A nurse is planning care for four clients. Which of the following tasks are within the nurse's scope of practice?

Teach a client about hemodialysis.

Create a plan of care for a client's discharge.

Assist in checking a unit of packed RBCs to administer to a client.

Regulate the client's infusion pump after initiating a heparin drip infusion

Answer and Explanation

Correct Answer : C,D

A. Teach a client about hemodialysis:

Educating clients about hemodialysis may require specialized knowledge that might exceed the standard nursing scope. However, nurses may provide basic information and support related to the procedure.

B. Create a plan of care for a client's discharge:

Although nurses often contribute to discharge planning by providing input, assessing needs, and communicating with the care team, the creation of a complete discharge plan may involve multidisciplinary collaboration, including social workers, case managers, and physicians.

C. Assist in checking a unit of packed RBCs to administer to a client:

Nurses are often responsible for verifying blood components (like packed red blood cells) before administration, ensuring proper patient identification, compatibility, and correct handling of the blood product.

D. Regulate the client's infusion pump after initiating a heparin drip infusion:

Nurses frequently regulate and monitor infusion pumps after starting medication infusions, ensuring the correct rate of administration according to the prescribed dosage.

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Correct Answer is A

Explanation

A. Engage the client in a repetitive activity as a distraction:

This is the correct answer. Redirecting the client's focus to a repetitive and calming activity can help distract them from the source of agitation and potentially de-escalate the situation.

B. Place the client in a seclusion room:

Seclusion should only be used in situations where it is absolutely necessary for the safety of the client or others. Placing a client with dementia in seclusion is not the first choice and should be avoided if possible.

C. Apply wrist restraints to the client:

Restraints should be a last resort and used only when there is an imminent risk of harm to the client or others. Restraints can escalate agitation and should not be the initial response.

D. Administer PRN haloperidol IM to the client:

The use of medication should be considered later in the escalation process and after other non-pharmacological interventions have been attempted. It is not the first intervention, especially when there are non-pharmacological options available.

A. Medication administration record B. Standardized care plan C. 180 record D. Client care Kardex

Correct Answer is D

Explanation

A. Medication administration record:

The medication administration record (MAR) primarily contains information related to medications, dosages, and administration times. While it provides important details about medications, it may not offer a comprehensive overview of the client's overall care.

B. Standardized care plan:

A standardized care plan typically outlines general care guidelines and interventions for specific conditions. It may provide a structured approach to care but might lack the individualized details needed for a specific client.

C. 180 record:

The term "180 record" does not commonly refer to a standard nursing documentation form. It might be a local or facility-specific term. Without additional information, it's unclear what type of information this form would contain.

D. Client care Kardex:

This is the correct answer. The Client care Kardex, also known as the patient care summary or Kardex, is a document that consolidates key information about a client's care, including diagnoses, treatments, procedures, and other relevant details. It provides a snapshot of the client's current status and facilitates communication among healthcare providers.

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A nurse is planning care for four clients. Which of the following tasks are within the nurse's scope of practice?

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