The nurse is reviewing interventions written for a client. Which of the following the nurse will consider as being independent?
Administer medication for high blood pressure
Reposition the client every 2 hours
Starting IV antibiotics
Administering medication for pain
Administering medication for pain
The Correct Answer is B
A. Administer medication for high blood pressure: Administering medication generally requires a physician's order and is not considered an independent nursing action.
B. Reposition the client every 2 hours: This intervention is within the nurse’s scope of practice and does not require a physician’s order. It is an independent action that helps prevent complications like pressure ulcers.
C. Starting IV antibiotics: This action requires a physician's order and is a dependent nursing intervention.
D. Administering medication for pain: Administering medication requires a physician’s order and is not considered an independent nursing action.
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Related Questions
Correct Answer is C
Explanation
A: This option is incorrect because the date is wrong, and it uses "TOJ" which is not a standard abbreviation in medical documentation. The correct format should include the date the order was received, the medication and dosage, frequency, reason for administration, and the initials of the person taking the order along with a 'read back' confirmation.
B: This choice is incorrect because it lacks the 'read back' confirmation which is a critical part of telephone orders to ensure accuracy. Additionally, the use of "TOJ" is incorrect, and the date format is inconsistent with standard medical records.
C: This is the correct choice because it includes all necessary information: the correct date, medication and dosage, frequency, reason for administration, and it correctly identifies the order as a telephone order with "TO" followed by the doctor's name, and includes the nurse's initials with a 'read back' confirmation.
D: This option is incorrect because it uses "VO" which stands for verbal order, not a telephone order. It also lacks the full date and has an inconsistent date format. The 'read back' confirmation is present, but the incorrect order type makes this entry invalid.
Correct Answer is C
Explanation
A. Place the chair at a 90° angle to the bed: Incorrect. The chair should be placed at an angle to facilitate a smoother transfer, usually around 45° to the bed, allowing easier movement from the bed to the chair.
B. Place the chair on the client's left side: Incorrect. The chair should be positioned on the strong side of the client if possible, or the side the client will be transferring towards, not necessarily the left side.
C. Lock the wheels on the client's bed: Correct. Locking the wheels on the bed ensures that the bed remains stationary during the transfer, providing safety and stability for the client.
D. Raise the height of the client's bed: Incorrect. The bed should be adjusted to a height that allows the nurse to safely transfer the client without excessive bending or stretching. However, raising it too high might make it difficult for the nurse to maneuver the client safely.
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