Saunders NCLEX RN Practice Questions - Nurselytic

Correct Answer: B

Rationale: When faced with a task that a nurse believes may be beyond their scope of practice, it is essential to refer to the state's specific scope of practice standards for nurses. This step is crucial as these standards can vary between states, providing clarity on what tasks are permissible. By reviewing these standards, the nurse can determine if the task falls within their scope of practice. Contacting the state board of nursing licensure to report the offense (
Choice
A) is premature and should only be considered if there is a serious violation after reviewing the scope of practice. Asking another nurse to perform the task (
Choice
C) does not address the issue of clarifying the scope of practice. Contacting the house supervisor (
Choice
D) may be necessary if the nurse cannot determine the appropriateness of the task based on the scope of practice standards.

Correct Answer: C

Rationale: Moral distress involves negative feelings or frustration toward situations that are deemed unfair, unethical, or that cause the nurse to feel helpless in their work. It can lead to nurse burnout when ongoing issues are not resolved. The most appropriate method for managing moral distress is to develop new policies that address the problematic situations. By creating policies, nurses can work towards changing current standards and reducing the number of situations that lead to moral distress.

Choices A and B are incorrect because recognizing life's unfairness and not taking action on unjustifiable requests do not actively address the root causes of moral distress or work towards resolving the issues.

Correct Answer: A

Rationale: Informed consent involves providing the client with an explanation of the reasons for the procedure, the potential risks, benefits, and available alternatives. It is essential for the healthcare provider to ensure that the client understands the information provided before agreeing to the procedure. While obtaining a signature on a consent form is part of the process, it is not the sole indicator of informed consent. Option C, which mentions liability statements, is incorrect as informed consent focuses on ensuring the client understands the procedure, not on affirming liability.
Therefore, the correct answer is the explanation of the reasons for the procedure.

Correct Answer: C

Rationale: Certain tasks can be safely delegated to unlicensed assistive personnel to assist nurses in their workload. Tasks that involve routine activities like incentive spirometry can be delegated. Unlicensed assistive personnel can assist clients with incentive spirometry, helping in promoting lung expansion and preventing respiratory complications. Cleansing a wound with peroxide (
Choice
A) and irrigating a colostomy (
Choice
B) involve more complex procedures that should be performed by licensed healthcare providers due to the risk of infection and potential complications. Removing a saline-lock IV (
Choice
D) requires specialized training and should only be performed by licensed personnel to prevent complications and ensure patient safety. The nurse remains responsible for delegating tasks appropriately and overseeing the care provided by unlicensed assistive personnel.

Correct Answer: A

Rationale: An occupational health nurse is involved in assessing the work environment, educating employees about safety practices, and infection control. When a nurse sustains an injury due to incorrect body mechanics, it falls under the purview of an occupational health nurse because they are responsible for documenting such incidents, providing necessary care or treatment, and ensuring that preventive measures are in place to avoid similar accidents in the future. The other options do not directly relate to the role of an occupational health nurse. Testifying in court, assisting a client with rehabilitation, or implementing a new electronic health record system are not typical scenarios where an occupational health nurse would be involved.