Which actions by the nurse are examples of dependent nursing interventions for a postoperative patient? (Select all that apply).
Calculating the patient’s fluid intake and output at the end of every shift.
Assessing the patient’s abdomen for distention, bowel sounds, and passage of flatus.
Administering a mild stool softener daily to prevent constipation.
Encouraging fluid and fiber intake to prevent constipation from pain medications.
Reinserting the patient's urinary catheter for retention of greater than 500 mL of urine.
Correct Answer : C
Choice A reason: This is an incorrect choice because calculating the patient’s fluid intake and output at the end of every shift is an example of an independent nursing intervention. An independent nursing intervention is an action that the nurse can perform based on their own knowledge, skills, and judgment without a physician's order. The nurse can monitor the patient’s fluid balance and document the results.
Choice B reason: This is an incorrect choice because assessing the patient’s abdomen for distention, bowel sounds, and passage of flatus is an example of an independent nursing intervention. An independent nursing intervention is an action that the nurse can perform based on their own knowledge, skills, and judgment without a physician's order. The nurse can perform a physical examination of the patient’s abdomen and document the findings.
Choice C reason: This is a correct choice because administering a mild stool softener daily to prevent constipation is an example of a dependent nursing intervention. A dependent nursing intervention is an action that the nurse can perform only with a physician's order. The nurse cannot give any medication to the patient without a prescription.
Choice D reason: This is an incorrect choice because encouraging fluid and fiber intake to prevent constipation from pain medications is an example of an independent nursing intervention. An independent nursing intervention is an action that the nurse can perform based on their own knowledge, skills, and judgment without a physician's order. The nurse can educate the patient about the importance of hydration and nutrition and document the teaching.
Choice E reason: This is a correct choice because reinserting the patient's urinary catheter for retention of greater than 500 mL of urine is an example of a dependent nursing intervention. A dependent nursing intervention is an action that the nurse can perform only with a physician's order. The nurse cannot insert or remove any invasive device from the patient without a prescription.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D","E"]
Explanation
Choice A reason: This is correct. Taking metoprolol to treat hypertension can put the patient at high risk for development of vision problems. Metoprolol is a beta-blocker medication that can lower the blood pressure and heart rate. It can also reduce the blood flow to the eyes and cause dry eyes, blurred vision, or eye irritation.
Choice B reason: This is incorrect. Taking docusate sodium for constipation does not put the patient at high risk for development of vision problems. Docusate sodium is a stool softener medication that can ease the passage of hard stools. It does not have any direct effect on the eyes or vision.
Choice C reason: This is incorrect. Taking acetaminophen for osteoarthritis pain does not put the patient at high risk for development of vision problems. Acetaminophen is a pain reliever medication that can reduce inflammation and fever. It does not have any significant impact on the eyes or vision.
Choice D reason: This is correct. Taking insulin glulisine for type 1 diabetes can put the patient at high risk for development of vision problems. Insulin glulisine is a fast-acting insulin medication that can lower the blood sugar level. It can also cause fluctuations in the fluid balance and pressure in the eyes, leading to blurred vision, cataracts, glaucoma, or diabetic retinopathy.
Choice E reason: This is correct. Taking prednisone for multiple sclerosis can put the patient at high risk for development of vision problems. Prednisone is a corticosteroid medication that can suppress the immune system and reduce inflammation. It can also increase the intraocular pressure and cause cataracts, glaucoma, or optic nerve damage.
Correct Answer is A
Explanation
Choice A reason: This is the correct choice because accountability is the nursing care concept that is demonstrated when the nurse takes the time to correct assessment information that was entered for the wrong patient. Accountability refers to the expectation and requirement to report and explain the actions taken and the results achieved. The nurse is accountable for the accuracy and completeness of the documentation and for the quality and safety of the patient care⁴. By correcting the assessment information, the nurse demonstrates accountability for their own mistake and prevents potential harm to the patient.
Choice B reason: This is an incorrect choice because responsibility is not the nursing care concept that is demonstrated when the nurse takes the time to correct assessment information that was entered for the wrong patient. Responsibility refers to the obligation and duty to perform the assigned tasks and achieve the desired results. The nurse is responsible for conducting and documenting the assessment and for providing appropriate care for the patient⁴. By correcting the assessment information, the nurse is not fulfilling their responsibility, but rather rectifying their error.
Choice C reason: This is an incorrect choice because empowerment is not the nursing care concept that is demonstrated when the nurse takes the time to correct assessment information that was entered for the wrong patient. Empowerment refers to the ability and right of individuals or groups to make their own decisions without interference from others. The nurse is empowered to use their own judgment and expertise to solve problems and improve performance⁴. By correcting the assessment information, the nurse is not exercising their empowerment, but rather admitting their fault.
Choice D reason: This is an incorrect choice because delegation is not the nursing care concept that is demonstrated when the nurse takes the time to correct assessment information that was entered for the wrong patient. Delegation refers to the process of assigning tasks or activities to other staff members based on their scope of practice, competence, and availability. The nurse is responsible for delegating tasks safely and effectively and for supervising and evaluating the delegated staff⁴. By correcting the assessment information, the nurse is not delegating any task, but rather correcting their own work.
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