A nurse is using a guide to provide moral standards for professional behavior in nursing. Which guide is the nurse using?

The Quality and Safety Education for Nurses

The American Nurses Association Standards of Professional Performance

The American Nurses Association Code of Ethics

The American Nurses Association Standards of Practice

Answer and Explanation

The Correct Answer is C

Choice A reason: The Quality and Safety Education for Nurses (QSEN) focuses on competencies like patient safety and quality improvement, not moral standards. It guides nursing education to enhance clinical skills and patient outcomes, addressing evidence-based practice and teamwork. Moral standards, involving ethical decision-making and professional conduct, are governed by the ANA Code of Ethics, not QSEN.

Choice B reason: The American Nurses Association Standards of Professional Performance outline behaviors like leadership and collaboration but focus on professional competence, not moral standards. These standards guide performance expectations, such as resource utilization and communication, rather than ethical principles like beneficence or autonomy, which are central to the ANA Code of Ethics for moral guidance.

Choice C reason: The American Nurses Association Code of Ethics provides moral standards for nursing, emphasizing principles like beneficence, nonmaleficence, autonomy, and justice. It guides ethical decision-making in patient care, addressing dilemmas like informed consent and confidentiality. This code ensures nurses uphold moral integrity in professional behavior, making it the correct guide for ethical standards.

Choice D reason: The American Nurses Association Standards of Practice define the nursing process (assessment, diagnosis, planning, etc.) but focus on clinical practice standards, not moral guidelines. These standards ensure competent care delivery but do not address ethical principles like patient autonomy or ethical dilemmas, which are covered by the ANA Code of Ethics.

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Correct Answer is A

Explanation

Choice A reason: Asking the client’s full name and date of birth ensures accurate identification, aligning with the Joint Commission’s two-identifier protocol. This method confirms the client’s identity directly, reducing medication errors and ensuring safety, as it is reliable and patient-specific, per medication administration standards.

Choice B reason: Verifying the client’s room number is unreliable, as patients may change rooms or share spaces. Room numbers are not unique identifiers and risk misidentification, leading to medication errors. This method fails to meet safety standards for patient verification, per hospital safety protocols.

Choice C reason: Checking the client’s name on the MAR is part of the process but insufficient alone, as it does not confirm the client’s identity at the bedside. Without direct patient verification, errors may occur if MARs are mismatched, making this inadequate, per medication safety guidelines.

Choice D reason: Asking a family member to verify identity is unreliable, as they may be mistaken or unavailable. Direct patient identifiers, like name and date of birth, are required to ensure accuracy, reducing errors. This method does not meet regulatory standards for patient identification, per safety protocols.

A. Report the exact milliliter of intake to the physician’s office nurse. B. Compare the total intake and output of fluids for the 24 hours. C. Compare the patient’s intake with the normal range of adult fluid intake. D. Ensure the information is included in the verbal end-of-shift report.

Correct Answer is B

Explanation

Choice A reason: Reporting only the exact intake to the physician’s nurse is incomplete, as fluid status requires balancing intake with output. Intake alone does not indicate hydration or overload, risking misinformed decisions. Comparing intake and output provides a full picture, per fluid balance assessment principles.

Choice B reason: Comparing total intake and output over 24 hours accurately assesses fluid status, as it reveals imbalances like dehydration (output > intake) or retention (intake > output). This guides interventions, ensuring proper fluid management, aligning with physiological monitoring and clinical assessment standards.

Choice C reason: Comparing intake to a normal range is useful but insufficient without output data. Normal intake varies, and fluid status depends on balance. This approach misses output-related issues like oliguria, reducing its accuracy for assessing hydration, per fluid and electrolyte management guidelines.

Choice D reason: Including intake in verbal reports is important but does not directly assess fluid status. Comparison of intake and output is needed to evaluate balance, guiding clinical decisions. Reporting alone risks overlooking imbalances, per nursing documentation and fluid assessment protocols.

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A nurse is using a guide to provide moral standards for professional behavior in nursing. Which guide is the nurse using?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Before administering a medication to a client, the nurse must identify the client. Which of the following methods of identification should the nurse use?

Correct Answer is A

Explanation

A nurse measures a patient’s 24-hour fluid intake and documents the findings. To be an accurate indicator of fluid status, what must the nurse do with the information?

Correct Answer is B

Explanation

A patient had abdominal surgery 2 hours ago. She is stating that she is hungry and would like something to eat. What is the first consideration that the nurse must make before allowing the patient to eat?

A nurse is auscultating a client’s lung sounds and identifies crackles in the left lower lobe. Which of the following interventions should the nurse take?

The nurse is to administer eye drops four times per day to a patient diagnosed with conjunctivitis. The nurse should administer the medication by gently dropping the medication onto which of the following areas?

A nurse is assessing a client who has a fever, has an infection of a flank incision, and is in severe pain. What type of pulse rate would the client most likely exhibit?

A nurse working on a busy medical-surgical unit does not take the vital signs of a client who is preparing for discharge but instead documents the same vital signs obtained earlier in the morning. For which tort would the nurse be potentially liable?

A nurse is caring for a patient with increased cholesterol, hypertension, and Type I Diabetes Mellitus. The dietician comes in with the nurse to discuss an appropriate diet with the patient. Which fats will the dietician most likely encourage the patient to limit?

An athlete runs 5 miles a day. His wife notices that after he runs, he becomes lethargic and pale. He is still talking and responding appropriately. After being taken to the E.R., and having his lab work assessed, which lab value might the nurse be most concerned with?

An adult client is assessed as having an apical pulse of 140. How would the nurse document this finding?