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 C
Explanation
A. Acute pain manifested by client's report: While this diagnosis reflects the client's report of pain, it does not address the underlying cause or etiology of the pain, which is important for forming an effective care plan.
B. Acute pain related to psychosomatic condition: This diagnosis implies a specific psychosomatic origin for the pain. Since the etiology is unknown, attributing it to a psychosomatic condition may not be accurate.
C. Acute pain related to unknown etiology: This diagnosis is the most appropriate because it acknowledges the presence of acute pain and explicitly notes that the cause is unknown, which aligns with the information provided.
D. Acute pain related to unknown factors: This diagnosis is similar to C, but "unknown factors" is less precise than "unknown etiology." The term "etiology" more accurately describes the underlying cause.
Correct Answer is D
Explanation
A. Anemia: While stress can have various effects on the body, anemia is not specifically a direct manifestation of prolonged stress. It is more commonly associated with nutritional deficiencies or chronic disease.
B. Hypoglycemia: Prolonged stress typically leads to increased levels of cortisol and other stress hormones, which can cause hyperglycemia (elevated blood sugar) rather than hypoglycemia (low blood sugar).
C. Decreased blood pressure: Prolonged stress usually causes increased blood pressure rather than decreased blood pressure. The body's stress response involves the release of hormones that typically raise blood pressure.
D. Impaired immune function: Prolonged stress can lead to immune system suppression, making the body more susceptible to infections and illnesses. This is a well-documented effect of chronic stress and is thus a correct manifestation to include in the teaching.
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