The nurse is reviewing the patient's plan of care and ordered treatments. Which of the following is (are) independent nursing interventions? (select all that apply)

A. Unacceptable because it is vague subjective data without supportive data: The documentation includes objective data (BP, pulse), a physician notification, an intervention (analgesic), and an outcome.

B. Good because it shows immediate response to the problem: While the response to the problem is immediate, this choice is incomplete as it does not acknowledge that the documentation reflects all aspects of assessment, intervention, and evaluation.

C. Inadequate because the time of physician notification is not listed: While including the exact time of physician notification is best practice, the record still meets documentation standards.

D. Acceptable because it includes assessment, intervention, and evaluation: The note follows the nursing process (assessment, intervention, and response/evaluation), making it acceptable documentation.

A. Teaching deep breathing and relaxation techniques as needed: Teaching non-pharmacological pain relief (such as deep breathing) is an independent nursing action that does not require a physician’s order.

B. Inserting a nasogastric tube (NG) to relieve gastric distention: NG tube insertion requires a physician's order, making it not independent.

C. Placing the nurse call button within reach at all times: Ensuring the patient’s call button is within reach is an independent nursing action to promote safety and communication.

D. Giving hand massages daily: Nurses can provide non-invasive comfort measures such as hand massages without a physician's order.

E. Repositioning the patient every 2 hours to reduce pressure injury risk: Repositioning is an independent intervention that prevents skin breakdown and pressure injuries.

F. Giving acetaminophen (Tylenol) 650 mg orally every 4 hours as needed: Medication administration requires a physician’s order, making it a dependent nursing action.