Which actions by the nurse are examples of independent nursing interventions for a postoperative patient? (Select all that apply).
Switching the patient’s injected pain medication to oral tablets before discharge.
Elevating the head of the patient’s bed to facilitate use of the incentive spirometer.
Administering intravenous fluids when the patient is unable to eat or drink.
Advancing a patient’s diet from clear liquids to solid foods after surgery.
Teaching patients with heart failure how to do accurate daily weights.
Correct Answer : A,B,D,E
Choice A reason: This is a correct choice because switching the patient’s injected pain medication to oral tablets before discharge 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 decide when to switch the route of administration of the pain medication based on the patient's condition, preference, and readiness for discharge.
Choice B reason: This is a correct choice because elevating the head of the patient’s bed to facilitate use of the incentive spirometer 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 adjust the position of the patient's bed to promote lung expansion and prevent atelectasis, which are common postoperative complications.
Choice C reason: This is an incorrect choice because administering intravenous fluids when the patient is unable to eat or drink 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 intravenous fluids to the patient without a prescription.
Choice D reason: This is a correct choice because advancing a patient’s diet from clear liquids to solid foods after surgery 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 progress the patient's diet based on the patient's tolerance, appetite, and bowel function.
Choice E reason: This is a correct choice because teaching patients with heart failure how to do accurate daily weights 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 monitoring their weight and fluid status and document the teaching.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is C
Explanation
Choice A reason: This is an incorrect choice because powerlessness related to inability to keep from eating during sleep is not the highest priority nursing diagnosis for a patient who developed sleep-related eating disorder when taking Zolpidem. Powerlessness is a psychosocial problem that affects the patient's sense of control and self-efficacy. However, it is not the most urgent or life-threatening problem for the patient, as it does not pose an immediate risk of harm or injury.
Choice B reason: This is an incorrect choice because wandering related to cognitive impairment from sleeping aid is not the highest priority nursing diagnosis for a patient who developed sleep-related eating disorder when taking Zolpidem. Wandering is a behavioral problem that involves moving about aimlessly or without purpose. However, it is not the most urgent or life-threatening problem for the patient, as it does not necessarily imply a risk of harm or injury.
Choice C reason: This is the correct choice because risk for falls related to ambulating to kitchen while asleep is the highest priority nursing diagnosis for a patient who developed sleep-related eating disorder when taking Zolpidem. Risk for falls is a safety problem that involves an increased likelihood of falling due to factors such as impaired balance, coordination, or judgment. This is the most urgent and life-threatening problem for the patient, as it can result in serious injuries or complications.
Choice D reason: This is an incorrect choice because risk for imbalanced nutrition: more than body requirements related to sleep eating is not the highest priority nursing diagnosis for a patient who developed sleep-related eating disorder when taking Zolpidem. Risk for imbalanced nutrition: more than body requirements is a physiological problem that involves an intake of nutrients that exceeds metabolic needs. However, it is not the most urgent or life-threatening problem for the patient, as it does not cause an immediate risk of harm or injury.
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