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 D
Explanation
Choice A reason: This is incorrect. The antipyretic medication will not inhibit bacterial growth within the culture tubes. Antipyretics are medications that reduce fever by affecting the hypothalamus, the part of the brain that regulates body temperature. They do not have any antibacterial effect.
Choice B reason: This is incorrect. Venous distension is not greater because of fluid retention from hyperthermia. Venous distension is the swelling of the veins due to increased pressure or volume of blood. Hyperthermia is the condition of having a body temperature above the normal range. It can cause dehydration, not fluid retention.
Choice C reason: This is incorrect. Elevated temperatures do not slow metabolic rate and improve blood oxygenation. Elevated temperatures increase metabolic rate and demand more oxygen. This can lead to tissue hypoxia, acidosis, and organ damage.
Choice D reason: This is correct. The causative organism is most prevalent during a spike in temperature. A spike in temperature is a sudden rise in body temperature that indicates an infection. Drawing a blood culture before giving an antipyretic medication can help identify the type and number of bacteria in the blood. This can guide the appropriate antibiotic therapy and monitor the response to treatment.
Correct Answer is B
Explanation
Choice A reason: This is incorrect. Cleaning the fixed IV pump and returning it to the floor can cause harm to the patient or the staff if the pump is used again.
Choice B reason: This is correct. Tagging the IV pump and removing it from the area prevents the pump from being used by mistake and alerts the maintenance staff to repair or replace it.
Choice C reason: This is incorrect. Contacting the IV pump manufacturer is not the role of the nurse. The nurse should report the malfunction to the appropriate person in the facility.
Choice D reason: This is incorrect. Initiating a work order on the IV pump is not enough to ensure the safety of the patient and the staff. The pump should be tagged and removed from the area as well.
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