A nurse is caring for a client experiencing respiratory distress. The provider orders oxygen therapy and elevating the head of the bed to a high-Fowler's position. What type of intervention is this?
Collaborative intervention
Independent intervention
Delegated intervention
Dependent intervention
The Correct Answer is D
A. Collaborative intervention: Collaborative interventions involve working with other healthcare team members, such as physical therapists or dietitians, to implement a plan of care. Oxygen therapy and prescribed positioning are not examples of team-dependent collaboration.
B. Independent intervention: Independent interventions are actions the nurse can initiate based on their knowledge and judgment without a provider’s order, such as repositioning for comfort or teaching deep-breathing exercises. The interventions requires provider direction.
C. Delegated intervention: Delegated interventions are tasks the nurse assigns to unlicensed assistive personnel (UAP) or other team members, such as taking vital signs or assisting with hygiene. Administering oxygen is not delegated without nurse supervision.
D. Dependent intervention: Dependent interventions require a healthcare provider’s order or prescription. Administering oxygen therapy and elevating the head of the bed as ordered are examples of dependent interventions, as the nurse must follow provider instructions to implement them safely.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Provide the spouse with educational materials about the client's condition: Offering information is helpful for understanding the client’s condition, but it does not directly address the spouse’s emotional state or demonstrate empathy. Emotional support requires acknowledgment of feelings.
B. Ask direct questions about their silence to get a response: Pressuring the spouse to speak may increase anxiety and inhibit communication. Empathy involves creating a safe, nonjudgmental space rather than forcing disclosure.
C. Focus on the client's needs and address the spouse's concerns later: Ignoring the spouse’s emotional cues can lead to feelings of isolation and distress. Providing support in the moment is essential for family-centered care.
D. Acknowledge the spouse's feelings by saying it seems like this situation might be overwhelming for you. What can I do to help?: This approach validates the spouse’s emotions and invites dialogue in a supportive way. It demonstrates empathy, encourages trust, and allows the nurse to respond to emotional needs while maintaining sensitivity to the family’s experience.
Correct Answer is A
Explanation
A. Performing hand hygiene before administering oral medication: Hand hygiene is a key component of medical asepsis, aimed at reducing the number of microorganisms and preventing their spread. This practice protects both the patient and healthcare provider from infection.
B. Wearing a sterile gown during wound irrigation: Using a sterile gown is part of surgical or sterile technique, which is considered surgical asepsis rather than medical asepsis. It prevents contamination during invasive procedures.
C. Cleaning the surgical site with antiseptic solution: Prepping a surgical site is a sterile procedure to eliminate pathogens before invasive surgery, aligning with surgical asepsis, not medical asepsis.
D. Using sterile gloves to insert a urinary catheter: Sterile gloves are part of surgical asepsis because catheter insertion requires maintaining a sterile field to prevent infection. This is distinct from medical asepsis practices.
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