Nursing interventions should be documented according to specific ...

[erika]

Nursing interventions should be documented according to specific criteria in order that they may be clearly understood by other members of the nursing team. The most appropriate of the fol-lowing intervention statements is:
 
  1. Offer fluids to the client q2h
  2. Observe the client's respirations
  3. Change the client's dressing daily
  4. Irrigate the nasogastric tube q2h with 30 ml normal saline

Question 2

Which one of the following interventions selected by the nurse is classified as Level 2, Domain 2 (Physiological: complex)?
 
  1. Maintaining regular bowel elimination
  2. Promoting the health of the entire family
  3. Managing severely restricted body movement
  4. Restoring tissue integrity to areas damaged by friction

[quynhmickitran]

Answer to Question 1

ANS: 4
Irrigate the nasogastric tube q2h with 30 ml normal saline is the most appropriate intervention statement. It includes the action, frequency, quantity, and method. Offer fluids to the client q2h lacks the component of quantity. Observe the client's respirations fails to indicate the frequency or method. Also, what is the reason for observation of the client's respirations? Change the cli-ent's dressing daily omits the method.

Answer to Question 2

ANS: 4
Interventions to maintain or restore tissue integrity are classified as Level 2, Domain 2 (Physio-logical: Complex). Maintaining regular bowel elimination is classified as Level 2, Domain 1 (Physiological: Basic). Promoting the health of the family is classified as Level 2, Domain 5 (Family). Managing restricted body movement is classified as Level 2, Domain 1 (Physiological: Basic).

[erika]

Excellent

[nanny]

TYSM