,Chapter 1 — Section: Scope of Nursing Practice; Title:
Standards of Practice & Standards of Professional Performance
Stem: A registered nurse (RN) admits a postoperative patient
and begins data collection. Which action best demonstrates the
RN fulfilling Standard 1: Assessment of the ANA Standards of
Practice?
A. Initiating a nurse-initiated medication protocol for pain.
B. Collecting the patient’s vital signs, surgical history, current
medications, and pain score.
C. Writing the nursing diagnosis without consulting the patient.
D. Delegating discharge teaching to a nursing assistant.
Correct Answer: B
Rationales:
• Correct: Collecting comprehensive, relevant data (vital
signs, history, meds, pain score) is the core of Standard 1
(Assessment); it provides the foundation for subsequent
clinical judgment and planning.
• A: Initiating a medication protocol may be appropriate
later but does not by itself demonstrate a comprehensive
assessment.
• C: Writing a diagnosis without collecting or verifying data
violates the assessment standard and risks error.
• D: Delegating discharge teaching to a nursing assistant is
inappropriate for teaching that requires RN assessment
and clinical judgment.
,Teaching Point: Collect complete, relevant data first —
assessment drives safe nursing decisions.
2.
Chapter 1 — Section: Scope of Nursing Practice; Title:
Standards of Practice & Standards of Professional Performance
Stem: An RN synthesizes assessment data and identifies a
patient problem. Which statement best describes Standard 2:
Nursing Diagnosis?
A. It is the physician’s sole responsibility to make diagnoses.
B. It requires analysis of assessment data to identify actual or
potential patient responses.
C. It only includes medical diagnoses (e.g., myocardial
infarction).
D. It involves only documentation of vital signs.
Correct Answer: B
Rationales:
• Correct: Standard 2 requires nurses to analyze assessment
data to determine nursing diagnoses (actual or
risk/potential responses), directing nursing care.
• A: Medical diagnosis is the provider’s role; nursing
diagnoses describe human responses within nursing scope.
• C: Nursing diagnoses differ from medical diagnoses and
focus on responses to health conditions.
, • D: Documentation of vital signs is part of assessment, not
the full diagnostic analysis.
Teaching Point: Nursing diagnoses reflect analyzed patient
responses, not medical disease labels.
3.
Chapter 1 — Section: Scope of Nursing Practice; Title:
Standards of Practice & Standards of Professional Performance
Stem: A patient with COPD has ineffective airway clearance.
Under Standard 3: Outcome Identification, which is the best
example of a measurable outcome?
A. The patient will “feel better.”
B. The patient will expectorate sputum more easily within 24
hours and maintain O₂ saturation ≥ 92%.
C. The nurse will continue to monitor the patient.
D. The family will be informed about the diagnosis.
Correct Answer: B
Rationales:
• Correct: Outcome Identification requires specific,
measurable, time-bound outcomes (e.g., expectorate
sputum, O₂ ≥ 92% within 24 hrs).
• A: “Feel better” is vague and not measurable.
• C: Ongoing monitoring is an action, not a patient-centered
outcome.
Standards of Practice & Standards of Professional Performance
Stem: A registered nurse (RN) admits a postoperative patient
and begins data collection. Which action best demonstrates the
RN fulfilling Standard 1: Assessment of the ANA Standards of
Practice?
A. Initiating a nurse-initiated medication protocol for pain.
B. Collecting the patient’s vital signs, surgical history, current
medications, and pain score.
C. Writing the nursing diagnosis without consulting the patient.
D. Delegating discharge teaching to a nursing assistant.
Correct Answer: B
Rationales:
• Correct: Collecting comprehensive, relevant data (vital
signs, history, meds, pain score) is the core of Standard 1
(Assessment); it provides the foundation for subsequent
clinical judgment and planning.
• A: Initiating a medication protocol may be appropriate
later but does not by itself demonstrate a comprehensive
assessment.
• C: Writing a diagnosis without collecting or verifying data
violates the assessment standard and risks error.
• D: Delegating discharge teaching to a nursing assistant is
inappropriate for teaching that requires RN assessment
and clinical judgment.
,Teaching Point: Collect complete, relevant data first —
assessment drives safe nursing decisions.
2.
Chapter 1 — Section: Scope of Nursing Practice; Title:
Standards of Practice & Standards of Professional Performance
Stem: An RN synthesizes assessment data and identifies a
patient problem. Which statement best describes Standard 2:
Nursing Diagnosis?
A. It is the physician’s sole responsibility to make diagnoses.
B. It requires analysis of assessment data to identify actual or
potential patient responses.
C. It only includes medical diagnoses (e.g., myocardial
infarction).
D. It involves only documentation of vital signs.
Correct Answer: B
Rationales:
• Correct: Standard 2 requires nurses to analyze assessment
data to determine nursing diagnoses (actual or
risk/potential responses), directing nursing care.
• A: Medical diagnosis is the provider’s role; nursing
diagnoses describe human responses within nursing scope.
• C: Nursing diagnoses differ from medical diagnoses and
focus on responses to health conditions.
, • D: Documentation of vital signs is part of assessment, not
the full diagnostic analysis.
Teaching Point: Nursing diagnoses reflect analyzed patient
responses, not medical disease labels.
3.
Chapter 1 — Section: Scope of Nursing Practice; Title:
Standards of Practice & Standards of Professional Performance
Stem: A patient with COPD has ineffective airway clearance.
Under Standard 3: Outcome Identification, which is the best
example of a measurable outcome?
A. The patient will “feel better.”
B. The patient will expectorate sputum more easily within 24
hours and maintain O₂ saturation ≥ 92%.
C. The nurse will continue to monitor the patient.
D. The family will be informed about the diagnosis.
Correct Answer: B
Rationales:
• Correct: Outcome Identification requires specific,
measurable, time-bound outcomes (e.g., expectorate
sputum, O₂ ≥ 92% within 24 hrs).
• A: “Feel better” is vague and not measurable.
• C: Ongoing monitoring is an action, not a patient-centered
outcome.
