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 A
Explanation
A. The specific time of all sudden changes in the patient's condition: Timely documentation of sudden changes ensures accuracy in patient records and supports clinical decision-making.
B. The period the shift covers: While shift documentation is important, it does not replace event-specific charting.
C. Every 2 hours: Documentation frequency depends on patient status; critical changes require immediate recording, not just every 2 hours.
D. Every hour on the hour: Routine hourly documentation is unnecessary unless required by patient condition (e.g., ICU monitoring).
Correct Answer is B
Explanation
A. Not used by anyone else but the direct care providers: Health records are used by multiple healthcare team members, including billing departments, insurance providers, and legal entities when required.
B. Concise, legal records of all care given and responses: Health records document all care provided, patient responses, and medical decisions. They serve as legal records in case of disputes or audits.
C. Owned by the patient, who has a right to see the data any time he/she wishes: The healthcare facility owns the records, but patients have a right to request access under HIPAA and other legal provisions.
D. Confidential information and cannot be taken to court: Health records can be subpoenaed and used in legal cases, provided they comply with confidentiality laws.
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