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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A reason: This is the correct choice because assessment is the step of the nursing process that involves collecting and organizing data about the patient's health status and needs. The nurse who carefully enters a new patient’s medical history and current medication list into the agency’s electronic health record (EHR) is performing an assessment by gathering relevant information from the patient and other sources.

Choice B reason: This is an incorrect choice because implementation is the step of the nursing process that involves carrying out the planned nursing interventions to achieve the patient's goals and outcomes. The nurse who carefully enters a new patient’s medical history and current medication list into the agency’s electronic health record (EHR) is not performing an implementation by executing any actions or treatments for the patient.

Choice C reason: This is an incorrect choice because diagnosis is the step of the nursing process that involves analyzing and interpreting the data to identify the patient's actual or potential health problems. The nurse who carefully enters a new patient’s medical history and current medication list into the agency’s electronic health record (EHR) is not performing a diagnosis by making any judgments or conclusions about the patient's condition.

Choice D reason: This is an incorrect choice because evaluation is the step of the nursing process that involves measuring and comparing the patient's progress and outcomes with the expected goals and outcomes. The nurse who carefully enters a new patient’s medical history and current medication list into the agency’s electronic health record (EHR) is not performing an evaluation by assessing any changes or improvements in the patient's status.

A. The patient takes 30 mg morphine sulfate daily. B. The patient has severe joint pain due to aggressive arthritis. C. The patient has a gastrointestinal bleed. D. The patient has a history of diabetes and early renal failure. E. The patient has allergies to shellfish, strawberries, and iodine.

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

Explanation

Choice A reason: This is incorrect. The patient takes 30 mg morphine sulfate daily does not lead the nurse to clarify the order for ibuprofen 600 mg PO every 8 hours. Morphine sulfate is an opioid analgesic that can be used in combination with ibuprofen, a nonsteroidal anti-inflammatory drug (NSAID), for moderate to severe pain. The nurse should monitor the patient for signs of respiratory depression, sedation, or constipation, but there is no need to clarify the order.

Choice B reason: This is incorrect. The patient has severe joint pain due to aggressive arthritis does not lead the nurse to clarify the order for ibuprofen 600 mg PO every 8 hours. Ibuprofen is indicated for the relief of signs and symptoms of rheumatoid arthritis and osteoarthritis. The nurse should assess the patient's pain level, response to treatment, and adverse effects, but there is no need to clarify the order.

Choice C reason: This is correct. The patient has a gastrointestinal bleed leads the nurse to clarify the order for ibuprofen 600 mg PO every 8 hours. Ibuprofen can cause gastrointestinal irritation, ulceration, bleeding, and perforation. The nurse should question the order and consider alternative analgesics for the patient, especially if they have a history of peptic ulcer disease, gastritis, or bleeding disorders.

Choice D reason: This is correct. The patient has a history of diabetes and early renal failure leads the nurse to clarify the order for ibuprofen 600 mg PO every 8 hours. Ibuprofen can impair renal function, increase blood pressure, and interfere with the effects of antihypertensive and antidiabetic drugs. The nurse should question the order and monitor the patient's renal function, blood pressure, and blood glucose levels closely.

Choice E reason: This is correct. The patient has allergies to shellfish, strawberries, and iodine leads the nurse to clarify the order for ibuprofen 600 mg PO every 8 hours. Ibuprofen can cause hypersensitivity reactions, such as rash, angioedema, bronchospasm, or anaphylaxis. The nurse should question the order and ask the patient about any previous reactions to NSAIDs or aspirin. The patient may need to avoid ibuprofen and use a different analgesic..

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which step of the nursing process is being performed by the nurse who carefully enters a new patient’s medical history and current medication list into the agency’s electronic health record (EHR)?

Correct Answer is A

Explanation

Which assessment findings lead the nurse to clarify the order for ibuprofen 600 mg PO every 8 hours? (Select all that apply.)

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

Explanation

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