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 A

Explanation

A. A head-to-toe assessment: A head-to-toe assessment is the most systematic approach to a complete physical exam, ensuring no body system is overlooked.

B. Subjective data collection: While subjective data is part of the process, it is not a structured approach to an entire physical exam.

C. Objective data collection: Objective data is collected during the exam, but the question asks about the approach to organizing the exam, not the data type.

D. Maslow’s Hierarchy of Needs: Maslow’s hierarchy helps prioritize care but is not a method for performing a physical assessment.

A. pain B. skin integrity C. fluid volume D. knowledge deficit

Correct Answer is A

Explanation

A. Pain: Pain is the most immediate concern in this scenario. Managing pain is critical for comfort and preventing further complications.

B. Skin integrity: While skin integrity may be a concern (e.g., pressure ulcers if immobile), it is not the most urgent issue at admission.

C. Fluid volume: There is no mention of dehydration or blood loss. Fluid volume is not the primary concern.

D. Knowledge deficit: While patient education is important, managing pain takes priority over knowledge deficits in acute injuries.

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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)

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