A nurse is preparing to administer morphine sulfate 2 mg IV to a client who has acute pain. Which of the following statements by the nurse is an example of an independent intervention?
"I will check your pain level and location before and after giving you the medication.”.
"I will flush your IV line with normal saline before and after giving you the medication.”.
"I will monitor your vital signs and level of consciousness every 15 minutes after giving you the medication.”.
"I will ask the physician to order naloxone in case you have an adverse reaction to the medication.".
The Correct Answer is A
Choice A reason:
Checking the pain level and location before and after giving the medication is an example of an independent intervention because it is within the nurse's scope of practice and does not require a provider's order. It is also part of the nursing process to assess the patient's pain and evaluate the effectiveness of the intervention.
Choice B reason:
Flushing the IV line with normal saline before and after giving the medication is not an independent intervention because it is a dependent intervention that requires a provider's order. It is also a standard procedure for administering IV medications to prevent occlusion and contamination of the IV line.
Choice C reason:
Monitoring the vital signs and level of consciousness every 15 minutes after giving the medication is not an independent intervention because it is a dependent intervention that requires a provider's order. It is also a safety measure to detect any adverse effects of the medication, such as respiratory depression, hypotension, or sedation.
Choice D reason:
Asking the physician to order naloxone in case of an adverse reaction to the medication is not an independent intervention because it is a collaborative intervention that involves consultation with another health care professional. It is also a precautionary measure to have an opioid antagonist available in case of overdose or severe respiratory depression.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:
Checking the pain level and location before and after giving the medication is an example of an independent intervention because it is within the nurse's scope of practice and does not require a provider's order. It is also part of the nursing process to assess the patient's pain and evaluate the effectiveness of the intervention.
Choice B reason:
Flushing the IV line with normal saline before and after giving the medication is not an independent intervention because it is a dependent intervention that requires a provider's order. It is also a standard procedure for administering IV medications to prevent occlusion and contamination of the IV line.
Choice C reason:
Monitoring the vital signs and level of consciousness every 15 minutes after giving the medication is not an independent intervention because it is a dependent intervention that requires a provider's order. It is also a safety measure to detect any adverse effects of the medication, such as respiratory depression, hypotension, or sedation.
Choice D reason:
Asking the physician to order naloxone in case of an adverse reaction to the medication is not an independent intervention because it is a collaborative intervention that involves consultation with another health care professional. It is also a precautionary measure to have an opioid antagonist available in case of overdose or severe respiratory depression.
Correct Answer is D
Explanation
Choice A reason:
Review the client’s medications and dosage instructions with them. This step is crucial to prevent medication errors and ensure the client understands their regimen. It helps in maintaining proper glycemic control and avoiding complications.
Choice B reason:
Evaluate the client’s blood glucose levels and insulin administration technique. This ensures the client can manage their diabetes effectively at home. Proper technique and understanding of blood glucose monitoring are essential for maintaining target glucose levels.
Choice C reason:
Refer the client to a home health nurse or a diabetes educator as needed. Ongoing support and education from healthcare professionals are vital for managing diabetes. This referral provides the client with resources and guidance to manage their condition effectively.
Choice D reason:
All of the above. Combining all these actions ensures a holistic approach to discharge planning, addressing medication management, self-monitoring, and continuous support, which are all critical for effective diabetes management.
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