a nurse is asked to perform a task that she believes is outside her scope of practice what is the appropriate response to this issue
Logo

Nursing Elites

NCLEX-RN

Saunders NCLEX RN Practice Questions

1. A nurse is asked to perform a task that she believes is outside her scope of practice. What is the appropriate response to this issue?

Correct answer: B

Rationale: When faced with a task that a nurse believes may be beyond their scope of practice, it is essential to refer to the state's specific scope of practice standards for nurses. This step is crucial as these standards can vary between states, providing clarity on what tasks are permissible. By reviewing these standards, the nurse can determine if the task falls within their scope of practice. Contacting the state board of nursing licensure to report the offense (Choice A) is premature and should only be considered if there is a serious violation after reviewing the scope of practice. Asking another nurse to perform the task (Choice C) does not address the issue of clarifying the scope of practice. Contacting the house supervisor (Choice D) may be necessary if the nurse cannot determine the appropriateness of the task based on the scope of practice standards.

2. A nurse is caring for a client who is post-op day #1 after a total hip replacement. Although the client was alert with a normal affect in the morning, by lunchtime, the nurse notes the client is confused, has slurred speech, and is having trouble with her balance. Her blood glucose level is 48 mg/dl. What is the next action of the nurse?

Correct answer: D

Rationale: A client with a blood glucose level of 48 mg/dl is experiencing significant hypoglycemia, as manifested by confusion, balance difficulties, and slurred speech. The nurse should work to correct this situation as rapidly as possible. The first measure that can be performed quickly and will have fast results is to give the client something to eat or drink that contains glucose, such as 6 oz. of orange juice. Administering a bolus of D20W through the IV (Choice B) would be too aggressive and could lead to complications in this scenario. Administering regular insulin (Choice C) would further lower the blood glucose level, worsening the client's symptoms. Contacting the physician (Choice A) is important, but immediate intervention to raise the blood glucose level is crucial to address the client's hypoglycemia.

3. While caring for a client who has just come from surgery and is in the recovery room with an endotracheal tube in place, the nurse deflates the cuff on the tube and removes it. The client sits up in bed, grasps his throat, and begins to make wheezing sounds. Which of the following conditions is the most likely cause of this situation?

Correct answer: D

Rationale: After surgery, some clients may experience a laryngospasm during emergence from anesthesia. A laryngospasm can lead to the closure of the laryngeal opening due to spasm of the vocal cords. In this scenario, the client's symptoms of wheezing and throat grasping are indicative of a laryngospasm rather than choking on the tube, anxiety, or a normal response from anesthesia. The nurse should act promptly to open the airway to aid breathing and consider administering muscle relaxants as necessary.

4. Your patient has been diagnosed with a left ankle sprain. On the discharge instructions, the physician has prescribed the RICE protocol. This acronym stands for:

Correct answer: A

Rationale: The correct answer is Rest, Ice, Compression, Elevation. This acronym, RICE, is commonly used for the treatment of injuries like an ankle sprain. Rest allows the injured area to heal, Ice helps reduce swelling and pain (20 minutes on each hour while awake), Compression is usually achieved with an elastic bandage to minimize swelling, and Elevation of the foot above the level of the heart assists in reducing swelling and promoting healing. Choices B, C, and D are incorrect because they include irrelevant terms like Radiology and Cast, which are not part of the standard treatment protocol for an ankle sprain.

5. A client is admitted to a nursing unit with a remittent fever. Which statement best describes this pattern of fever?

Correct answer: A

Rationale: A remittent fever is characterized by temperature fluctuations where the fever spikes and then lowers but does not return to normal temperature. Option A best describes this pattern of fever. Option B describes a pattern of fever known as a biphasic fever, where the fever alternates between days of fever and normal temperature. Option C describes a pattern of fever that is more indicative of an intermittent fever, where the fever lasts for a specific duration followed by an interval of normal temperature. Option D does not accurately describe a remittent fever, as it suggests a persistent fever that has lasted over 24 hours, which is not specific to the remittent pattern.

Similar Questions

Which technological advance is MOST likely to place you at risk for HIPAA violations?
Which action represents the evaluation stage of the plan of care?
A 58-year-old client is being tested for rheumatoid arthritis. Her physician orders an erythrocyte sedimentation rate (ESR). Which of the following results is most likely to be associated with arthritis?
The BRAT diet is often prescribed for patients with gastroenteritis. This acronym stands for:
Which of the following conditions may cause an increased respiratory rate?

Access More Features

NCLEX RN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • Comprehensive NCLEX coverage
  • 30 days access

NCLEX RN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • Comprehensive NCLEX coverage
  • 30 days access

Other Courses