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

Answer and Explanation

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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Correct Answer is C

Explanation

A. Grandparents: While grandparents can provide useful information, the primary and most accurate data source for a toddler's immediate care and developmental history would typically be the parents, who are the primary caregivers.
B. Admitting provider: The admitting provider offers valuable medical information, but the best source of data regarding the child’s current condition and history would come from those who are closest to the child and involved in their daily care.
C. Parents: Parents are the most reliable source for accurate and up-to-date information about their child’s health, developmental history, and current condition. They are directly involved in the child's daily life and care.
D. Medical record: While the medical record contains important historical data, the most current and relevant information about the toddler’s condition and immediate needs should be obtained from the parents.

A. Orthostatic hypotension increases a client's risk of a fall. B. Orthostatic hypotension is indicated by a decrease in systolic blood pressure of 10 mm Hg. C. Orthostatic hypotension increases a client's risk of a pulmonary emboli D. Orthostatic hypotension is indicated by a decrease in diastolic blood pressure of 5 mm Hg.

Correct Answer is A

Explanation

A. Orthostatic hypotension increases a client's risk of a fall: Correct. Orthostatic hypotension can lead to dizziness or lightheadedness when standing, increasing the risk of falls.
B. Orthostatic hypotension is indicated by a decrease in systolic blood pressure of 10 mm Hg: This is not specific enough. Orthostatic hypotension is typically defined by a decrease in systolic blood pressure of 20 mm Hg or more when standing.
C. Orthostatic hypotension increases a client's risk of a pulmonary emboli: This is not directly related. Orthostatic hypotension mainly affects balance and fall risk, not the risk of pulmonary emboli.
D. Orthostatic hypotension is indicated by a decrease in diastolic blood pressure of 5 mm Hg: This is incorrect. Orthostatic hypotension is more commonly assessed by a significant drop in systolic blood pressure rather than diastolic pressure.

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The nurse is reviewing interventions written for a client. Which of the following the nurse will consider as being independent?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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