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

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. Use a Nursing Diagnosis from a source other than NANDA-I: NANDA-I provides standardized nursing diagnoses that ensure accurate problem identification and care planning.

B. Limit the number of interventions: Interventions should be appropriate and sufficient rather than arbitrarily limited.

C. Select interventions which will be easy to implement: Interventions should be effective and individualized, not just easy.

D. Involve the patient in the process: Patient involvement ensures better adherence, understanding, and personalized care.

A. Physician's Order Sheet B. Narcotic Administration Sheet C. Care Plan D. MAR and Narcotic Administration Sheet

Correct Answer is D

Explanation

A. Physician's Order Sheet: While the physician orders narcotics, administration is not documented here.

B. Narcotic Administration Sheet: The Narcotic Administration Sheet is specifically for controlled substances, ensuring proper tracking and preventing misuse.

C. Care Plan: The care plan outlines patient goals and interventions, not medication administration.

D. MAR (Medication Administration Record) and Narcotic Administration Sheet: The MAR (Medication Administration Record) documents all medications given to the patient. The Narcotic Administration Sheet is required for controlled substances to comply with regulations.

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