Which action by the nurse demonstrates the concept of nurse autonomy?
The nurse braids the patient’s long hair to prevent tangles.
The nurse checks the policy manual before changing the central line dressing.
The nurse counts the patient’s pulse before administering digoxin.
The nurse directs the nursing assistant to obtain the patient's weight.
The Correct Answer is B
Choice A reason: This is an incorrect choice because the nurse braids the patient’s long hair to prevent tangles is not an action that demonstrates the concept of nurse autonomy. Nurse autonomy refers to the ability and right of nurses to make independent decisions about patient care without interference from others. Braiding the patient’s hair is a personal care task that does not require the nurse to use their own judgment or expertise.
Choice B reason: This is the correct choice because the nurse checks the policy manual before changing the central line dressing is an action that demonstrates the concept of nurse autonomy. Nurse autonomy refers to the ability and right of nurses to make independent decisions about patient care without interference from others. Checking the policy manual before changing the central line dressing shows that the nurse is responsible for following the evidence-based guidelines and standards of practice for this procedure.
Choice C reason: This is an incorrect choice because the nurse counts the patient’s pulse before administering digoxin is not an action that demonstrates the concept of nurse autonomy. Nurse autonomy refers to the ability and right of nurses to make independent decisions about patient care without interference from others. Counting the patient’s pulse before administering digoxin is a routine task that is prescribed by the physician and does not involve the nurse’s own decision making.
Choice D reason: This is an incorrect choice because the nurse directs the nursing assistant to obtain the patient's weight is not an action that demonstrates the concept of nurse autonomy. Nurse autonomy refers to the ability and right of nurses to make independent decisions about patient care without interference from others. Directing the nursing assistant to obtain the patient's weight is a task that is delegated by the nurse and does not reflect the nurse’s own authority or initiative.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: This is the correct choice because melatonin is the safest sleep aid for the elderly patient with insomnia. Melatonin is a natural hormone that regulates the sleep-wake cycle. It has few side effects and interactions, and does not cause dependence or withdrawal. Melatonin can improve the quality and duration of sleep, and reduce the time to fall asleep.
Choice B reason: This is an incorrect choice because temazepam is not the safest sleep aid for the elderly patient with insomnia. Temazepam is a benzodiazepine that enhances the activity of GABA, a neurotransmitter that inhibits brain activity. It has many side effects and interactions, and can cause dependence, tolerance, or withdrawal. Temazepam can also impair cognitive and motor functions, and increase the risk of falls, fractures, and delirium.
Choice C reason: This is an incorrect choice because trazodone is not the safest sleep aid for the elderly patient with insomnia. Trazodone is an antidepressant that blocks the reuptake of serotonin, a neurotransmitter that regulates mood and sleep. It has many side effects and interactions, and can cause orthostatic hypotension, cardiac arrhythmias, priapism, or serotonin syndrome. Trazodone can also impair cognitive and motor functions, and increase the risk of falls, fractures, and delirium.
Choice D reason: This is an incorrect choice because triazolam is not the safest sleep aid for the elderly patient with insomnia. Triazolam is a benzodiazepine that enhances the activity of GABA, a neurotransmitter that inhibits brain activity. It has many side effects and interactions, and can cause dependence, tolerance, or withdrawal. Triazolam can also impair cognitive and motor functions, and increase the risk of falls, fractures, and delirium.
Correct Answer is ["C","D","E"]
Explanation
Choice A reason: This is incorrect. The patient takes 30 mg morphine sulfate daily does not lead the nurse to clarify the order for ibuprofen 600 mg PO every 8 hours. Morphine sulfate is an opioid analgesic that can be used in combination with ibuprofen, a nonsteroidal anti-inflammatory drug (NSAID), for moderate to severe pain. The nurse should monitor the patient for signs of respiratory depression, sedation, or constipation, but there is no need to clarify the order.
Choice B reason: This is incorrect. The patient has severe joint pain due to aggressive arthritis does not lead the nurse to clarify the order for ibuprofen 600 mg PO every 8 hours. Ibuprofen is indicated for the relief of signs and symptoms of rheumatoid arthritis and osteoarthritis. The nurse should assess the patient's pain level, response to treatment, and adverse effects, but there is no need to clarify the order.
Choice C reason: This is correct. The patient has a gastrointestinal bleed leads the nurse to clarify the order for ibuprofen 600 mg PO every 8 hours. Ibuprofen can cause gastrointestinal irritation, ulceration, bleeding, and perforation. The nurse should question the order and consider alternative analgesics for the patient, especially if they have a history of peptic ulcer disease, gastritis, or bleeding disorders.
Choice D reason: This is correct. The patient has a history of diabetes and early renal failure leads the nurse to clarify the order for ibuprofen 600 mg PO every 8 hours. Ibuprofen can impair renal function, increase blood pressure, and interfere with the effects of antihypertensive and antidiabetic drugs. The nurse should question the order and monitor the patient's renal function, blood pressure, and blood glucose levels closely.
Choice E reason: This is correct. The patient has allergies to shellfish, strawberries, and iodine leads the nurse to clarify the order for ibuprofen 600 mg PO every 8 hours. Ibuprofen can cause hypersensitivity reactions, such as rash, angioedema, bronchospasm, or anaphylaxis. The nurse should question the order and ask the patient about any previous reactions to NSAIDs or aspirin. The patient may need to avoid ibuprofen and use a different analgesic..
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