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 C
Explanation
Choice A reason: This is an incorrect choice because insisting that the patient remove the bracelet and give it to a family member during surgery is not the most appropriate action of the nurse. This action may violate the patient's right to autonomy, religious freedom, and cultural sensitivity. The nurse should respect the patient's beliefs and preferences and try to accommodate them as much as possible, unless they pose a significant risk to the patient's safety or the surgical procedure.
Choice B reason: This is an incorrect choice because notifying the patient’s surgeon of the patient’s refusal to remove the bracelet before having surgery is not the most appropriate action of the nurse. This action may imply that the patient is non-compliant or difficult, and may create a conflict between the patient and the surgeon. The nurse should communicate with the patient and the surgeon in a respectful and collaborative manner, and seek a mutually agreeable solution.
Choice C reason: This is the correct choice because calling the operating room staff to determine if the bracelet can stay on during surgery is the most appropriate action of the nurse. This action shows that the nurse is willing to advocate for the patient and to consult with the relevant authorities to find out the best option. The nurse should follow the policies and protocols of the operating room and the infection control guidelines, and ensure that the bracelet does not interfere with the surgical site, the equipment, or the sterile field.
Choice D reason: This is an incorrect choice because removing the bracelet from the patient's wrist after sedating medication has been administered is not the most appropriate action of the nurse. This action may be considered unethical, dishonest, or disrespectful, as the nurse is taking advantage of the patient's altered mental status and going against the patient's wishes. The nurse should obtain the patient's informed consent before performing any intervention, and should not deceive or coerce the patient.
Correct Answer is C
Explanation
Choice A reason: This is an incorrect choice because the axillary method is not the most accurate measurement of the core temperature. The axillary method involves placing a thermometer under the patient's armpit and measuring the temperature of the skin surface. This method can be affected by factors such as sweating, clothing, and ambient temperature. The axillary method can underestimate the core temperature by 0.5°C to 1.5°C¹.
Choice B reason: This is an incorrect choice because the oral method is not the most accurate measurement of the core temperature. The oral method involves placing a thermometer in the patient's mouth and measuring the temperature of the sublingual pocket. This method can be affected by factors such as eating, drinking, smoking, and mouth breathing. The oral method can underestimate the core temperature by 0.3°C to 0.8°C¹.
Choice C reason: This is the correct choice because the rectal method is the most accurate measurement of the core temperature. The rectal method involves inserting a thermometer into the patient's rectum and measuring the temperature of the rectal mucosa. This method reflects the temperature of the blood flowing through the core of the body. The rectal method is considered the gold standard for measuring the core temperature¹.
Choice D reason: This is an incorrect choice because the forehead method is not the most accurate measurement of the core temperature. The forehead method involves placing a thermometer on the patient's forehead and measuring the temperature of the temporal artery. This method can be affected by factors such as sweating, hair, and ambient temperature. The forehead method can overestimate or underestimate the core temperature by 0.5°C to 1°C¹.
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