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.

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Correct Answer is B

Explanation

Choice A reason: Whole wheat pasta contains gluten, contraindicated in celiac disease, causing intestinal damage. Corn tortillas are gluten-free. Recommending wheat pasta risks exacerbation of symptoms like diarrhea, critical to avoid in ensuring dietary safety and preventing long-term complications in preschoolers with celiac disease.

Choice B reason: A corn tortilla with black beans is gluten-free, safe for celiac disease, avoiding intestinal damage. This recommendation supports nutritional needs, critical for growth, preventing symptoms like malabsorption, and ensuring dietary adherence, essential for managing celiac disease effectively in preschoolers with dietary restrictions.

Choice C reason: Barley contains gluten, harmful in celiac disease, risking intestinal inflammation. Corn tortillas are safe. Recommending barley soup risks symptoms like abdominal pain, critical to avoid in ensuring gluten-free nutrition, supporting health, and preventing complications in preschoolers managing celiac disease through diet.

Choice D reason: Rye bread contains gluten, contraindicated in celiac disease, causing gut damage. Corn tortillas are appropriate. Recommending rye risks malabsorption or growth issues, critical to prevent in ensuring a gluten-free diet, supporting nutritional health, and managing celiac disease in preschoolers effectively.

A. Pour cool water over the client's perineum. B. Tell the client to gently stroke their lower abdomen. C. Instruct the client to lean slightly backward. D. Turn on the faucets in the client's sink.

Correct Answer is D

Explanation

Choice A reason: Pouring cool water over the perineum may cause discomfort or infection risk and is not a standard method to stimulate urination. It does not address psychological or reflex triggers for voiding, making it ineffective for bedpan urination difficulties.

Choice B reason: Stroking the lower abdomen may stimulate bladder contraction but is less effective than auditory cues for triggering the voiding reflex. It is not a primary intervention for bedpan urination issues, making it less appropriate than running water.

Choice C reason: Leaning slightly backward may increase intra-abdominal pressure, hindering bladder emptying. A forward-leaning or upright position is preferred to facilitate urination, so this instruction is counterproductive for helping the client urinate into a bedpan.

Choice D reason: Turning on faucets creates running water sounds, stimulating the voiding reflex via auditory cues, a proven method to aid urination in bedbound clients. This non-invasive approach addresses psychological barriers, making it the correct action for bedpan difficulties.

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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

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Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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