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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A reason: This is incorrect. Making sure that the earpieces fit loosely in the nurse’s ear canals will not help the nurse hear the heartbeat more clearly. Loose earpieces can let in ambient noise and reduce the sound quality.

Choice B reason: This is incorrect. Utilizing a stethoscope with the longest possible tubing will not help the nurse hear the heartbeat more clearly. Long tubing can reduce the sound transmission and create interference.

Choice C reason: This is correct. Placing the diaphragm firmly against the patient’s skin will help the nurse hear the heartbeat more clearly. The diaphragm is the flat circular part of the chest piece that is used to listen to low-pitched sounds, such as the heart. Firm pressure creates a good seal and blocks out external noise.

Choice D reason: This is incorrect. Positioning the bell very lightly over the patient’s sternum will not help the nurse hear the heartbeat more clearly. The bell is the small cup-shaped part of the chest piece that is used to listen to high-pitched sounds, such as the lungs. Light pressure is needed to avoid activating the diaphragm, but the sternum is not the best location to listen to the apical pulse.

A. Turn on the television to drown out noise from other patients. B. Institute a unit-wide quiet time at 10:00 p.m. each night. C. Reduce the number of visitors to the patient’s room. D. Provide a dedicated period of rest time each afternoon. E. Coordinate therapies and tests with other departments and providers.

Correct Answer is ["B","C","D","E"]

Explanation

Choice A reason: This is incorrect. Turning on the television to drown out noise from other patients can worsen the sensory overload by adding more auditory stimulation. The patient may prefer a quiet and calm environment.

Choice B reason: This is correct. Instituting a unit-wide quiet time at 10:00 p.m. each night can benefit the patient by reducing the noise level and promoting rest and relaxation. The patient may sleep better and feel less agitated.

Choice C reason: This is correct. Reducing the number of visitors to the patient’s room can benefit the patient by minimizing the social and emotional demands and allowing the patient to have some privacy and personal space. The patient may feel less overwhelmed and more comfortable.

Choice D reason: This is correct. Providing a dedicated period of rest time each afternoon can benefit the patient by giving the patient a break from the sensory input and activities of the day. The patient may use this time to meditate, listen to soothing music, or do other calming activities.

Choice E reason: This is correct. Coordinating therapies and tests with other departments and providers can benefit the patient by avoiding unnecessary duplication or interruption of services and ensuring a smooth and consistent care plan. The patient may feel less stressed and more confident.

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Which actions by the nurse are examples of dependent nursing interventions for a postoperative patient? (Select all that apply).

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is having difficulty hearing his patient’s apical pulse with his stethoscope. Which action will help the nurse hear the heartbeat more clearly?

Correct Answer is C

Explanation

The nurse is caring for a patient who becomes agitated when visitors stay for extended periods or the hospital unit becomes noisy. The nurse identifies this as sensory overload. Which interventions will be of benefit to the patient? (Select all that apply.)

Correct Answer is ["B","C","D","E"]

Explanation

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