Question

A nurse is caring for a client who has a rectal temperature of 350 C (950 F)- Which of the following actions should the nurse take?

Answer 1

Correct Answers:

Place a warming blanket over the client.

Rationale :

🔷 Hypothermia at 35.0 °C (95 °F) requires active rewarming, not cooling.

🔷 A warming blanket provides controlled external heat to raise core temperature safely.

🔷 Avoid antipyretics—there is no fever; these work on set‑point, not on low temp.

🔷 Lowering room temp or using a fan would increase heat loss via convection.

🔷 Monitor for dysrhythmias and shivering, and reassess core temp frequently.

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Answer 2

Correct Answers:

A client who has a coagulation disorder
A client who has hemorrhoids

Rationale :

💠 Oral temperature is appropriate when oral tissues are intact and cooperation is possible.

💠 Coagulation disorders do not affect oral temp safety; they mainly contraindicate intramuscular/rectal routes.

💠 Hemorrhoids affect the rectal route; oral measurement avoids bleeding/pain risk.

💠 Ice water use falsely lowers oral readings—delay 15–30 min instead.

💠 Mouth breathers and recent oral surgery reduce accuracy/safety for the oral route.

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Answer 3

Correct Answers:

"Identifying the problem is the first step of the EBP process."

Rationale :

🔶 EBP begins by formulating a clinical question (e.g., PICOT), i.e., identify the problem.

🔶 Then search for the best evidence, appraise it, and apply it to care.

🔶 Final step is to evaluate outcomes and disseminate—not the first.

🔶 Personal experience can inform context but is not evidence by itself.

🔶 Knowing the sequence ensures systematic and reproducible practice changes.

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Answer 4

Correct Answers:

Observe the client.

Rationale :

◆ After a medication error, assess the client first to identify immediate harm.

◆ Physiologic changes guide urgent interventions and further notifications.

◆ Provider notification and incident reporting come after client assessment.

◆ This aligns with safety and priority frameworks (A•B•C, first do no harm).

◆ Early assessment findings shape treatment and monitoring plans.

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Answer 5

Correct Answers:

Radial pulse regular 68/min

Rationale :

🟣 Includes site (radial), rhythm (regular), and rate (68/min)—a complete entry.

🟣 Units (/min) properly specified for pulse.

🟣 Specificity (radial) improves continuity among caregivers.

🟣 Other examples omit needed qualifiers (e.g., position, site, device, scale/oxygen source).

🟣 Clear documentation supports trend analysis and clinical decisions.

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Answer 6

Correct Answers:

The nurse who delegated the tasks

Rationale :

🟢 Accountability for outcomes remains with the delegating nurse.

🟢 The delegator must ensure right task/person/circumstance/direction/supervision.

🟢 Follow‑up and evaluation are part of the delegator’s responsibility.

🟢 Delegation transfers performance, not accountability.

🟢 Clear expectations and feedback loops prevent care gaps.

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Answer 7

Correct Answers:

False imprisonment

Rationale :

🔴 Restraining a competent client who wants to leave AMA constitutes false imprisonment.

🔴 Autonomy allows clients to refuse or leave, after informed risks are explained.

🔴 Use of restraints requires a clinical safety indication, not convenience or disagreement.

🔴 Document capacity, teaching, and the client’s decision; offer AMA form.

🔴 Seek de‑escalation and provider involvement without coercion.

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Answer 8

Correct Answers:

Providing postmortem care on a client who has died

Rationale :

🟠 Postmortem care is within AP scope with clear directions.

🟠 Sterile/complex procedures (e.g., central line dressing) require licensed staff.

🟠 Assessment/interpretation (e.g., vital sign interpretation) cannot be delegated to APs.

🟠 Education requires nursing knowledge and is not delegated to APs.

🟠 Appropriate delegation promotes efficiency while maintaining safety.

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Answer 9

Correct Answers:

Pass a law to regulate nursing practice of a law within a state

Rationale :

🔵 The NPA starts with a statute (law) enacted by the state legislature.

🔵 Then a board of nursing is empowered to implement/enforce rules.

🔵 Rules and scope definitions flow from the statutory authority.

