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Pull the visible part of the suture through the underlying tissue: Pulling the external portion of the suture through the tissue can introduce surface bacteria into the wound. This increases the risk of infection and should be avoided.

Cleanse the wound with sterile water prior to removing the sutures: Wounds are typically cleansed with sterile normal saline or an antiseptic solution, not sterile water. Normal saline is isotonic and safe for wound irrigation, whereas sterile water can damage tissue.

Remove the sutures in a consecutive order: Sutures are usually removed every other one first to prevent wound dehiscence. Removing them consecutively can place stress on the wound edges and increase the risk of reopening.

Insertion of an endotracheal tube: Endotracheal intubation is outside the scope of practice for registered nurses. This procedure is performed by providers such as anesthesiologists, respiratory therapists, or specially trained advanced practice nurses.

Placement of nylon sutures: Suturing is a procedure performed by providers or advanced practice nurses, not registered nurses. Performing sutures is outside the RN’s scope of practice in most care settings.

Administering a bolus dose of medication through an epidural catheter: Epidural bolus administration requires advanced training and is usually limited to anesthesiologists, certified registered nurse anesthetists (CRNAs), or pain specialists.

Insert an indwelling urinary catheter: Indwelling catheters increase the risk of urinary tract infections and are not recommended solely for immobility. Managing incontinence with skin care and barrier products is safer for preserving skin integrity.

Reposition the client every 4 hr: Immobile clients should be repositioned at least every 2 hours, not every 4. Prolonged pressure over bony areas can rapidly lead to pressure injuries if turning is delayed.

Massage the skin over bony prominences: Massaging over bony prominences can damage fragile tissue and worsen the risk of pressure injury. Instead, gentle repositioning and cushioning should be used to protect the skin.

Request additional information about the caller's relationship to the client: Even if the caller provides details about their relationship, this does not guarantee that the client has authorized disclosure. Verifying identity alone is not sufficient to maintain confidentiality.

Provide a general update about the client's condition over the telephone: Giving any medical information, even general, without the client’s consent is a breach of confidentiality and violates HIPAA regulations.

Refer the family member to the client's provider for the update: Referring the caller to the provider still risks confidentiality concerns if the client has not given explicit permission. Authorization must come from the client before anyone shares details.

Apply foot cream between the toes: Moisturizing between the toes can create a warm, moist environment that promotes fungal or bacterial infections. Foot cream should be applied to the tops and bottoms of the feet, avoiding spaces between the toes.

Use a pumice stone to soften calluses: Using a pumice stone can cause skin breaks or ulcers in clients with peripheral neuropathy due to reduced sensation. Callus management should be performed by a healthcare professional to prevent injury.

Round the toenail edges when clipping: Toenails should be trimmed straight across to prevent ingrown nails and reduce the risk of infection. Rounding the edges can increase the likelihood of nail problems in clients with neuropathy.

Identify how culture influences family functioning: Cultural influences are important in understanding family dynamics, but assessing the client’s perception of family comes first. Culture shapes interactions, but only after the nurse knows who the family members are from the client’s perspective.

Determine if the client has an external support system: Knowing about external supports is valuable, but this information is secondary to identifying the client’s family structure and relationships. Support systems can be assessed once the family context is clear.

Identify how the family deals with unexpected health changes: Assessing coping strategies is necessary for planning interventions, but it should occur after the nurse has first established who comprises the client’s family and understands their roles.

"I should breathe normally while I am performing this relaxation technique.": Progressive relaxation often involves focused, deep, and controlled breathing to enhance muscle relaxation. Simply breathing normally may not maximize the effectiveness of the technique.

"I should imagine myself in a peaceful, garden-like setting as I begin.": Visualizing a calming scene is a technique used in guided imagery, not progressive muscle relaxation. While relaxation may result, this reflects a different stress-reduction method.

"I'll use a series of stretches when I practice this technique.": Stretching is part of physical exercise routines and differs from progressive relaxation. The focus in progressive relaxation is on controlled tension and release of muscle groups, not performing stretches.