A nurse is providing nursing care to a group of patients. Which actions are direct care interventions? (Select all that apply.)

Teaching about medications

Performing resuscitation

Inserting a feeding tube

Documenting wound care

Ambulating a patient

Answer and Explanation

Correct Answer : A,B,C,E

A. Teaching about medications. This is correct because providing education to a patient is a direct care intervention, as it involves interaction with the patient to improve their health outcomes.

B. Performing resuscitation. This is correct because resuscitation is a hands-on, immediate intervention aimed at stabilizing a patient, making it a direct care intervention.

C. Inserting a feeding tube. This is correct because placing a feeding tube is a direct intervention that involves a hands-on nursing procedure.

D. Documenting wound care. This is incorrect because documentation is an indirect care intervention. While it is essential for communication and continuity of care, it does not directly affect the patient's condition.

E. Ambulating a patient. This is correct because physically assisting a patient with walking is a direct care intervention that helps prevent complications such as deep vein thrombosis and pneumonia.

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Correct Answer is C

Explanation

A. Only at the beginning of the hospital stay to establish a baseline. This is incorrect because while an initial assessment establishes a baseline, ongoing assessments are necessary to monitor changes in the patient’s condition.

B. Once a week during routine rounds. This is incorrect because patient conditions can change rapidly, and weekly assessments are insufficient for monitoring acute care patients.

C. At each shift change to identify any changes in the patient's condition. This is correct because ongoing assessments should be performed regularly, especially at the beginning of each shift. This allows the nurse to detect changes early, adjust care plans, and intervene as needed.

D. Only when the patient reports new symptoms. This is incorrect because waiting for a patient to report symptoms may delay critical interventions. Many conditions, such as sepsis or respiratory distress, can progress without the patient immediately recognizing symptoms. Routine monitoring helps identify early signs of deterioration.

A. Explaining to the patient that self-reporting of severe pain is not consistent with the minor procedure that was performed B. Administering pain-relief medication according to what was given last shift C. Offering pain-relief medication based on the health care provider's orders D. Asking the patient what pain-relief methods, pharmacological and nonpharmacological, have worked in the past

Correct Answer is D

Explanation

A. Pain is subjective, and patients experience it differently. Dismissing their report based on the procedure undermines their experience and may lead to inadequate pain management.

B. Pain levels fluctuate, and treatment should be based on current assessment rather than past administration. This approach lacks critical thinking and fails to address the patient's individual needs.

C. While following provider orders is necessary, blindly administering medication without assessing the patient's current pain level and preferences is not critical thinking.

D. This approach individualizes care and involves the patient in decision-making, which is a key component of critical thinking in nursing.

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A nurse is providing nursing care to a group of patients. Which actions are direct care interventions? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is D

Explanation

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