A nurse is planning care for a client who is preoperative for a surgical procedure. The nurse should identify that which of the following tasks is outside of their scope of practice?
Collecting a clean catch urine specimen.
Explaining the risks of the procedure.
Reinforcing preoperative teaching.
Performing a preoperative skin preparation.
The Correct Answer is B
Rationale:
A. Collecting a clean catch urine specimen: This is within the nurse’s scope of practice and is a routine part of preoperative preparation to screen for infection or other abnormalities before surgery.
B. Explaining the risks of the procedure: Explaining surgical risks is the responsibility of the provider performing the procedure. Nurses may reinforce information but are not authorized to introduce or explain risks, as this constitutes part of informed consent.
C. Reinforcing preoperative teaching: Reinforcement of teaching provided by the surgeon or anesthesiologist is within the nurse’s role. The nurse can clarify instructions or ensure the client understands how to prepare for surgery based on what was already explained.
D. Performing a preoperative skin preparation: Nurses are responsible for tasks like preoperative skin prep, which helps reduce infection risk. This is a common nursing duty that supports surgical readiness.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. Urinary frequency: As death approaches, urinary output typically decreases due to reduced kidney perfusion. Urinary frequency is not a common sign of impending death and may suggest other unrelated conditions.
B. Difficulty swallowing: Difficulty swallowing is a common manifestation of impending death. As muscle tone declines, the child may struggle to manage secretions or food, increasing the risk of aspiration and signaling the body is shutting down.
C. Decreased sleep: Clients nearing death often exhibit increased sleep or lethargy, not decreased sleep. Diminished responsiveness and longer periods of unresponsiveness are expected in the final stages of life.
D. Increased senses: Sensory function generally declines as death nears. Vision, hearing, taste, and touch may all diminish, and the child may become less responsive to external stimuli. Increased senses are not expected at this stage
Correct Answer is B
Explanation
Rationale:
A. Ensure the client is aware of the scheduled time for the procedure: While knowing the time of surgery is helpful for preparation, it is not a requirement for informed consent. The key issue is whether the client understands the procedure itself and its implications.
B. Make sure the client has been informed about the risks of the procedure: Before witnessing informed consent, the nurse must confirm that the client has received complete information from the provider about the procedure, including its purpose, risks, benefits, and alternatives. This ensures the client is making an informed decision.
C. Ensure the client receives opioid medication prior to giving consent for the procedure: Administering opioids before consent can impair the client's cognitive ability to understand and voluntarily agree. Consent must be obtained while the client is alert and oriented, prior to any sedating medications.
D. Make sure the client's family agrees to the procedure: Consent is only valid when given by the competent client. Family agreement is not legally required unless the client is unable to consent and a legal surrogate is designated.
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