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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Provide written educational material for the client: While important, this action is not the first step as it assumes the client is ready to receive and understand the information.
B. Ask the client to demonstrate checking their blood sugar: This is a practical step but should come after assessing the client’s readiness to learn and understanding their current knowledge.
C. Identify short-term goals for the client: Goal-setting is crucial but should follow an assessment of the client's readiness to learn to ensure that goals are realistic and tailored to their current level of understanding.
D. Determine the client's readiness to learn: This is the first step in the teaching process as it helps tailor the teaching plan to the client's current state of mind, comprehension level, and willingness to engage with the educational material.
Correct Answer is C
Explanation
A. Acute pain manifested by client's report: This diagnosis is too general and does not address the specific issue of unknown etiology or the need for further investigation.
B. Acute pain related to psychosomatic condition: This diagnosis assumes a psychosomatic cause without sufficient evidence. The cause of the pain is not yet clear, so this may not be accurate.
C. Acute pain related to unknown etiology: This diagnosis accurately reflects the situation of pain with an unclear cause and is appropriate for guiding further assessment and investigation.
D. Acute pain related to unknown factors: This diagnosis is vague and less specific than "unknown etiology," which provides a clearer framework for understanding the cause of the pain.
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