A health care provider has ordered vital signs every 4 hours.
The client’s 8:00 AM temperature was 99° F (37.2° C).
At 10 AM, the client reported chills.
A nurse takes the client’s temperature again. Which type of nursing action does this exemplify?
Interdependent.
Dependent.
Collaborative.
Independent.
The Correct Answer is D
Independent. An independent nursing intervention is an action that a nurse can perform by themselves, without any management from a doctor or another discipline.
Taking the client’s temperature again is an example of an independent nursing intervention because it does not require a physician’s order or collaboration with other health care professionals.
Choice A is wrong because an interdependent nursing intervention is an action that requires collaboration or consultation with other health care professionals.
Taking the client’s temperature again does not involve working with other disciplines.
Choice B is wrong because a dependent nursing intervention is an action that requires an order from a physician or another health care provider.
Taking the client’s temperature again does not require a physician’s order.
Choice C is wrong because a collaborative nursing intervention is an action that involves working with other health care professionals to provide patient care.
Taking the client’s temperature again does not require collaboration with other disciplines.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
This is because a client with obstructive sleep apnea (OSA) may have periods of apnea lasting more than 10 seconds during sleep, which can lead to hypoxia and hypercapnia. These conditions can cause the client to be difficult to arouse and may indicate respiratory failure.
The nurse should take immediate action to stimulate the client, provide oxygen, and call for help.
Choice B is wrong because blood pressure 142/92 mmHg is not an emergency for a client with OSA. It is within the stage 1 hypertension range, which may be caused by OSA or other factors. The nurse should monitor the client’s blood pressure and encourage lifestyle modifications, such as weight loss, exercise, and dietary changes.
Choice C is wrong because apneic periods lasting more than 10 seconds are expected in a client with OSA. This is the criterion for diagnosing OSA during a sleep study. The nurse should educate the client about the use of continuous positive airway pressure (CPAP) or other treatments to prevent apnea and improve oxygenation during sleep.
Choice D is wrong because oxygen desaturation to 90% when asleep is not an emergency for a client with OSA. It is a common finding in OSA due to the intermittent obstruction of the upper airway. The nurse should ensure that the client has supplemental oxygen available and teach the client about the benefits of CPAP or other devices to maintain airway patency and oxygen saturation during sleep.
Correct Answer is A
Explanation
Maintain trust and avoid behaviors that may increase agitation. This is the priority action because it is important for the nurse to attempt to de-escalate the client and maintain trust.
A. Ordering the client to go to their room and alerting security is not the priority action because it may increase agitation and does not maintain trust.
C. Telling the client to sit down or risk isolation and loss of privileges is not the priority action because it may increase agitation and does not maintain trust.
D. Sedating the client after collecting a lithium level is not the priority action because it does not address the immediate need to de-escalate the situation and maintain trust.
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