A newly licensed nurse is unsure if an assigned task is within their scope Of practice. Which Of the following resources should the nurse consult?

Institutional policies and procedures

Verbal direction from the nurse manager

State Nurse Practice Act

Written prescription from the provider

Answer and Explanation

The Correct Answer is C

A. Institutional policies and procedures: While institutional policies provide guidance on how tasks are performed within a facility, they cannot legally expand or limit a nurse’s scope of practice. Nurses must always ensure tasks are permitted by state law first.
B. Verbal direction from the nurse manager: Managers may offer direction, but their guidance should not override legal regulations. Relying solely on verbal instructions risks performing tasks outside the legal scope of practice, which can lead to liability issues.
C. State Nurse Practice Act: The Nurse Practice Act is a legal document specific to each state that defines the scope of practice for nurses. It outlines what tasks are legally permissible and serves as the most authoritative reference for professional responsibilities.
D. Written prescription from the provider: Although a provider can order treatments or procedures, nurses are still responsible for ensuring those actions fall within their legal scope. Following a prescription without verifying legality may result in practicing beyond licensure.

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Correct Answer is D

Explanation

A. Coarse lung sounds: These are indicative of secretions in the larger airways and may suggest fluid overload or pulmonary complications but are not specific to cardiac tamponade and are considered a later or unrelated finding in this context.
B. Decreased jugular vein distention: Accumulation of fluid in the pericardial sac compresses the heart and impairs its ability to fill typically causing increased jugular venous pressure, so a decrease would not be expected and does not indicate early tamponade.
C. Widening pulse pressure: Narrowing, not widening, of the pulse pressure is more characteristic of cardiac tamponade due to decreased stroke volume and rising intrapericardial pressure.
D. Muffled heart sounds: This is a classic early sign of cardiac tamponade caused by fluid accumulation in the pericardial sac, which dampens the sound of the heart during auscultation. This is one of the key components of Beck's triad, along with hypotension and elevated jugular venous pressure.

A. The client slept 5 hr the previous night. B. The client takes 2 short naps during the day. C. The client consumes 8 oz of high-calorie fluids each hour. D. The client engages in quiet activities in their room. E. The client appears to listen to unseen others.

Correct Answer is ["A","C","D"]

Explanation

A. The client slept 5 hr the previous night: Acute manic episodes often involve severe sleep deprivation, sometimes going days without sleep. Achieving 5 hours of rest indicates reduced hyperactivity and a positive response to treatment.
B. The client takes 2 short naps during the day: While napping may seem beneficial, in manic clients it can indicate ongoing disrupted sleep-wake cycles. Full, restorative nighttime sleep is a more reliable sign of improvement.
C. The client consumes 8 oz of high-calorie fluids each hour: During mania, clients often neglect nutritional needs. Actively consuming adequate fluids suggests improved awareness, cooperation, and decreased impulsivity.
D. The client engages in quiet activities in their room: Initially, the client was extremely restless and disruptive. Choosing calm, solitary activities reflects improved impulse control and reduced manic energy.
E. The client appears to listen to unseen others: This suggests persistent auditory hallucinations, indicating that psychotic symptoms remain present and untreated or only partially managed. This is not a sign of improvement.

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A newly licensed nurse is unsure if an assigned task is within their scope Of practice. Which Of the following resources should the nurse consult?

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Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who is postoperative following a coronary artery bypass graft surgery. The nurse should identify that which of the following findings is an early indication of cardiac tamponade?

Correct Answer is D

Explanation

The nurse is continuing to care for the client. Exhibits The nurse is assessing the client. Which of the following findings indicate an improvement in the client's condition? Select all that apply.

Correct Answer is ["A","C","D"]

Explanation

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