🔵 Licensure requirements and discipline derive from this legal framework.

🔵 Knowing the hierarchy prevents scope‑of‑practice errors.

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Answer 10

Correct Answers:

"You will have to sign a written request for access to your record."

Rationale :

✅ Clients have a right to access their medical record under policy and law.

✅ Facilities often require a written request to document identity and track release.

✅ Staff should not refuse access nor demand a reason.

✅ Provide guidance on process and expected timeframes for copies.

✅ Protect privacy (verify identity) while supporting transparency.

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Custom: VNIOO FON Midterm Exam

No.

1 :
A nurse is caring for a client who has a rectal temperature of 350 C (950 F)- Which of the following actions should the nurse take?

2 :
A nurse is reinforcing teaching with a newly licensed nurse about measuring body temperature in clients. The nurse should instruct to obtain an oral temperature in which of the following clients? (Select all that apply.)

3 :
A nurse is discussing the process of evidence-based practice (EBP) with a newly licensed nurse. Which of the following statements made by the newly licensed nurse indicates an understanding of the process?

4 :
A client receives the wrong medication in error. The nurse who made the medication error should do which of the following first?

5 :
A nurse is reinforcing teaching with a newly licensed nurse about documenting vital signs. Which Of the following documentation made by the newly licensed nurse indicates an understanding of the teaching?

8 :
A nurse is assigning care to an assistive personnel (AP). Which of the following tasks should the nurse delegate to the AP?

9 :
A nurse is providing an in-service to a group of newly licensed nurses on the Nurse Practice Act (NPA). Which of the following is the first step in defining the scope of nursing in the NPA practice?

10 :
A nurse on a medical-surgical unit is caring for a client who asks to review his medical record. Which of the following responses should the nurse make?

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Custom: VNIOO FON Midterm Exam

No.

1 : A nurse is caring for a client who has a rectal temperature of 350 C (950 F)- Which of the following actions should the nurse take?

2 : A nurse is reinforcing teaching with a newly licensed nurse about measuring body temperature in clients. The nurse should instruct to obtain an oral temperature in which of the following clients? (Select all that apply.)

3 : A nurse is discussing the process of evidence-based practice (EBP) with a newly licensed nurse. Which of the following statements made by the newly licensed nurse indicates an understanding of the process?

4 : A client receives the wrong medication in error. The nurse who made the medication error should do which of the following first?

5 : A nurse is reinforcing teaching with a newly licensed nurse about documenting vital signs. Which Of the following documentation made by the newly licensed nurse indicates an understanding of the teaching?

8 : A nurse is assigning care to an assistive personnel (AP). Which of the following tasks should the nurse delegate to the AP?

9 : A nurse is providing an in-service to a group of newly licensed nurses on the Nurse Practice Act (NPA). Which of the following is the first step in defining the scope of nursing in the NPA practice?

10 : A nurse on a medical-surgical unit is caring for a client who asks to review his medical record. Which of the following responses should the nurse make?

1 :
A nurse is caring for a client who has a rectal temperature of 350 C (950 F)- Which of the following actions should the nurse take?

2 :
A nurse is reinforcing teaching with a newly licensed nurse about measuring body temperature in clients. The nurse should instruct to obtain an oral temperature in which of the following clients? (Select all that apply.)

3 :
A nurse is discussing the process of evidence-based practice (EBP) with a newly licensed nurse. Which of the following statements made by the newly licensed nurse indicates an understanding of the process?

4 :
A client receives the wrong medication in error. The nurse who made the medication error should do which of the following first?

5 :
A nurse is reinforcing teaching with a newly licensed nurse about documenting vital signs. Which Of the following documentation made by the newly licensed nurse indicates an understanding of the teaching?

8 :
A nurse is assigning care to an assistive personnel (AP). Which of the following tasks should the nurse delegate to the AP?

9 :
A nurse is providing an in-service to a group of newly licensed nurses on the Nurse Practice Act (NPA). Which of the following is the first step in defining the scope of nursing in the NPA practice?

10 :
A nurse on a medical-surgical unit is caring for a client who asks to review his medical record. Which of the following responses should the nurse make?