Only $2.99/month

Mary Ann Hogan NCLEX PN

Terms in this set (100)

<correct>3</correct>
<rationale>An incident report must be completed because of the inaccurate narcotic count. Narcotics are controlled substances and fall under federal law and regulation. Both the pharmacy and nursing administration must be notified. If the staff nurse is found to be using a controlled substance, this finding must be reported to the state board of nursing. Individual state boards of nursing identify the legal boundaries of nursing practice, including disciplinary action, through nurse practice acts (which differ among the states). The American Nurses Association, through the Code of Ethics for Nurses, provides guidance to nurses and protection for clients and their families but does not have the authority to discipline nurses.</rationale>

<cognitive_level>Application</cognitive_level>

<client_need>Safe Effective Care Environment: Coordinated Care</client_need>

<integrated_process>Nursing Process: Planning</integrated_process>

<content_area>Leadership/Management</content_area>

<strategy>The core issue of the question is an understanding of the nature and purpose of professional nursing organizations and institutions. Each state board is responsible for the regulation of nursing and articulates the principles for delegation and disciplinary action. Options 1 and 2 represent actions that a nurse manager would have to take to protect the public good. The functions of professional nursing organizations do not include statutory laws but rather ethical codes of conduct for both nursing students and professional nurses. Option 4 refers to professional organizations like ANA who may have a Council on Nursing Practice which strive to develop standards of practice for professional nurses.</strategy>
3, 5, 1, 4, 2</correct>

<rationale>Priority setting can be implemented using a variety of models. The client who is postoperative should be seen first because the client is newly arrived on the unit and is at most risk of becoming unstable or experiencing a change in clinical condition. The client with pneumonia should be seen next because the infection involves the airway, although oxygen saturation levels are higher than the critical value of 90% or less. The client who is 4 hours post-cardiac catheterization should be seen next to evaluate the site and conduct general examination of the affected extremity. The client who will be discharged should be seen next to determine that there are no last minute needs or issues. The client who needs teaching should be seen last because this is not a physiological need.</rationale>

<cognitive_ll>Analysis</cognitive_level>

<client_need>Safe Effective Care Environment: Coordinated Care</client_need>

<integrated_process>Nursing Process: Planning</integrated_process>

<content_area>Leadership/Management</content_area>

<strategy>Determine which client is at most risk of becoming unstable to pick client 3, followed by monitoring the client whose airway is potentially at risk (client 5). The client with the cardiac catheter could become unstable but has been on the unit for 4 hours, so this client can be seen third. The fourth client scheduled for discharge should be checked fourth, because of time—it will not take long to address any remaining issues or concerns. The client needing teaching will need the most time and can be planned for last.</strategy> <special_handling>0</special_handling> </record>