Which action by the nurse demonstrates the concept of nurse autonomy?
The nurse braids the patient’s long hair to prevent tangles.
The nurse checks the policy manual before changing the central line dressing.
The nurse counts the patient’s pulse before administering digoxin.
The nurse directs the nursing assistant to obtain the patient's weight.
The Correct Answer is B
Choice A reason: This is an incorrect choice because the nurse braids the patient’s long hair to prevent tangles is not an action that demonstrates the concept of nurse autonomy. Nurse autonomy refers to the ability and right of nurses to make independent decisions about patient care without interference from others. Braiding the patient’s hair is a personal care task that does not require the nurse to use their own judgment or expertise.
Choice B reason: This is the correct choice because the nurse checks the policy manual before changing the central line dressing is an action that demonstrates the concept of nurse autonomy. Nurse autonomy refers to the ability and right of nurses to make independent decisions about patient care without interference from others. Checking the policy manual before changing the central line dressing shows that the nurse is responsible for following the evidence-based guidelines and standards of practice for this procedure.
Choice C reason: This is an incorrect choice because the nurse counts the patient’s pulse before administering digoxin is not an action that demonstrates the concept of nurse autonomy. Nurse autonomy refers to the ability and right of nurses to make independent decisions about patient care without interference from others. Counting the patient’s pulse before administering digoxin is a routine task that is prescribed by the physician and does not involve the nurse’s own decision making.
Choice D reason: This is an incorrect choice because the nurse directs the nursing assistant to obtain the patient's weight is not an action that demonstrates the concept of nurse autonomy. Nurse autonomy refers to the ability and right of nurses to make independent decisions about patient care without interference from others. Directing the nursing assistant to obtain the patient's weight is a task that is delegated by the nurse and does not reflect the nurse’s own authority or initiative.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: This is the correct choice because presence of pedal pulses and intact sensation is the most important bath time assessment of the diabetic patient. Pedal pulses are the pulses that can be felt on the top or side of the foot, and they indicate the blood flow to the lower extremities. Intact sensation is the ability to feel touch, pain, temperature, and vibration on the skin, and it indicates the nerve function of the lower extremities. Diabetic patients are at risk of developing peripheral vascular disease and peripheral neuropathy, which can impair the blood flow and nerve function of the lower extremities, and lead to ulcers, infections, or amputations. The nurse should assess the pedal pulses and intact sensation of the diabetic patient regularly, especially before and after bathing, to monitor for any signs of complications or deterioration.
Choice B reason: This is an incorrect choice because presence of fingernail clubbing is not the most important bath time assessment of the diabetic patient. Fingernail clubbing is a condition where the nails become curved and enlarged, and the nail bed becomes soft and spongy. It is a sign of chronic hypoxia or low oxygen levels in the blood, and it can be associated with various diseases such as lung cancer, cystic fibrosis, or congenital heart defects. However, it is not a common or specific complication of diabetes, and it does not pose an immediate risk of harm or injury to the diabetic patient.
Choice C reason: This is an incorrect choice because presence of abdominal rebound tenderness is not the most important bath time assessment of the diabetic patient. Abdominal rebound tenderness is a sign of peritoneal inflammation, which is the inflammation of the membrane that lines the abdominal cavity and organs. It is elicited by pressing and releasing the abdomen quickly, and it causes pain when the pressure is released. It can be caused by various conditions such as appendicitis, diverticulitis, or peritonitis. However, it is not a common or specific complication of diabetes, and it does not pose an immediate risk of harm or injury to the diabetic patient.
Choice D reason: This is an incorrect choice because presence of any petechiae or bruises is not the most important bath time assessment of the diabetic patient. Petechiae are small, red, or purple spots on the skin that are caused by bleeding under the skin. Bruises are larger, blue, or purple areas on the skin that are caused by bleeding under the skin. They can be caused by various factors such as trauma, infection, medication, or blood disorders. However, they are not a common or specific complication of diabetes, and they do not pose an immediate risk of harm or injury to the diabetic patient.
Correct Answer is B
Explanation
Choice A reason: This is incorrect. Hydromorphone 0.5 mg IV is not the best option for providing consistent control of the patient's chronic pain. Hydromorphone is a potent opioid analgesic that can relieve severe pain, but it has a short duration of action. It is given intravenously, which means it has a rapid onset and peak, but also a rapid decline and elimination. The patient may experience fluctuations in pain relief and need frequent doses.
Choice B reason: This is correct. Fentanyl transdermal patch 25 mcg is the best option for providing consistent control of the patient's chronic pain. Fentanyl is a potent opioid analgesic that can relieve severe pain, but it has a long duration of action. It is given transdermally, which means it is absorbed through the skin and released slowly and steadily into the bloodstream. The patient may experience continuous and stable pain relief and need less frequent doses.
Choice C reason: This is incorrect. Fentanyl oral lozenge 200 mcg is not the best option for providing consistent control of the patient's chronic pain. Fentanyl is a potent opioid analgesic that can relieve severe pain, but it has a short duration of action. It is given orally, which means it has to pass through the digestive system and the liver before reaching the bloodstream. The patient may experience delayed and variable pain relief and need frequent doses.
Choice D reason: This is incorrect. Morphine sulfate liquid 10 mg is not the best option for providing consistent control of the patient's chronic pain. Morphine is a moderate opioid analgesic that can relieve moderate to severe pain, but it has a short duration of action. It is given orally, which means it has to pass through the digestive system and the liver before reaching the bloodstream. The patient may experience delayed and variable pain relief and need frequent doses.
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