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
Using an automatic BP cuff with a shivering client with a history of an irregular heart rate can result in inaccurate and low readings.
This is because shivering can interfere with the cuff inflation and deflation, and an irregular heart rate can affect the accuracy of the device.
The nurse should intervene and use a manual BP cuff with a stethoscope instead.
Choice B is wrong because pulling the client’s ear pinna backward, up and out to obtain a tympanic membrane temperature is the correct technique for adults and older children. This helps to straighten the ear canal and allow the light to reflect on the tympanic membrane, which shares the same vascular artery as the hypothalamus.
Choice C is wrong because counting the client’s radial pulse who is supine with the forearm straight alongside the body is an appropriate method.
The radial pulse can be easily palpated at the wrist, and the supine position and straight forearm do not affect the pulse rate.
Choice D is wrong because counting the respirations for one full minute for a client with tachypnea is a recommended practice.
Tachypnea means rapid breathing, and counting for one full minute can ensure accuracy and detect any variations in the respiratory pattern.
Correct Answer is D
Explanation
One drop left eye daily.
This is because it uses the correct abbreviation for left eye (os) and the correct frequency (daily).
The other choices are wrong because:
Choice A uses od which means right eye, not once daily.
Choice B uses ou which means both eyes, not each eye.
Choice C uses right ear which is not an eye drop medication. Some common eye drop prescription abbreviations are:
- gt or gtt for drop or drops
- od for right eye
- os for left eye
- ou for both eyes
- bid for twice a day
- tid for three times a day
- qid for four times a day
- prn for as needed
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