Documenting the type of interventions carried out, the time care was given, and the signature of the care giver results in recording:

patient's nursing problem

interventions carried out to meet the patient's needs

patient's medical problem

the patient's response to the intervention carried out

Answer and Explanation

The Correct Answer is B

A. Patient's nursing problem: Nursing problems are identified in assessments, not the actual care documentation.

B. Interventions carried out to meet the patient’s needs: Documentation should include interventions, the time they were performed, and the caregiver’s signature for legal and professional accountability.

C. Patient’s medical problem: Medical problems are diagnosed by physicians, while nurses document care interventions related to nursing diagnoses.

D. The patient's response to the intervention carried out: While patient responses should be documented, this question focuses on recording interventions, not patient reactions.

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Correct Answer is A

Explanation

A. Focused: A focused assessment is ongoing and directed at specific problems based on the patient’s condition (e.g., assessing pain, circulation, or respiratory status frequently).

B. Body systems: Body systems assessments are structured assessments that evaluate a particular system (e.g., cardiovascular, respiratory) rather than continuous monitoring.

C. Subjective: Subjective assessment includes patient-reported symptoms but does not define the type of continuous assessment nurses perform.

D. Complete: A complete (or comprehensive) assessment is done at admission, not continuously.

A. Teaching deep breathing and relaxation techniques as needed B. Inserting a nasogastric tube (NG) to relieve gastric distention C. Placing the nurse call button within reach at all times D. Giving hand massages daily E. Repositioning the patient every 2 hours to reduce pressure injury risk F. Giving acetaminophen (Tylenol) 650 mg orally every 4 hours as needed

Correct Answer is ["A","C","D","E"]

Explanation

A. Teaching deep breathing and relaxation techniques as needed: Teaching non-pharmacological pain relief (such as deep breathing) is an independent nursing action that does not require a physician’s order.

B. Inserting a nasogastric tube (NG) to relieve gastric distention: NG tube insertion requires a physician's order, making it not independent.

C. Placing the nurse call button within reach at all times: Ensuring the patient’s call button is within reach is an independent nursing action to promote safety and communication.

D. Giving hand massages daily: Nurses can provide non-invasive comfort measures such as hand massages without a physician's order.

E. Repositioning the patient every 2 hours to reduce pressure injury risk: Repositioning is an independent intervention that prevents skin breakdown and pressure injuries.

F. Giving acetaminophen (Tylenol) 650 mg orally every 4 hours as needed: Medication administration requires a physician’s order, making it a dependent nursing action.

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Documenting the type of interventions carried out, the time care was given, and the signature of the care giver results in recording:

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Naxlex Comprehensive Predictor Exams

Select the type of assessment which is performed continuously throughout nurse-patient contact:

Correct Answer is A

Explanation

The nurse is reviewing the patient's plan of care and ordered treatments. Which of the following is (are) independent nursing interventions? (select all that apply)

Correct Answer is ["A","C","D","E"]

Explanation

Show that documentation of patient care by the nurse is very important by selecting from the following: (select all that apply)

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Documenting the type of interventions carried out, the time care was given, and the signature of the care giver results in recording: