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.

Inserting a tunneled central venous catheter.

Irrigation of an external ear canal.

Administering a platelet transfusion.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Changing the inner cannula on a tracheostomy is within the legal scope of practice for registered nurses. Nurses are trained to perform tracheostomy care, including changing the inner cannula. This procedure is within the nursing scope of practice and does not require a physician's intervention.

Choice B rationale:

Inserting a tunneled central venous catheter (such as a Hickman line) is a specialized procedure that generally falls under the scope of practice for advanced practice nurses (such as nurse practitioners or clinical nurse specialists) or physicians. RNs typically do not have the required training or authority to perform this invasive procedure.

Choice C rationale:

Irrigation of an external ear canal is within the legal scope of practice for registered nurses. Ear irrigation is a common nursing procedure used to remove impacted cerumen (earwax) and foreign bodies from the ear canal. Nurses are trained to perform this procedure safely and effectively.

Choice D rationale:

Administering blood products, including platelet transfusions, is within the legal scope of practice for an RN. RNs are responsible for preparing, verifying, and administering blood products according to institutional policies and procedures. This includes monitoring the patient during and after the transfusion for any adverse reactions.

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Correct Answer is B

Explanation

Choice A rationale:

A sore throat is a common and expected finding after a tonsillectomy due to irritation from the procedure. While it can cause discomfort, it is not a priority concern unless it worsens significantly or is accompanied by other symptoms indicating complications such as bleeding or infection.

Choice B rationale:

Frequent swallowing can be a sign of bleeding after a tonsillectomy. The child may swallow more often to clear blood or blood clots from the throat, which could indicate that there is active bleeding from the surgical site.

Choice C rationale:

Blood-tinged mucus is a common finding in the immediate postoperative period after a tonsillectomy. It is expected due to the healing process and is not a cause for concern unless it becomes profuse or is accompanied by active bleeding.

Choice D rationale:

While dark brown vomit may indicate that the child has swallowed blood, it is not as immediately concerning as frequent swallowing, which could suggest active bleeding at the surgical site. Dark brown emesis is typically less alarming, but it should still be monitored closely.

A. "What are the voices telling you?" B. "Have you taken your medication today?" C. "I realize the voices are real to you, but I don't hear anything." D. "How long have you been hearing the voices?"

Correct Answer is A

Explanation

The correct answer is Choice A.

Choice A rationale: “What are the voices telling you?” This is the priority response because it directly addresses the client’s immediate concern. The nurse is acknowledging the client’s experience and seeking to understand more about it. This can help the nurse assess the potential for harm to the client or others, as the voices may be instructing the client to engage in dangerous behaviors.

Choice B rationale: “Have you taken your medication today?” While medication adherence is important in managing schizophrenia, this response does not address the client’s immediate concern about hearing voices. It may also come across as dismissive of the client’s experience.

Choice C rationale: “I realize the voices are real to you, but I don’t hear anything.” This response validates the client’s experience, but it does not gather further information about what the voices are saying, which is crucial for assessing safety.

Choice D rationale: “How long have you been hearing the voices?” While this question is relevant for understanding the client’s history and the progression of their illness, it is not the priority response. The immediate concern should be what the voices are saying to assess for potential harm.

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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

A nurse is assessing a child who is postoperative following a tonsillectomy. Which of the following findings should the nurse identify as the priority?

Correct Answer is B

Explanation

A nurse is admitting a client who has schizophrenia. The client states, "I'm hearing voices." Which of the following responses is the priority for the nurse to state?

Correct Answer is A

Explanation

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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?