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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Rationale:

A. Changing a sterile dressing on a client's open wound: Sterile procedures require nursing judgment and knowledge of aseptic technique. This task falls within the scope of practice for licensed nurses, not assistive personnel.

B. Performing postmortem care for a client: Postmortem care, such as cleaning the body and preparing it for transport, is a non-sterile, routine task that can be safely delegated to assistive personnel in accordance with facility policy and under nurse supervision.

C. Interpreting a client's laboratory values: Interpretation of lab results requires clinical judgment and is the responsibility of licensed personnel. Assistive personnel are not trained or authorized to interpret clinical data.

D. Inserting a client's NG tube: Inserting a nasogastric tube is an invasive procedure that requires assessment and verification of placement. This task is beyond the scope of assistive personnel and should be performed by a nurse.

A. Offer the client fluids and toileting every 15 min. B. Obtain a prescription before removing the restraints. C. Ensure the restraints are removed from the client within 6 hr. D. Place the client in prone position on a soft mattress.

Correct Answer is B

Explanation

Rationale:

A. Offer the client fluids and toileting every 15 min: While regular offering of fluids and toileting is essential, the standard protocol is typically every 2 hours not every 15 minutes unless otherwise indicated. Overly frequent checks may not be feasible or necessary unless clinically justified.

B. Obtain a prescription before removing the restraints: Mechanical restraints are considered a restrictive intervention and require a physician's order for both application and removal. This ensures medical oversight and client safety.

C. Ensure the restraints are removed from the client within 6 hr: Time limits for restraints depend on the client’s age. For adults, a new order must be obtained every 4 hours, not 6. For children and adolescents (9-17 years), it's 2 hours, and for children under 9 years, it's 1 hour.

D. Place the client in prone position on a soft mattress: Prone restraint positions are not safe and are strongly discouraged due to risk of asphyxiation or injury. Restraints should always allow for safe positioning, typically with the client in a supine or semi-Fowler’s position.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

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Correct Answer is B

Explanation

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