meet established quality and safety standards.

TJC is a for-profit organization. TJC is a non-profit organization that works to improve healthcare quality and safety. Its accreditation process is designed to promote excellence in patient care rather than generate profits.