A nurse manager is teaching a group of newly licensed nurses about which procedures are within their scope of practice. Which of the following examples should the nurse include in the teaching?

Insertion of an endotracheal tube

Monitoring a continuous intra-arterial infusion of a thrombolytic medication

Placement of nylon sutures

Administering a bolus dose of medication through an epidural catheter

Answer and Explanation

The Correct Answer is B

A. 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.

B. Monitoring a continuous intra-arterial infusion of a thrombolytic medication: Nurses are responsible for closely monitoring patients receiving high-risk infusions. This includes assessing for complications such as bleeding, changes in vital signs, and effectiveness of therapy, which falls within an RN’s scope of practice.

C. 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.

D. 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.

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Correct Answer is A

Explanation

A. 30° lateral: The 30-degree lateral position is recommended to reduce pressure on bony prominences such as the trochanters, sacrum, and heels. It distributes weight more evenly and decreases the risk of pressure injury compared to lying directly on the side or back.

B. Lateral semi-prone recumbent: This position places significant pressure on the greater trochanter and shoulder, which increases the risk of skin breakdown. It is not the safest choice for clients at high risk of pressure injuries.

C. Supine: Lying flat on the back concentrates pressure on the sacrum, heels, and occiput. Prolonged supine positioning without frequent repositioning contributes to rapid development of pressure injuries.

D. 45° supported Fowler's: While Fowler’s position can help with breathing, it increases pressure on the sacrum and ischial tuberosities. Extended use in this position places immobile clients at a greater risk for pressure injuries.

A. Place a vibrating tuning fork on the top of the client's head. B. Move a vibrating tuning fork's prongs in front of the client's left or right ear canal. C. Activate a tuning fork and place the prongs on the client's occipital area. D. Instruct the client to occlude one ear and repeat a softly spoken phrase by the nurse.

Correct Answer is B

Explanation

A. Place a vibrating tuning fork on the top of the client's head: This describes the Weber test, which assesses lateralization of sound to determine conductive versus sensorineural hearing loss.

B. Move a vibrating tuning fork's prongs in front of the client's left or right ear canal: In the Rinne test, the nurse compares bone conduction and air conduction. After placing the fork on the mastoid bone, it is moved in front of the ear canal to test air conduction, which should normally be longer than bone conduction.

C. Activate a tuning fork and place the prongs on the client's occipital area: Placing the tuning fork on the occipital bone is not part of any standard hearing assessment test. It would not yield useful information about bone or air conduction.

D. Instruct the client to occlude one ear and repeat a softly spoken phrase by the nurse: This describes the whisper test, a screening tool for gross hearing acuity. It is not related to the Rinne test procedure.

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A nurse manager is teaching a group of newly licensed nurses about which procedures are within their scope of practice. Which of the following examples should the nurse include in the teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is at risk for pressure injury formation due to immobility. The nurse should place the client in which of the following positions to reduce pressure on the client's bony prominences?

Correct Answer is A

Explanation

A nurse is assessing a client for hearing acuity by performing the Rinne test. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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