The patient is confined to bed rest. This contributes to immobility of the patient. How should bed rest be indicated on the nursing care plan?

as difficult to maintain

as a risk factor

as a nursing responsibility

as contributing to the patient's recovery

Answer and Explanation

The Correct Answer is B

A. As difficult to maintain: This is a subjective statement and not a proper nursing diagnosis.

B. As a risk factor: Bed rest increases the risk of complications such as pressure ulcers, deep vein thrombosis (DVT), and muscle atrophy.

C. As a nursing responsibility: While nurses help manage bed rest, it is not classified as a responsibility but as an intervention.

D. As contributing to the patient's recovery: Although bed rest may be necessary, prolonged immobility can have negative effects, making this statement incomplete.

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Correct Answer is C

Explanation

A. The LPN should document the care that he/she provided and the care that was given by unlicensed assistive staff.: While the LPN is responsible for documenting their own care, they are not responsible for documenting care provided by unlicensed assistive personnel (UAP). Each staff member is responsible for documenting their own care.

B. The registered nurse must document all care provided by the nursing assistants because the RN is responsible for all patient care.: While RNs oversee patient care, UAPs and LPNs must document the care they perform themselves.

C. All staff members should document all of the care that they have provided.: Every healthcare provider is responsible for documenting their own interventions to maintain accurate and legal records.

D. All staff should document all care they provided, but the RN (as the only independent practitioner) must sign their notes.: While RNs may sign their own documentation, they do not need to sign documentation made by LPNs or UAPs unless verification is required.

A. Teaching deep breathing and relaxation techniques as needed B. Inserting a nasogastric tube (NG) to relieve gastric distention C. Placing the nurse call button within reach at all times D. Giving hand massages daily E. Repositioning the patient every 2 hours to reduce pressure injury risk F. Giving acetaminophen (Tylenol) 650 mg orally every 4 hours as needed

Correct Answer is ["A","C","D","E"]

Explanation

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.

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The patient is confined to bed rest. This contributes to immobility of the patient. How should bed rest be indicated on the nursing care plan?

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Naxlex Comprehensive Predictor Exams

Who should document care in the patient record?

Correct Answer is C

Explanation

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)

Correct Answer is ["A","C","D","E"]

Explanation

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