The nurse is reviewing the patient's plan of care and ordered treatments. Which of the following is (are) independent nursing interventions? (select all that apply)
Teaching deep breathing and relaxation techniques as needed
Inserting a nasogastric tube (NG) to relieve gastric distention
Placing the nurse call button within reach at all times
Giving hand massages daily
Repositioning the patient every 2 hours to reduce pressure injury risk
Giving acetaminophen (Tylenol) 650 mg orally every 4 hours as needed
Correct Answer : A,C,D,E
A. Teaching deep breathing and relaxation techniques as needed: Teaching non-pharmacological pain relief (such as deep breathing) is an independent nursing action that does not require a physician’s order.
B. Inserting a nasogastric tube (NG) to relieve gastric distention: NG tube insertion requires a physician's order, making it not independent.
C. Placing the nurse call button within reach at all times: Ensuring the patient’s call button is within reach is an independent nursing action to promote safety and communication.
D. Giving hand massages daily: Nurses can provide non-invasive comfort measures such as hand massages without a physician's order.
E. Repositioning the patient every 2 hours to reduce pressure injury risk: Repositioning is an independent intervention that prevents skin breakdown and pressure injuries.
F. Giving acetaminophen (Tylenol) 650 mg orally every 4 hours as needed: Medication administration requires a physician’s order, making it a dependent nursing action.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Signs: Signs are objective findings (e.g., fever, rash), observed by the nurse.
B. Objective cues: Objective cues are measurable and observable, whereas subjective data is based on the patient’s self-report.
C. Symptoms: Symptoms (e.g., pain, nausea, dizziness) are subjective because they cannot be measured directly and are reported by the patient.
D. Observable data: Observable data includes measurable signs, making it objective, not subjective.
Correct Answer is C
Explanation
A. The care plan: While important for care, the care plan alone does not provide a full picture of patient care over time.
B. The medical orders: Medical orders show physician instructions but do not capture the full scope of patient care.
C. The entire record: The entire medical record can be subpoenaed and used as legal evidence, including notes, orders, test results, and nursing documentation.
D. Nursing notes: Nursing notes are part of the medical record but do not represent the full legal documentation on their own.
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