An example of an intervention independently initiated by the nurse is

Questions 42

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Question 1 of 5

An example of an intervention independently initiated by the nurse is

Correct Answer: A

Rationale: Teaching plans (A) are independent RN functions, unlike B, C, and D, which require physician orders (diet, labs, meds). A reflects RN autonomy, making it correct.

Question 2 of 5

Which action demonstrates that the nurse understands the purpose of the Rapid Response Team?

Correct Answer: C

Rationale: The Rapid Response Team (RRT) intervenes rapidly for clients beginning to decline clinically, such as a significant drop in blood pressure (52 mm Hg), to prevent respiratory or cardiac arrest. Monitoring postoperative status (A), maintaining a flow sheet (B), and reporting restlessness (D) are important but not specific to the RRT's purpose.

Question 3 of 5

Which action by the nurse demonstrates the best practice for nursing documentation on a computerized record?

Correct Answer: D

Rationale: Documenting at the point of care ensures accuracy and timeliness, the best practice for computerized records. Deleting errors (A) compromises integrity, red font (B) is non-standard, and end-of-shift summaries (C) risk omissions.

Question 4 of 5

The physician prescribes warfarin (Coumadin) 15 mg daily. The nurse notes that this is three times the normal dose for this client based on the client's medication profile and laboratory work. What does the nurse do first?

Correct Answer: C

Rationale: Calling the physician first ensures safety by clarifying a potentially erroneous dose. Giving the dose (A) risks harm, consulting the pharmacy (B) delays direct resolution, and holding (D) without communication is unsafe.

Question 5 of 5

A client has metastatic lung cancer and is hospitalized for chemotherapy. Which intervention does the nurse delegate to the unlicensed assistive personnel? ((Select ONE that does not apply.)

Correct Answer: B

Rationale: UAP can assist with repositioning (A), take vital signs (C), and record intake/output (D). Teaching (B) and promoting grief expression (E) require nursing expertise and cannot be delegated.

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