A community health nurse is planning an educational program on Lyme disease for the general public. Which of the following statements should the nurse include in the program?

 

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.

Choice A reason: Tinnitus is not a typical adverse effect of disulfiram-alcohol reaction, which causes acetaldehyde buildup, leading to hypertension, flushing, and nausea. Monitoring for hypertension is critical. Assuming tinnitus risks missing cardiovascular effects, delaying interventions like IV fluids, essential for managing severe reactions in alcohol use disorder treatment.

Choice B reason: Disulfiram with alcohol causes a severe reaction, including hypertension, due to acetaldehyde accumulation, risking cardiovascular complications. Monitoring blood pressure is critical to manage this potentially life-threatening reaction, ensuring timely interventions like supportive care or antihistamines, essential for client safety in alcohol use disorder treatment with disulfiram.

Choice C reason: Headache may occur in disulfiram-alcohol reaction but is less specific and severe than hypertension, which poses greater cardiovascular risk. Focusing on headache risks underestimating the reaction’s severity, delaying critical monitoring of blood pressure, essential for preventing complications like stroke in clients on disulfiram who ingest alcohol.

Choice D reason: Insomnia is not a primary adverse effect of disulfiram-alcohol reaction, which prominently features hypertension, nausea, and flushing. Assuming insomnia risks overlooking acute cardiovascular effects, delaying interventions like blood pressure management, critical for ensuring safety and preventing severe complications in clients with alcohol use disorder.