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 A

Explanation

A. The nurse determines to remove a wound dressing when the patient reveals the time of the last dressing change and notices old and new drainage. This is correct because data validation involves verifying information before taking action. The nurse gathers subjective data from the patient (time of last dressing change) and objective data (drainage) before making a clinical decision.

B. The nurse administers pain medicine due at 1700 at 1600 because the patient reports increased pain and the family wants something done. This is incorrect because the nurse has not validated whether the pain medication can be given early or if other interventions should be attempted first.

C. The nurse immediately asks the health care provider for an order of potassium when a patient reports leg cramps. This is incorrect because the nurse has not validated whether the leg cramps are due to low potassium. Leg cramps can result from multiple causes, including dehydration or circulatory issues. Lab values should be checked first.

D. The nurse elevates a leg cast when the patient reports decreased mobility. This is incorrect because decreased mobility does not necessarily indicate the need for elevation. Data validation should include assessing for swelling, circulation, and pain before making a decision.

A. Skip a meal break to catch up on charting. B. Offer to complete another nurse's task. C. Plan time for disruptions. D. Complete the easiest tasks first.

Correct Answer is C

Explanation

A. Skipping breaks can lead to burnout.

B. Taking on another nurse’s task may cause delays in primary responsibilities.

C. Planning for interruptions improves efficiency and prioritization.

D. Completing the easiest tasks first may not be the most efficient approach.

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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

Which scenario best illustrates the nurse using data validation when making a nursing clinical decision for a patient?

Correct Answer is A

Explanation

A nurse is discussing time management strategies with another nurse. The nurse should include which of the following as an example of a time management strategy?

Correct Answer is C

Explanation

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