, 1. Chapter Reference: Chapter 1 — Section:
Foundations of Nursing Practice — Title:
Nursing: Scope and Standards of Practice, 5th
Ed.
Stem: A registered nurse (RN) encounters an unfamiliar clinical
situation outside their usual setting. According to the ANA
Scope and Standards, what is the RN’s best first action?
A. Provide the same care used in prior settings because nursing
is universal.
B. Consult the Scope and Standards to determine accountability
and seek necessary resources.
C. Defer care entirely to a physician because the situation is
unfamiliar.
D. Delegate the care to nursing assistive personnel (NAP) to
avoid liability.
Correct Answer: B
Rationale (Correct): The ANA Scope and Standards require
nurses to use professional judgment and to consult standards
and resources when practice situations fall outside their usual
experience; seeking guidance supports safe, competent care
and professional accountability.
Rationale (A incorrect): Nursing principles vary by setting;
assuming universality risks unsafe practice.
Rationale (C incorrect): Deferring entirely to a physician
,neglects the RN’s assessment and accountability
responsibilities; collaboration is appropriate.
Rationale (D incorrect): Delegation is permissible only when
the RN determines the task is within the delegatee’s scope and
after appropriate supervision; blanket delegation to avoid
liability is inappropriate.
Teaching Point: Use ANA standards to guide decisions and seek
resources when practice falls outside experience.
Chapter 1 — Section: Definition of Nursing — Title: Scope &
Standards Overview
2.
Stem: Which of the following best describes the purpose of the
ANA “Scope of Nursing Practice” statement?
A. To list every procedure a nurse must perform.
B. To define legal statutes for nursing practice in each state.
C. To describe the who, what, where, when, why, and how of
nursing practice.
D. To replace institutional policies and procedures.
Correct Answer: C
Rationale (Correct): The Scope of Nursing Practice articulates
the profession’s boundaries and describes who practices, what
they do, and the contexts and methods of nursing — guiding
professional expectations.
Rationale (A incorrect): It does not exhaustively list procedures;
, it provides guiding principles.
Rationale (B incorrect): Legal statutes (nurse practice acts) are
separate; scope informs practice but is not the law.
Rationale (D incorrect): Institutional policies operationalize
practice and complement the scope; the scope does not replace
local policy.
Teaching Point: Scope statements define nursing’s role and
purpose, not minute procedures.
Chapter 1 — Section: Standards of Practice — Title: Standards
Overview (Nursing Process)
3.
Stem: An RN completes a comprehensive assessment and
documents new acute shortness of breath. According to ANA
Standards of Practice, which next step is the RN required to
perform?
A. Immediately discharge the patient if symptoms persist.
B. Analyze assessment data to determine nursing diagnoses
(Standard: Diagnosis).
C. Wait 24 hours to let symptoms evolve before acting.
D. Only notify family members; documentation is optional.
Correct Answer: B
Rationale (Correct): The Standards of Practice define diagnosis
as analyzing assessment data to identify actual or potential
issues; this step directs subsequent outcomes and
Foundations of Nursing Practice — Title:
Nursing: Scope and Standards of Practice, 5th
Ed.
Stem: A registered nurse (RN) encounters an unfamiliar clinical
situation outside their usual setting. According to the ANA
Scope and Standards, what is the RN’s best first action?
A. Provide the same care used in prior settings because nursing
is universal.
B. Consult the Scope and Standards to determine accountability
and seek necessary resources.
C. Defer care entirely to a physician because the situation is
unfamiliar.
D. Delegate the care to nursing assistive personnel (NAP) to
avoid liability.
Correct Answer: B
Rationale (Correct): The ANA Scope and Standards require
nurses to use professional judgment and to consult standards
and resources when practice situations fall outside their usual
experience; seeking guidance supports safe, competent care
and professional accountability.
Rationale (A incorrect): Nursing principles vary by setting;
assuming universality risks unsafe practice.
Rationale (C incorrect): Deferring entirely to a physician
,neglects the RN’s assessment and accountability
responsibilities; collaboration is appropriate.
Rationale (D incorrect): Delegation is permissible only when
the RN determines the task is within the delegatee’s scope and
after appropriate supervision; blanket delegation to avoid
liability is inappropriate.
Teaching Point: Use ANA standards to guide decisions and seek
resources when practice falls outside experience.
Chapter 1 — Section: Definition of Nursing — Title: Scope &
Standards Overview
2.
Stem: Which of the following best describes the purpose of the
ANA “Scope of Nursing Practice” statement?
A. To list every procedure a nurse must perform.
B. To define legal statutes for nursing practice in each state.
C. To describe the who, what, where, when, why, and how of
nursing practice.
D. To replace institutional policies and procedures.
Correct Answer: C
Rationale (Correct): The Scope of Nursing Practice articulates
the profession’s boundaries and describes who practices, what
they do, and the contexts and methods of nursing — guiding
professional expectations.
Rationale (A incorrect): It does not exhaustively list procedures;
, it provides guiding principles.
Rationale (B incorrect): Legal statutes (nurse practice acts) are
separate; scope informs practice but is not the law.
Rationale (D incorrect): Institutional policies operationalize
practice and complement the scope; the scope does not replace
local policy.
Teaching Point: Scope statements define nursing’s role and
purpose, not minute procedures.
Chapter 1 — Section: Standards of Practice — Title: Standards
Overview (Nursing Process)
3.
Stem: An RN completes a comprehensive assessment and
documents new acute shortness of breath. According to ANA
Standards of Practice, which next step is the RN required to
perform?
A. Immediately discharge the patient if symptoms persist.
B. Analyze assessment data to determine nursing diagnoses
(Standard: Diagnosis).
C. Wait 24 hours to let symptoms evolve before acting.
D. Only notify family members; documentation is optional.
Correct Answer: B
Rationale (Correct): The Standards of Practice define diagnosis
as analyzing assessment data to identify actual or potential
issues; this step directs subsequent outcomes and
