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 A
Explanation
Choice A reason: This is correct. Teaching the patient to wear low-heeled, comfortable, supportive footwear at all times is the highest priority intervention for a patient with diabetic neuropathy who has lost sensation in both feet. This can prevent foot injuries, ulcers, and infections that can lead to amputation.
Choice B reason: This is incorrect. Encouraging the patient to participate in tai chi exercises to promote balance is a beneficial intervention for a patient with diabetic neuropathy who has lost sensation in both feet, but not the highest priority. Tai chi can improve muscle strength, coordination, and flexibility, but it does not protect the feet from injury.
Choice C reason: This is incorrect. Evaluating the patient's blood pressure for orthostatic hypotension is an important intervention for a patient with diabetic neuropathy who has lost sensation in both feet, but not the highest priority. Orthostatic hypotension is a condition where the blood pressure drops when the patient changes position, causing dizziness and fainting. It can be caused by autonomic neuropathy, which affects the nerves that control blood pressure and heart rate.
Choice D reason: This is incorrect. Instructing the patient to wear a medical alert bracelet that identifies risk for falls is a helpful intervention for a patient with diabetic neuropathy who has lost sensation in both feet, but not the highest priority. A medical alert bracelet can alert emergency personnel of the patient's condition and medications, but it does not prevent falls or foot injuries.
Correct Answer is D
Explanation
Choice A reason: This is incorrect. Wiping up the liquid with paper towels and gloves can spread the mercury droplets and increase the risk of exposure. Mercury can also penetrate through nitrile gloves and cause skin irritation.
Choice B reason: This is incorrect. Disinfecting the area with chlorine bleach can create toxic vapours that can harm the respiratory system. Chlorine bleach is not effective in removing mercury from the surface.
Choice C reason: This is incorrect. Contacting the housekeeping staff to mop up the liquid can delay the proper clean-up and disposal of mercury. Mopping can also disperse the mercury droplets and contaminate the mop and the water.
Choice D reason: This is correct. Consulting the agency’s materials safety data sheets (MSDS) is the priority action of the nurse. MSDS provide information on the hazards, precautions, and procedures for handling and disposing of mercury. The nurse should follow the MSDS guidelines and use the appropriate equipment and methods to clean up the spill.
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