Which actions by the nurse are examples of dependent nursing interventions for a postoperative patient? (Select all that apply).

Calculating the patient’s fluid intake and output at the end of every shift.

Assessing the patient’s abdomen for distention, bowel sounds, and passage of flatus.

Administering a mild stool softener daily to prevent constipation.

Encouraging fluid and fiber intake to prevent constipation from pain medications.

Reinserting the patient's urinary catheter for retention of greater than 500 mL of urine.

Answer and Explanation

Correct Answer : C

Choice A reason: This is an incorrect choice because calculating the patient’s fluid intake and output at the end of every shift is an example of an independent nursing intervention. An independent nursing intervention is an action that the nurse can perform based on their own knowledge, skills, and judgment without a physician's order. The nurse can monitor the patient’s fluid balance and document the results.

Choice B reason: This is an incorrect choice because assessing the patient’s abdomen for distention, bowel sounds, and passage of flatus is an example of an independent nursing intervention. An independent nursing intervention is an action that the nurse can perform based on their own knowledge, skills, and judgment without a physician's order. The nurse can perform a physical examination of the patient’s abdomen and document the findings.

Choice C reason: This is a correct choice because administering a mild stool softener daily to prevent constipation is an example of a dependent nursing intervention. A dependent nursing intervention is an action that the nurse can perform only with a physician's order. The nurse cannot give any medication to the patient without a prescription.

Choice D reason: This is an incorrect choice because encouraging fluid and fiber intake to prevent constipation from pain medications is an example of an independent nursing intervention. An independent nursing intervention is an action that the nurse can perform based on their own knowledge, skills, and judgment without a physician's order. The nurse can educate the patient about the importance of hydration and nutrition and document the teaching.

Choice E reason: This is a correct choice because reinserting the patient's urinary catheter for retention of greater than 500 mL of urine is an example of a dependent nursing intervention. A dependent nursing intervention is an action that the nurse can perform only with a physician's order. The nurse cannot insert or remove any invasive device from the patient without a prescription.

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Correct Answer is D

Explanation

Choice A reason: This is incorrect. Documenting the finding in the patient’s medical record is an important step, but not the most appropriate first action of the nurse. The nurse should first confirm the irregularity by counting the apical pulse.

Choice B reason: This is incorrect. Assessing the brachial pulse for a pulse deficit is a useful technique, but not the most appropriate first action of the nurse. A pulse deficit is the difference between the apical and radial pulse rates. The nurse should first count the apical pulse before comparing it with the radial pulse.

Choice C reason: This is incorrect. Notifying the health care provider immediately is a necessary step, but not the most appropriate first action of the nurse. The nurse should first gather more information by counting the apical pulse and determining the type and severity of the irregularity.

Choice D reason: This is correct. Counting the patient’s apical pulse for one full minute is the most appropriate first action of the nurse. The apical pulse is the most accurate way to measure the heart rate and rhythm. The nurse should listen to the heart sounds at the apex of the heart, which is located at the fifth intercostal space, left midclavicular line. The nurse should count the number of beats and note any irregularities, such as skipped, extra, or uneven beats.

A. The patient is grouchy and inappropriate, always causing trouble for the nurses. B. The patient’s nurse assistant always took her time to answer his call lights. C. The patient probably urinated on the floor and slipped on the wet floor. D. The patient was found on the floor and his urinal was on the floor next to him.

Correct Answer is D

Explanation

Choice A reason: This is an inappropriate statement for the nurse to include in the description of the incident because it is subjective, biased, and disrespectful. The nurse should not make judgments or assumptions about the patient's personality or behavior, but rather report the facts and observations of the situation.

Choice B reason: This is an inappropriate statement for the nurse to include in the description of the incident because it is irrelevant, speculative, and accusatory. The nurse should not blame or criticize the nurse assistant's performance, but rather focus on the patient's condition and the actions taken to prevent or manage the fall.

Choice C reason: This is an inappropriate statement for the nurse to include in the description of the incident because it is uncertain, hypothetical, and unprofessional. The nurse should not use words like "probably" or "maybe" that indicate a lack of clarity or certainty, but rather state the facts and evidence of the situation.

Choice D reason: This is an appropriate statement for the nurse to include in the description of the incident because it is objective, factual, and concise. The nurse should report the patient's location, status, and environment at the time of the fall, and the possible cause or contributing factors of the fall.

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Which actions by the nurse are examples of dependent nursing interventions for a postoperative patient? (Select all that apply).

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse notes that the patient’s radial pulse is irregular. What is the most appropriate first action of the nurse?

Correct Answer is D

Explanation

The nurse is completing the charting after a patient suffered a fall. Which statement is appropriate for the nurse to include in the description of the incident?

Correct Answer is D

Explanation

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Which actions by the nurse are examples of dependent nursing interventions for a postoperative patient? (Select all that apply).