The nurse is reviewing interventions written for a client. Which of the following the nurse will consider as being independent?
Administer medication for high blood pressure
Reposition the client every 2 hours
Starting IV antibiotics
Administering medication for pain
Administering medication for pain
The Correct Answer is B
A. Administer medication for high blood pressure: Administering medication generally requires a physician's order and is not considered an independent nursing action.
B. Reposition the client every 2 hours: This intervention is within the nurse’s scope of practice and does not require a physician’s order. It is an independent action that helps prevent complications like pressure ulcers.
C. Starting IV antibiotics: This action requires a physician's order and is a dependent nursing intervention.
D. Administering medication for pain: Administering medication requires a physician’s order and is not considered an independent nursing action.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Current Medical condition: The situation component of ISBARR focuses on the patient's current medical condition and why they are in the facility. It provides a snapshot of the client's immediate situation.
B. List of medications: While important, the list of medications is more relevant to the background or assessment components of the report.
C. Vital signs: Vital signs are part of the assessment, providing data on the client’s current health status.
D. Treatment: Treatment information falls under the recommendation or background sections of the report, detailing the plans or historical context rather than the immediate situation.
Correct Answer is C
Explanation
A. Acute pain manifested by client's report: This diagnosis is too general and does not address the specific issue of unknown etiology or the need for further investigation.
B. Acute pain related to psychosomatic condition: This diagnosis assumes a psychosomatic cause without sufficient evidence. The cause of the pain is not yet clear, so this may not be accurate.
C. Acute pain related to unknown etiology: This diagnosis accurately reflects the situation of pain with an unclear cause and is appropriate for guiding further assessment and investigation.
D. Acute pain related to unknown factors: This diagnosis is vague and less specific than "unknown etiology," which provides a clearer framework for understanding the cause of the pain.
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