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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

A toileting routine is the priority intervention for a client diagnosed with total urinary incontinence because it helps to prevent skin breakdown, infection, and odor. It also promotes dignity and comfort for the client.

Choice B. Kegel exercises are wrong because they are not effective for total urinary incontinence, which is the complete loss of bladder control. Kegel exercises are more useful for stress or urge urinary incontinence, which are caused by weak pelvic floor muscles.

Choice C. Surgery is wrong because it is not a priority intervention for total urinary incontinence.

Surgery may be considered a last resort option if other conservative measures fail to improve the condition. Surgery may also have risks and complications that need to be weighed against the benefits.

Choice D. Anticholinergic drug therapy is wrong because it is not a priority intervention for total urinary incontinence.

Anticholinergic drugs are used to treat overactive bladder or urge urinary incontinence, which are caused by involuntary bladder contractions. Anticholinergic drugs may have side effects such as dry mouth, constipation, blurred vision, and confusion.

A. Fluoroscopy to identify location. B. Aspirate contents and measure the pH. C. Inject air and listen for gurgling sounds. D. Observe for bubbles after placing the end of the tube in a cup of water.

Correct Answer is B

Explanation

This is because the pH of gastric contents is acidic (less than 5.5) and can indicate that the tube is in the stomach. This method is predictive of the correct placement of a nasogastric tube.

Choice A is wrong because fluoroscopy is not the most reliable method to confirm the correct placement of a nasogastric tube. It is an imaging technique that uses X-rays to show the movement of the tube, but it is not always available or feasible.

Choice C is wrong because injecting air and listening for gurgling sounds is not a reliable method to confirm the correct placement of a nasogastric tube. It can cause false-positive results and does not differentiate between the stomach and the respiratory tract.

Choice D is wrong because observing for bubbles after placing the end of the tube in a cup of water is not a reliable method to confirm the correct placement of a nasogastric tube. It can also cause false-positive results and does not differentiate between the stomach and the respiratory tract.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which nursing action is the priority intervention for a client diagnosed with total urinary incontinence?

Correct Answer is A

Explanation

Which technique is most reliable to confirm correct placement of a nasogastric tube prior to initiating tube feedings?

Correct Answer is B

Explanation

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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?