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)?

Choice A reason: This is the correct choice because the nurse checks if the hospital policy allows the licensed practical nurse to perform venipuncture before delegating the task is an action that demonstrates the concept of right supervision. Right supervision is one of the five rights of delegation, which are the principles that guide the nurse to delegate tasks safely and effectively. Right supervision means that the nurse provides appropriate guidance and monitoring of the delegated task and evaluates the outcomes³. By checking the hospital policy, the nurse ensures that the task is within the scope of practice and competency of the licensed practical nurse and that the delegation is consistent with the standards of care.

Choice B reason: This is an incorrect choice because the nurse confirms that the patient’s urine output is entered into the medical record by the nursing assistant by the end of the shift is not an action that demonstrates the concept of right supervision. Right supervision is one of the five rights of delegation, which are the principles that guide the nurse to delegate tasks safely and effectively. Right supervision means that the nurse provides appropriate guidance and monitoring of the delegated task and evaluates the outcomes³. By confirming the documentation, the nurse is performing a quality check, but not providing supervision of the delegated task.

Choice C reason: This is an incorrect choice because the nurse ensures that the scale is accurate before directing the nursing assistant to obtain the patient’s weight is not an action that demonstrates the concept of right supervision. Right supervision is one of the five rights of delegation, which are the principles that guide the nurse to delegate tasks safely and effectively. Right supervision means that the nurse provides appropriate guidance and monitoring of the delegated task and evaluates the outcomes³. By ensuring the accuracy of the scale, the nurse is preparing the equipment, but not providing supervision of the delegated task.

Choice D reason: This is an incorrect choice because the nurse directs the nursing assistant to ambulate the patient at least 20 feet in the hallway using the gait belt before lunch is not an action that demonstrates the concept of right supervision. Right supervision is one of the five rights of delegation, which are the principles that guide the nurse to delegate tasks safely and effectively. Right supervision means that the nurse provides appropriate guidance and monitoring of the delegated task and evaluates the outcomes³. By directing the nursing assistant, the nurse is assigning the task, but not providing supervision of the delegated task.

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.