July 23, 2026
The situation
Cheri, an LPN, calls Kim-Ly, the in-charge RN, about Mr. Carlson's distended abdomen, pain, and bladder scan of 950 mL. With Mr. Carlson's history of urinary retention, Kim-Ly considers next steps.
- Read the full case
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Kim-Ly, an RN, is in charge at a multi-level care facility. One afternoon she receives a phone call from Cheri, an LPN working on the special care unit, who is concerned about a client, Mr. Carlson.
Over the phone, Cheri reports her assessment findings: Mr. Carlson has a firm and distended abdomen, he grimaces on palpation, and he has an urgent need to void. A bladder scan shows 950 mL of retained urine. Cheri also reminds Kim-Ly that Mr. Carlson has a history of benign prostate hypertrophy and episodes of urinary retention.
Kim-Ly recalls treating Mr. Carlson for urinary retention in the past. Drawing on her knowledge of his history, her professional judgment, and the assessment findings, she considers her options. Kim-Ly knows that within her autonomous scope of practice she can make a nursing diagnosis, determine appropriate treatment, and either carry out the treatment herself or provide a client-specific order for another nurse to act with. She also knows her organization has a decision support tool (DST) that guides initiation of catheterization for urinary retention.
Based on the information provided by Cheri, Kim-Ly diagnoses Mr. Carlson's condition as urinary retention. She determines that an in-and-out catheterization is the most appropriate treatment. Returning to the unit, Kim-Ly writes a client-specific order for the procedure in Mr. Carlson's chart.
Kim-Ly accepts responsibility and accountability for the order. She understands that although she is responsible for making sure the order is appropriate and carried out in a timely manner, she is not responsible for determining whether Cheri has the competence to perform the procedure—that determination rests with the nurse carrying out the order.
After reviewing the order, Cheri confirms that in-and-out catheterization is within her scope of practice and that she has the competence to perform it. She follows her unit's DST to carry out the catheterization, relieves Mr. Carlson's urinary retention, and documents her actions and the outcome in his chart.
Following up, Kim-Ly reviews the outcome with Cheri. She also contacts the facility's nurse practitioner to inform her of Mr. Carlson's condition, the assessment findings, the actions taken, and the results. Kim-Ly documents this communication and her own decision-making in the client record, ensuring continuity of care and accountability.
Kim-Ly's actions
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Step 1: Assessment - Confirms urinary retention using assessment and history.
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Step 2: Decision - Determines in-and-out catheterization is appropriate.
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Step 3: Action - Writes a client-specific order following DST.
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Step 4: Collaboration - Discusses with Cheri and follows up with NP.
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Step 5: Documentation – Records orders, actions, and outcomes.
Apply the standard
Which of the following actions are within Kim-Ly's autonomous scope of practice?
- Option A: Prescribing antibiotics to prevent infection
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Not correct. Prescribing medications is not within an RN's autonomous scope (except for NPs or certified practice nurses within their certified area).
- Option B: Ordering an in-and-out catheterization using a decision support tool (DST)
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Correct. Acting within her autonomous scope and supported by a DST, an RN like Kim-Ly may give an order for catheterization to treat urinary retention when competent and authorized by BCCNM standards and employer policy.
- Option C: Referring Mr. Carlson directly to a urologist
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Not correct. Referral to a medical specialist requires a physician or NP; RNs cannot independently refer clients to specialists.
- Option D: Ordering diagnostic imaging to determine the cause of retention.
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Not correct. Ordering diagnostic tests such as ultrasounds is outside an RN's autonomous scope. These require an order from an authorized prescriber (e.g., NP or physician). Acting beyond scope breaches regulation and accountability standards.
How Kim-Ly meets the standards
Kim-Ly demonstrates that she is meeting all expectations in the practice standard
Acting Within Autonomous Scope of Practice. This includes:
- Conducting an assessment based on Cheri's findings and making a nursing diagnosis of urinary retention.
- Determining an appropriate treatment (in-and-out catheterization) supported by competence and organizational DST.
- Writing a client-specific order for in-and-out catheterization within her autonomous scope of practice.
- Collaborating with Cheri to ensure the order is carried out and following up with the nurse practitioner.
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Documenting her assessment, decision, order, communication, and outcome, and accepting accountability for her actions.
Kim-Ly may give a client-specific order, provided she:
- Meets BCCNM's standards, limits, and conditions for Acting Under Client-specific Orders and Acting Within Autonomous Scope of Practice
- Follows employer policies and DSTs
- Acts within their individual competence
Acting within autonomous scope of practice – recap
Within their autonomous scope of practice, nurses can make autonomous decisions about diagnosing conditions, determining appropriate treatments, and either carrying out those treatments or writing client-specific orders―provided they have the competence and meet any limits and conditions set by BCCNM and employer policy. This may include:
Non-restricted activities:
- Monitoring and reporting assessment findings
- Communicating changes in client condition
- Supporting daily living needs (feeding, mobility, hygiene)
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Health teaching
Restricted activities that do not require an order (within competence and BCCNM limits or conditions):
Outside autonomous scope: Restricted activities that require an order (e.g., prescribing medications, starting most IV therapies, referring directly to medical specialists), or activities limited by BCCNM standards, employer policy, or legislation.
Key point
Even when an activity falls within autonomous scope, nurses must apply all four controls on practice—legislation/regulation, BCCNM standards, employer policy, and individual competence—before acting.