A nurse is teaching a class about providing care within the legal scope of practice to a group of nurses. The nurse should include that which of the following procedures is outside the legal scope of practice for an RN?

Changing the inner cannula on a tracheostomy

Irrigation of an external ear canal

Inserting a tunneled central venous catheter

Administering a platelet transfusion

Answer and Explanation

The Correct Answer is C

Choice A reason: Changing a tracheostomy inner cannula is within an RN’s scope, involving routine airway maintenance. It requires sterile technique and training but is a standard nursing procedure, not restricted to advanced practitioners, making it a permissible task.

Choice B reason: Irrigating an external ear canal is within an RN’s scope, used to remove cerumen or debris. It requires proper technique to avoid injury, but RNs are trained for this, making it a standard nursing intervention, not outside their legal scope.

Choice C reason: Inserting a tunneled central venous catheter is outside an RN’s scope, as it requires surgical skills and is performed by physicians or advanced practice providers. RNs may assist or manage catheters post-insertion, but insertion is restricted, making this the correct choice.

Choice D reason: Administering a platelet transfusion is within an RN’s scope, involving monitoring for reactions and following protocols. It is a standard nursing procedure in settings like oncology, not restricted to advanced practitioners, making it a permissible task.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A reason: Reporting tight restraints indicates discomfort, requiring adjustment, not discontinuation, which depends on behavioral safety. Calmly following commands justifies removal. Ignoring tightness risks injury or agitation, delaying safe restraint removal, critical for ethical care and preventing harm in clients with aggressive behavior.

Choice B reason: Calmly following commands indicates the client is no longer a danger, justifying restraint discontinuation per least-restrictive principles. This ensures safety and ethical care, critical for de-escalation, preventing prolonged restraint risks like injury, and supporting client dignity in acute behavioral management situations.

Choice C reason: Four hours in restraints triggers reassessment, not automatic discontinuation, which depends on behavior (e.g., calmly following commands). Assuming time alone justifies removal risks premature release if unsafe, potentially endangering staff or client, critical to avoid in managing aggressive behavior with mechanical restraints.

Choice D reason: Explaining behavior shows insight but doesn’t guarantee safety; calmly following commands is a stronger indicator for restraint removal. Assuming explanation suffices risks premature discontinuation, potentially compromising safety, critical for ensuring restraints are used only until the client is stable and non-threatening in acute settings.

A. Respiratory rate 11/min B. SpO2 > 94% on room air C. Lungs clear to auscultation D. Reports pain worsening in right forearm. E. States right hand is “tingly.” F. Able to move fingers

Correct Answer is ["D","E"]

Explanation

Choice A reason: A respiratory rate of 11/min is slightly below normal (12-20/min) but not immediately concerning in a stable elderly client without respiratory distress. It warrants monitoring but does not require urgent follow-up compared to neurological or musculoskeletal symptoms.

Choice B reason: SpO2 > 94% on room air is normal, indicating adequate oxygenation. This finding does not suggest respiratory compromise, so it does not require immediate follow-up, aligning with expected respiratory status in a stable client.

Choice C reason: Clear lung auscultation is a normal finding, indicating no airway obstruction or fluid. It does not suggest respiratory pathology, so it does not require immediate follow-up, reflecting stable pulmonary function in the client’s assessment.

Choice D reason: Worsening forearm pain after a fall suggests potential fracture, compartment syndrome, or nerve injury, especially in an elderly client. This escalating symptom requires immediate imaging and evaluation to prevent complications like tissue damage, making it critical for follow-up.

Choice E reason: Tingling in the right hand indicates possible nerve compression or injury, such as radial nerve damage from a fall. This neurological symptom demands urgent assessment to prevent permanent impairment, making it a priority for immediate follow-up.

Choice F reason: Ability to move fingers is a positive finding, suggesting some preserved motor function. While reassuring, it does not negate the need to address worsening pain and tingling, so it does not require immediate follow-up compared to other symptoms.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is teaching a class about providing care within the legal scope of practice to a group of nurses. The nurse should include that which of the following procedures is outside the legal scope of practice for an RN?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who is in mechanical restraints after hitting a staff member. Which of the following findings indicates that the nurse should discontinue the restraints?

Correct Answer is B

Explanation

Click to highlight the findings that require immediate follow-up. (Select all that apply)

Correct Answer is ["D","E"]

Explanation

A nurse is creating an incident report due to an accidental omission of a client's dressing change during the previous shift. Which of the following statements should the nurse document on the incident report form?

A school nurse is using the Weber’s test to check a child’s hearing acuity. Which of the following actions should the nurse take?

A charge nurse is observing an assistive personnel perform delegated tasks. Which of the following actions by the AP requires the charge nurse to intervene?

A nurse is observing an assistive personnel (AP) measure blood pressures from the right arms of a group of clients. The nurse should instruct the AP to measure the blood pressure in the left arm of which of the following clients?

A nurse is admitting a school-age child who has bacterial meningitis. Which of the following types of isolation precautions should the nurse initiate?

A nurse is planning care for a client who is at 32 weeks of gestation and has severe preeclampsia. Which of the following actions should the nurse plan to take?

A nurse is teaching a client who is postpartum about caring for their newborn's umbilical cord. Which of the following instructions should the nurse include?

A nurse is planning care for a client who has a history of urinary tract infections (UTIs) and requires placement of an indwelling urinary catheter. Which of the following actions should the nurse take to help minimize the client's risk for acquiring a UTI?