, Chapter1: Foundations of Nursing Practice
Stem: A registered nurse (RN) encounters a request from a
patient to perform an advanced procedure that is not in the
nurse’s job description or state nurse practice act. Which action
best reflects adherence to the ANA Scope of Practice?
A. Accept the request and perform the procedure if supervised
by a physician.
B. Refuse the task and report the patient for inappropriate
requests.
C. Clarify scope limitations, decline if outside scope, and seek
appropriate referral.
D. Perform the procedure and document that it was patient-
driven.
Correct Answer: C
Rationales:
Correct: Clarifying scope limitations, declining when outside
one’s legal/ethical scope, and arranging appropriate referral
align with ANA standards for safe, competent practice and
accountability. Nurses must ensure patient safety by working
within legal and professional boundaries.
A: Supervision by a physician does not automatically authorize a
nurse to perform tasks outside the state nurse practice act or
institutional policy.
B: Refusing without offering alternatives neglects patient
advocacy and continuity of care obligations.
,D: Performing outside scope and documenting patient request
still breaches legal and professional standards and risks harm
and liability.
Teaching Point: Always verify legal scope and refer when tasks
exceed nursing authority.
2.
Chapter Reference: Chapter 1 — Section 1.2 — Title: Standards
of Practice (Assessment)
Stem: During admission, a nurse conducts a focused respiratory
assessment and documents findings. Which statement best
describes how this action maps to the ANA Standards of
Practice?
A. It fulfills the standard of evaluation.
B. It fulfills the standard of assessment.
C. It fulfills the standard of diagnosis.
D. It fulfills the standard of outcomes identification.
Correct Answer: B
Rationales:
Correct: The Standards of Practice list assessment as the
systematic collection of patient data—performing and
documenting a focused respiratory assessment directly meets
this standard.
A: Evaluation refers to assessing outcomes after interventions,
, not initial data collection.
C: Diagnosis involves interpreting assessment data to identify
problems; assessment alone is not diagnosis.
D: Outcomes identification is establishing expected results of
care; assessment gathers the data used for that step.
Teaching Point: Assessment is the foundational standard that
informs diagnosis and plan of care.
3.
Chapter Reference: Chapter 1 — Section 1.3 — Title: Standards
of Practice (Diagnosis & Outcomes)
Stem: A nurse notices early signs of pressure injury in an
immobile patient and documents a problem statement and
expected outcomes. Which standard of practice is the nurse
primarily exercising?
A. Standard I: Assessment
B. Standard II: Diagnosis
C. Standard IV: Implementation
D. Standard VI: Evaluation
Correct Answer: B
Rationales:
Correct: Formulating a nursing diagnosis (problem statement)
based on assessment data and identifying expected outcomes is
central to the Diagnosis standard.
Stem: A registered nurse (RN) encounters a request from a
patient to perform an advanced procedure that is not in the
nurse’s job description or state nurse practice act. Which action
best reflects adherence to the ANA Scope of Practice?
A. Accept the request and perform the procedure if supervised
by a physician.
B. Refuse the task and report the patient for inappropriate
requests.
C. Clarify scope limitations, decline if outside scope, and seek
appropriate referral.
D. Perform the procedure and document that it was patient-
driven.
Correct Answer: C
Rationales:
Correct: Clarifying scope limitations, declining when outside
one’s legal/ethical scope, and arranging appropriate referral
align with ANA standards for safe, competent practice and
accountability. Nurses must ensure patient safety by working
within legal and professional boundaries.
A: Supervision by a physician does not automatically authorize a
nurse to perform tasks outside the state nurse practice act or
institutional policy.
B: Refusing without offering alternatives neglects patient
advocacy and continuity of care obligations.
,D: Performing outside scope and documenting patient request
still breaches legal and professional standards and risks harm
and liability.
Teaching Point: Always verify legal scope and refer when tasks
exceed nursing authority.
2.
Chapter Reference: Chapter 1 — Section 1.2 — Title: Standards
of Practice (Assessment)
Stem: During admission, a nurse conducts a focused respiratory
assessment and documents findings. Which statement best
describes how this action maps to the ANA Standards of
Practice?
A. It fulfills the standard of evaluation.
B. It fulfills the standard of assessment.
C. It fulfills the standard of diagnosis.
D. It fulfills the standard of outcomes identification.
Correct Answer: B
Rationales:
Correct: The Standards of Practice list assessment as the
systematic collection of patient data—performing and
documenting a focused respiratory assessment directly meets
this standard.
A: Evaluation refers to assessing outcomes after interventions,
, not initial data collection.
C: Diagnosis involves interpreting assessment data to identify
problems; assessment alone is not diagnosis.
D: Outcomes identification is establishing expected results of
care; assessment gathers the data used for that step.
Teaching Point: Assessment is the foundational standard that
informs diagnosis and plan of care.
3.
Chapter Reference: Chapter 1 — Section 1.3 — Title: Standards
of Practice (Diagnosis & Outcomes)
Stem: A nurse notices early signs of pressure injury in an
immobile patient and documents a problem statement and
expected outcomes. Which standard of practice is the nurse
primarily exercising?
A. Standard I: Assessment
B. Standard II: Diagnosis
C. Standard IV: Implementation
D. Standard VI: Evaluation
Correct Answer: B
Rationales:
Correct: Formulating a nursing diagnosis (problem statement)
based on assessment data and identifying expected outcomes is
central to the Diagnosis standard.
