A. 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.

B. 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).

C. The nurse should include the BON regulates and monitors laws and rules set by the Nurse Practice Act. The Board of Nursing (BON) ensures that nurses adhere to the legal and ethical standards outlined in the Nurse Practice Act. It grants licensure, oversees disciplinary actions, and enforces regulations to protect public safety. This aligns directly with its primary role in nursing practice.

D. 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.

A. 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.

B. 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.

C. 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.

D. Explaining the steps of a surgical procedure to a client. It is the responsibility of the provider performing the procedure to explain its risks, benefits, alternatives, and expected outcomes. When a nurse provides detailed explanations of a surgical procedure, it may be considered outside their scope of practice, leading to misinformation or legal liability.

A. The client will explain 4 principles of crutch safety. This statement lacks a specific time frame, making it not a timed component of SMART goals.

B. The client will teach back information about safe crutch walking on day 1. The goal includes a clear time frame (day 1), making it a timed component that aligns with SMART criteria.

C. The client will walk 10 feet by day 2. This goal includes a specific distance and deadline (day 2), making it measurable and time-bound.

D. The client will demonstrate safe crutch walking. While this is an important skill, the statement does not specify a time frame, meaning it does not meet the timed component of SMART goals.

E. The client will walk 20 feet by day 3. This statement sets a clear distance goal with a deadline (day 3), making it a timed SMART goal.

F. The client will not lean on the crutches to support their body weight. While this is an important behavior, it lacks a time frame, meaning it is not a timed component.

G. The client will explain how to keep crutches in working condition. This statement is a general goal without a deadline, making it not a timed SMART goal.

H. The client will ambulate 5 feet in one day. This goal provides a specific distance and deadline (one day), making it a timed component of the SMART criteria.

A. 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.

B. Accountability. Accountability means taking responsibility for one’s actions, including errors, and following appropriate steps to address them. By assessing the client, informing the provider, and completing an incident report, the nurse demonstrates professional integrity and commitment to ethical practice.

C. 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.

D. 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.

A. Nursing blogs online. While nursing blogs may offer personal insights and experiences, they are not always evidence-based or peer-reviewed. The reliability of information varies, making them less ideal for lifelong learning compared to formal educational resources.

B. Scholarly journals. Scholarly journals provide peer-reviewed, evidence-based research that supports nursing practice, policy updates, and clinical advancements. They are essential resources for lifelong learning as they offer the latest scientific findings and best practices in nursing.

C. Workshops. Workshops offer hands-on learning experiences, skill development, and networking opportunities with other healthcare professionals. They enhance clinical competency and keep nurses updated on new techniques, policies, and medical advancements.

D. Online continuing education. Online continuing education courses help nurses fulfil licensure requirements, expand their knowledge base, and stay current with healthcare advancements. They provide flexible learning opportunities that accommodate different schedules and learning paces.

E. Nursing topics on social media. While social media can be a platform for discussion and networking, the accuracy and credibility of shared information are often questionable. Relying on social media alone for professional learning may lead to misinformation and is not a recommended primary educational resource.

A. 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.

B. 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.

C. Responsibility. Responsibility involves following through on nursing interventions and ensuring patient safety. By checking on the client to evaluate the effectiveness of a pain medication, the nurse is demonstrating accountability for patient care and adherence to proper nursing practice.

D. 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.

A. 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.

B. 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.

C. 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.

D. Heart rate 108/min. Fever stimulates the sympathetic nervous system, increasing heart rate (tachycardia) to meet the body’s higher metabolic and oxygen demands. A heart rate of 108/min is expected in response to a fever of 39°C (102.2°F).

A. "The State Board of Nursing can reprimand you for a breach of client confidentiality." The State Board of Nursing has the authority to discipline nurses for violations of professional conduct, including breaches of confidentiality. Consequences can include reprimands, fines, license suspension, or revocation.

B. "The civil penalties for breach of confidentiality can include imprisonment." Civil penalties typically involve monetary damages rather than imprisonment. Criminal penalties, such as jail time, may apply only in severe cases, such as intentional misuse of protected health information (PHI) for personal gain.

C. "A breach in confidentiality is considered an act of professional negligence." While breaching confidentiality is a serious ethical and legal violation, it is not classified as professional negligence, which refers to failure to provide standard care resulting in harm. A breach of confidentiality is more accurately categorized as a violation of privacy laws, such as HIPAA.

D. "Your institution can receive monetary fines for a breach in confidentiality." Healthcare institutions are subject to fines and penalties under laws such as HIPAA if they fail to protect client confidentiality. These fines can be significant, depending on the severity and intent of the breach.

E. "Your employer can terminate your employment if there is a breach in confidentiality." Employers enforce strict confidentiality policies, and violations can result in disciplinary actions, including termination. Organizations must uphold patient privacy to maintain compliance with federal and state regulations.

A. 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.

B. 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.

C. 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.

D. Hypertension. Acute pain stimulates the release of stress hormones such as epinephrine and norepinephrine, leading to vasoconstriction and increased blood pressure. This is a common physiological response to pain as the body prepares to react to the perceived threat.

A. 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.

B. 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.

C. TJC provides accreditation to facilities. The Joint Commission accredits hospitals, long-term care facilities, and other healthcare organizations, ensuring they meet national patient safety and quality standards. Accreditation by TJC signifies compliance with best practices and can impact funding and reputation.

D. 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.