, 1. Chapter Reference: Chapter 1 — Section:
Foundations of Nursing Practice — Title:
Nursing: Scope and Standards of Practice, 5th
Ed.
Stem: A registered nurse (RN) is asked to accept a new patient
assignment that exceeds the nurse’s current knowledge and
skill level. According to ANA Scope and Standards principles, the
nurse’s BEST action is to:
A. Accept the assignment and learn on the job.
B. Refuse the assignment and report the manager.
C. Accept the assignment but request assistance and
supervision.
D. Delegate the care to a less-experienced colleague.
Correct Answer: C
Rationales:
Correct: The nurse must ensure safe, competent care; accepting
with requested assistance/supervision demonstrates
accountability while protecting patient safety. This aligns with
standards requiring nurses to practice within competence and
seek help when needed.
Incorrect A: Learning on the job without oversight may place
patients at risk and violates practice standards for competence
and safety.
Incorrect B: Immediately refusing and reporting without first
,discussing alternatives is not the most collaborative or patient-
centered first step.
Incorrect D: Delegating to someone less experienced when you
yourself lack competence transfers risk and is not appropriate
delegation.
Teaching Point: Nurses must remain within competence and
obtain supervision when assigned beyond their skill level.
2.
Chapter 1, Section 1: Foundations of Nursing Practice and
Professional Roles
Stem: During a rapid change in patient condition, a nurse must
prioritize interventions. Which ANA Standard most directly
guides the nurse’s clinical judgment and prioritization?
A. Standard: Education.
B. Standard: Assessment.
C. Standard: Ethics.
D. Standard: Collaboration.
Correct Answer: B
Rationales:
Correct: The Assessment standard requires systematic
collection and analysis of data; accurate assessment is
foundational for clinical judgment and prioritizing interventions.
Incorrect A: Education addresses professional learning, not
immediate clinical prioritization.
, Incorrect C: Ethics guides moral decision-making but doesn’t
replace timely assessment for clinical priorities.
Incorrect D: Collaboration supports team care but relies on
assessment to inform priorities.
Teaching Point: Thorough assessment is the foundation for
effective clinical decision-making and prioritization.
3.
Chapter 1, Section 1: Foundations of Nursing Practice and
Professional Roles
Stem: A nurse documents that a patient received a medication
but inadvertently omits the dose. According to ANA
documentation standards, the MOST appropriate immediate
action is to:
A. Leave the entry as-is and document the omission later if
discovered.
B. Add the dose later in the record without noting the time of
correction.
C. Immediately correct the documentation with a clear
addendum noting the time and reason.
D. Erase the original entry and replace it with the corrected
information.
Correct Answer: C
Rationales:
Correct: Accurate, timely, and transparent documentation is
Foundations of Nursing Practice — Title:
Nursing: Scope and Standards of Practice, 5th
Ed.
Stem: A registered nurse (RN) is asked to accept a new patient
assignment that exceeds the nurse’s current knowledge and
skill level. According to ANA Scope and Standards principles, the
nurse’s BEST action is to:
A. Accept the assignment and learn on the job.
B. Refuse the assignment and report the manager.
C. Accept the assignment but request assistance and
supervision.
D. Delegate the care to a less-experienced colleague.
Correct Answer: C
Rationales:
Correct: The nurse must ensure safe, competent care; accepting
with requested assistance/supervision demonstrates
accountability while protecting patient safety. This aligns with
standards requiring nurses to practice within competence and
seek help when needed.
Incorrect A: Learning on the job without oversight may place
patients at risk and violates practice standards for competence
and safety.
Incorrect B: Immediately refusing and reporting without first
,discussing alternatives is not the most collaborative or patient-
centered first step.
Incorrect D: Delegating to someone less experienced when you
yourself lack competence transfers risk and is not appropriate
delegation.
Teaching Point: Nurses must remain within competence and
obtain supervision when assigned beyond their skill level.
2.
Chapter 1, Section 1: Foundations of Nursing Practice and
Professional Roles
Stem: During a rapid change in patient condition, a nurse must
prioritize interventions. Which ANA Standard most directly
guides the nurse’s clinical judgment and prioritization?
A. Standard: Education.
B. Standard: Assessment.
C. Standard: Ethics.
D. Standard: Collaboration.
Correct Answer: B
Rationales:
Correct: The Assessment standard requires systematic
collection and analysis of data; accurate assessment is
foundational for clinical judgment and prioritizing interventions.
Incorrect A: Education addresses professional learning, not
immediate clinical prioritization.
, Incorrect C: Ethics guides moral decision-making but doesn’t
replace timely assessment for clinical priorities.
Incorrect D: Collaboration supports team care but relies on
assessment to inform priorities.
Teaching Point: Thorough assessment is the foundation for
effective clinical decision-making and prioritization.
3.
Chapter 1, Section 1: Foundations of Nursing Practice and
Professional Roles
Stem: A nurse documents that a patient received a medication
but inadvertently omits the dose. According to ANA
documentation standards, the MOST appropriate immediate
action is to:
A. Leave the entry as-is and document the omission later if
discovered.
B. Add the dose later in the record without noting the time of
correction.
C. Immediately correct the documentation with a clear
addendum noting the time and reason.
D. Erase the original entry and replace it with the corrected
information.
Correct Answer: C
Rationales:
Correct: Accurate, timely, and transparent documentation is
