Which of the following nursing actions is most likely a result of the nurse’s clinical experience?
1. Placing an immobile client on a turning schedule
2. Always assessing a client’s IV site before hanging a new bag of fluid
3. Requesting that the nursing assistant have vital signs recorded by 0815
4. Administering a pain medication 30 minutes before changing a burn dressing
ANSWER
ANS: 2
As a nurse gains clinical experience, he or she will be able to consider which interventions have worked previously, which have not, and why. The decision to check each IV site has become a practice standard for this nurse as a result of previous experiences with IV sites. The remaining options are either standards of care or facility/unit standards.
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