Identify the independent nursing actions. (Select All That Apply)
administering pain medication
teaching a patient how to change their dressing before they are discharged
changing a patient's diet from pureed to regular
giving a back rub.
repositioning a patient in bed
Correct Answer : B,D,E
A. Administering pain medication: Administering medication typically requires a healthcare provider's order. Nurses can administer medications, but this action is not independent; it relies on a prescription.
B. Teaching a patient how to change their dressing before they are discharged: This is an independent nursing action. Nurses are educated and trained to provide patient education. Teaching patients about wound care and dressing changes falls under their scope of practice and doesn't require a physician's order.
C. Changing a patient's diet from pureed to regular: Changing a patient's diet usually involves dietary guidelines set by a healthcare provider. Nurses can implement these dietary changes based on the provider's orders but cannot independently change a patient's diet without an order from a healthcare provider.
D. Giving a back rub: Providing comfort measures like a back rub is an independent nursing action. It falls under the domain of holistic nursing care and doesn't require a specific physician's order. Nurses often use such measures to promote relaxation and alleviate discomfort.
E. Repositioning a patient in bed: This is an independent nursing action. Regular repositioning is crucial for preventing pressure ulcers and maintaining a patient's comfort. Nurses assess the patient's mobility and reposition them as needed without requiring specific orders each time.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. North American Nursing Diagnosis Association (NANDA) revises the diagnostic labels every 5 years:
This statement is not accurate. The North American Nursing Diagnosis Association (NANDA) International does review and revise the nursing diagnoses regularly, but it's not on a fixed 5-year schedule. Changes are made based on evolving healthcare practices, new research, and emerging health issues.
B. A nursing diagnosis describes a health problem amenable to intervention:
This statement is true. A nursing diagnosis identifies a specific health problem that can be addressed through nursing interventions. It provides the basis for selecting nursing interventions to achieve outcomes for which the nurse is accountable.
C. Medical diagnosis is included in the nursing diagnosis:
This statement is incorrect. Nursing diagnoses are distinct from medical diagnoses. Medical diagnoses identify diseases or pathologies, whereas nursing diagnoses focus on the patient's responses to the health condition. Nursing diagnoses are within the domain of nursing practice and are formulated based on nursing assessments.
D. LPNs/LVNs formulate nursing diagnoses:
This statement is generally true. Licensed Practical Nurses (LPNs) or Licensed Vocational Nurses (LVNs) can formulate nursing diagnoses as part of their scope of practice. However, the complexity of the diagnosis and the depth of assessment often determine the level of nurse involved in formulating nursing diagnoses. Registered Nurses (RNs) typically handle more complex patient cases and nursing diagnoses
Correct Answer is D
Explanation
A. Pain:
Explanation: Pain is a subjective experience because it is based on the patient's feelings and emotions. It varies from person to person and can't be precisely measured or observed by others. Patients often describe their pain based on personal sensations, making it subjective information.
B. Headache:
Explanation: Like pain, a headache is a subjective symptom. Patients report their experience of a headache based on personal sensations, such as throbbing or pressure. It can't be directly measured or observed by healthcare providers; instead, it relies on the patient's description.
C. Lightheadedness:
Explanation: Lightheadedness is another subjective symptom. Patients may feel dizzy or unsteady, but this sensation can't be quantified objectively. It is based on the patient's perception of feeling lightheaded, making it subjective information.
D. Temperature:
Explanation: Temperature is objective data because it can be precisely measured using a thermometer. It provides a specific numerical value, such as 98.6°F (37°C). Objective data is observable and measurable, making temperature a clear example of objective information obtained through examination or assessment.
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