A nurse is assessing a client who has an ankle fracture of the right foot and is at risk for complex regional pain syndrome (CRPS). The nurse should identify that which of the following findings is a manifestation of CRPS?

Tingling in the toes

1+ dorsalis pedis pulse

Capillary refill of 3 seconds

Increased edema of the foot

Answer and Explanation

The Correct Answer is D

A. Tingling in the toes: Tingling in the toes is not specific to CRPS. It might be a general symptom but is not a classic sign of CRPS.
B. 1+ dorsalis pedis pulse: A weak pulse might indicate reduced circulation but is not specific to CRPS. CRPS is more associated with pain, swelling, and changes in skin color or temperature.
C. Capillary refill of 3 seconds: A capillary refill time of 3 seconds is prolonged and suggests possible circulation issues, but it is not a specific manifestation of CRPS.
D. Increased edema of the foot: Increased edema of the foot is a common manifestation of CRPS. CRPS often presents with localized swelling, along with other symptoms like pain and changes in skin color or temperature.

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Correct Answer is A

Explanation

A. The state's nurse practice acts:This is correct. State nurse practice acts provide legal guidelines and scope of practice for nurses within that state.
B. The American Nurses Association: While the ANA offers valuable resources and guidelines, it does not provide legal scope of practice specific to each state.
C. The facility's job descriptions :Facility job descriptions can outline specific roles and responsibilities but are not the legal source for scope of practice.
D. The Joint Commission's legal department: The Joint Commission sets accreditation standards but does not provide legal scope of practice guidelines for individual nurses.

A. Provide information about the risks of a surgical procedure to the client. B. Request the client sign the informed consent form after administering a preoperative sedative. C. Mark the client's surgical site with a small strip of nonporous tape. D. Call a "time out" to verify client identity before starting a surgical procedure.

Correct Answer is D

Explanation

A. Provide information about the risks of a surgical procedure to the client. Providing risk information is part of informed consent, not specifically part of Universal Protocol.
B. Request the client sign the informed consent form after administering a preoperative sedative. Informed consent should be obtained before administering sedatives to ensure the client is fully aware and able to consent.
C. Mark the client's surgical site with a small strip of nonporous tape. The surgical site should be marked with a permanent marker to ensure it remains visible and clear throughout the surgical preparation and procedure.
D. Call a "time out" to verify client identity before starting a surgical procedure. This is correct. The Universal Protocol includes a "time out" to verify the correct patient, procedure, and site before starting the surgery.

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A nurse is assessing a client who has an ankle fracture of the right foot and is at risk for complex regional pain syndrome (CRPS). The nurse should identify that which of the following findings is a manifestation of CRPS?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A charge nurse is teaching a newly licensed nurse about the guidelines for legal scope of practice. For reference, which of the following sources should the nurse consult?

Correct Answer is A

Explanation

A nurse manager is developing an in-service about The Joint Commission's National Patient Safety Goals for a group of surgical nurses. Which of the following information regarding Universal Protocol should the nurse include in the in-service?

Correct Answer is D

Explanation

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