Nokea
Patient with edema has a problem of fluid overload
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. 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: A,C,D,E
Rationale: A: Teaching non-pharmacological techniques is within a nurse's scope without a physician's order. C: Ensuring the call button is accessible promotes safety independently. D: Hand massages are a comfort measure nurses can provide independently. E: Repositioning prevents pressure injuries and is an independent action. B requires a physician's order, and F involves medication administration, which is dependent.
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Patient is confined to bed rest
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?
- A. as difficult to maintain
- B. as a risk factor
- C. as a nursing responsibility
- D. as contributing to the patient's recovery
Correct Answer: B
Rationale: Bed rest (B) is a risk factor for complications like pressure ulcers or DVT, which should be noted in the care plan. A is subjective, C is an intervention, and D is incomplete as bed rest can hinder recovery if prolonged.
Clarify the primary purpose of nursing orders:
- A. to clarify nursing principles
- B. to resolve the patient's problems
- C. to support physician's orders
- D. to provide broad, general statements
Correct Answer: B
Rationale: Nursing orders (B) aim to address patient problems directly through targeted interventions. A, C, and D do not capture this primary focus.
Patient walks with a limp; Patient reports pain level as 3 on a scale of 1 to 10; Coughed up 5 mL yellow sputum; Headache in frontal area
The nurse is documenting patient data. Which of the following should the nurse document under objective data? (select all that apply)
- A. Assistive personnel reports the patient walks with a limp
- B. Patient reports pain level as 3 on a scale of 1 to 10
- C. Heart rate 72 beats per minute
- D. Respiratory rate 22 per minute with even unlabored respirations
- E. Coughed up 5 mL yellow sputum
- F. Headache in frontal area
Correct Answer: C,D,E
Rationale: C: Heart rate is measured, making it objective. D: Respiratory rate is observed and quantified, thus objective. E: Sputum volume and color are observable, hence objective. A is secondhand, B and F are subjective patient reports.
Patient health care records are:
- A. not used by anyone else but the direct care providers
- B. concise, legal records of all care given and responses
- C. owned by the patient, who has a right to see the data any time he/she wishes
- D. confidential information and cannot be taken to court
Correct Answer: B
Rationale: Records (B) are legal, concise documentation of care and responses, used by multiple parties. A, C, and D are incorrect regarding usage, ownership, and legal status.
On what form/forms should the nurse chart when administering a narcotic?
- A. Physician's Order Sheet
- B. Narcotic Administration Sheet
- C. Care Plan
- D. MAR and Narcotic Administration Sheet
Correct Answer: D
Rationale: Narcotics are documented on both the MAR (Medication Administration Record) (D) for all medications and the Narcotic Administration Sheet for controlled substances to ensure tracking and compliance. A, B alone, and C are incorrect.