The nurse is providing care to a patient in an acute care facility. Which of the following are examples of independent nursing interventions? (Select All that Apply.)
Assisting a client with activities of daily living
Administering intravenous fluids
Collaborating with the interprofessional healthcare team
Assessing client's pain level
Administering medication as prescribed by the physician
Correct Answer : A,D
A. Independent nursing interventions do not require a provider’s order. Nurses can assist with ADLs independently.
B. IV fluids require a provider’s order.
C. Collaboration is not an independent intervention.
D. Independent nursing interventions do not require a provider’s order. Nurses can assist with ADLs and assess pain independently.
E. Administering prescribed medication requires an order.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["D","E","F"]
Explanation
A. The patient will be educated about the signs of infection. This is incorrect because it is not specific or measurable. The statement does not describe how the nurse will evaluate whether the patient has understood the information.
B. The patient will know how to manage diabetes effectively. This is incorrect because "know" is not measurable. A better outcome statement would describe a specific action the patient will perform to demonstrate their understanding of diabetes management.
C. The patient will understand the importance of medication adherence. This is incorrect because "understand" is not an observable or measurable behavior. Instead, an outcome should describe an action the patient will take, such as demonstrating how to take medication correctly.
D. The patient will walk 50 feet with a walker unassisted by the end of the week. This is correct because it is specific, measurable, and time-bound. It describes a clear action that the nurse can assess.
E. The patient will demonstrate correct use of an inhaler by the end of the teaching session. This is correct because it is measurable and observable. The nurse can directly assess whether the patient correctly uses the inhaler.
F. The patient will report a pain level of less than 4 on a scale of 0 to 10 within 24 hours of receiving pain medication. This is correct because it is specific, includes a measurable criterion (pain scale), and has a clear timeframe.
Correct Answer is B
Explanation
A. Assessment. This is incorrect because assessment refers to the initial data collection before interventions are performed. The nurse auscultating the lungs after administering the medication is part of evaluating the effectiveness of treatment.
B. Evaluation. This is correct because evaluation involves determining whether the intervention was successful in achieving the desired outcome. The nurse is assessing lung sounds to determine if the inhaled medication improved airway clearance and breathing.
C. Diagnosis. This is incorrect because diagnosis involves identifying the patient's health problems based on assessment data. The nurse is not formulating a diagnosis in this scenario but rather checking the response to treatment.
D. Planning. This is incorrect because planning involves setting patient goals and selecting interventions before implementation. The nurse auscultating lung sounds after treatment is an evaluation step, not a planning step.
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