A nurse is participating on a committee that is considering the creation of a policy that will allow nurses to remove chest tubes. Which of the following is an appropriate resource for the nurse to consult in planning for this policy?

State nurse practice act

ANA Standards of Practice

ANA Code of Ethics

Institute of Medicine

Answer and Explanation

The Correct Answer is A

Choice A reason: The state nurse practice act is an appropriate resource for the nurse to consult in planning for this policy. The state nurse practice act defines the scope of practice and the legal authority for nurses in each state. The nurse should ensure that the policy is consistent with the state regulations and does not exceed the nurse's level of competence and education.

Choice B reason: The ANA Standards of Practice are not the most appropriate resource for the nurse to consult in planning for this policy. The ANA Standards of Practice describe the expectations and responsibilities for the professional nursing practice, such as assessment, diagnosis, outcome identification, planning, implementation, and evaluation. The standards are general and broad, and do not provide specific guidance on the procedure of removing chest tubes.

Choice C reason: The ANA Code of Ethics is not the most appropriate resource for the nurse to consult in planning for this policy. The ANA Code of Ethics outlines the ethical principles and values that guide the nursing practice, such as respect, autonomy, beneficence, nonmaleficence, justice, fidelity, and veracity. The code does not address the technical or legal aspects of removing chest tubes.

Choice D reason: The Institute of Medicine is not the most appropriate resource for the nurse to consult in planning for this policy. The Institute of Medicine is an independent, nonprofit organization that provides evidence-based recommendations and research on health care issues, such as quality, safety, and innovation. The institute does not regulate or define the nursing practice or scope.

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Correct Answer is D

Explanation

Choice A reason: A client who has bipolar disorder and is exhibiting signs of hallucination is not the highest priority for treatment. The client may have a psychiatric emergency, but their condition is not life-threatening or unstable. The nurse should assess the client's safety and provide emotional support, but they can wait for further intervention.

Choice B reason: A client who has major burns over 75% of their body surface area is a high priority for treatment, but not the highest. The client has a serious injury that can cause shock, infection, and organ failure. The nurse should monitor the client's vital signs, fluid status, and wound care, but they can wait for a short time.

Choice C reason: A client who has two open chest wounds with a left tracheal deviation is a high priority for treatment, but not the highest. The client has a tension pneumothorax, which is a life-threatening condition that causes air to accumulate in the pleural space and compress the lung and the heart. The nurse should seal the wounds with an occlusive dressing and prepare for chest tube insertion, but they can wait for a few minutes.

Choice D reason: A client who has a neck injury and is unable to breathe spontaneously is the highest priority for treatment. The client has a respiratory emergency, which is the most urgent condition that requires immediate intervention. The nurse should establish an airway, provide oxygen, and stabilize the neck, as well as call for help and notify the provider.

A. The belief that the client has a difficult relationship with his son B. The steps to follow when providing wound care C. The time the client received his last dose of pain medication D. The client's preferred time for bathing

Correct Answer is B

Explanation

Choice A reason: The belief that the client has a difficult relationship with his son is not relevant for the change-of-shift report. This is a subjective and personal opinion that does not affect the client's care or recovery.

Choice B reason: The steps to follow when providing wound care is relevant for the change-of-shift report. This is an objective and clinical information that ensures the continuity and quality of the client's care.

Choice C reason: The time the client received his last dose of pain medication is not relevant for the change-of-shift report. This is a routine and standard information that can be found in the medication administration record or the electronic health record.

Choice D reason: The client's preferred time for bathing is not relevant for the change-of-shift report. This is a preference and not a priority information that can be communicated later or documented in the care plan.

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A nurse is participating on a committee that is considering the creation of a policy that will allow nurses to remove chest tubes. Which of the following is an appropriate resource for the nurse to consult in planning for this policy?

Nursing Test Bank

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Correct Answer is B

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