Question

A nurse is caring for a client who has a rectal temperature of 35° C (95° F). Which of the following actions should the nurse take?

Answer 1

Correct Answers:

Place a warming blanket over the client.

Rationale :

💎 Hypothermia is indicated by rectal temp <36°C, requiring active warming interventions.

💎 Warming blankets provide external heat to increase core body temperature safely.

💎 Decreasing room temperature or using a cooling fan is contraindicated, as it worsens hypothermia.

💎 Antipyretics treat fever, not hypothermia, so are inappropriate here.

💎 Monitoring vital signs during warming prevents complications like cardiac arrhythmias.

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Answer 2

Correct Answers:

Sensory deficits

Rationale :

💎 Sensory deficits (vision/hearing loss) can limit ability to access or navigate care.

💎 Sedentary lifestyle, family history, and nutritional status are not direct barriers to access.

💎 Recognizing sensory deficits allows for targeted interventions like assistive devices.

💎 Early identification helps prevent health disparities.

💎 Supports nursing advocacy and patient-centered care planning.

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Answer 3

Correct Answers:

A nurse informs their sibling who works on another unit that the nurse's client has HIV.

Rationale :

💎 Intentional torts involve deliberate violations of client rights, like breaching confidentiality.

💎 Sharing HIV status without consent violates HIPAA and confidentiality laws.

💎 Other options describe negligence or unintentional acts, not intentional torts.

💎 Protecting client privacy is a legal and ethical nursing responsibility.

💎 Intentional torts may result in civil lawsuits against the nurse or facility.

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Answer 4

Correct Answers:

Increased disparities in health care

Rationale :

💎 Cultural bias can lead to unequal treatment or misunderstanding client needs.

💎 May cause delayed or suboptimal care, worsening health outcomes.

💎 Awareness of bias supports culturally competent care.

💎 Bias does not improve assessment or communication; it negatively impacts care quality.

💎 Nursing interventions can mitigate bias through education and reflection.

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Answer 5

Correct Answers:

The site where the blood pressure was obtained.
A client's position when the blood pressure was obtained.

Rationale :

💎 Proper documentation includes measurement site and client position to ensure accuracy and reproducibility

💎 Frequency of measurement and interventions may be documented separately but are not part of standard BP documentation.

💎 Client response is important but not required for BP measurement record.

💎 Accurate documentation prevents misinterpretation of readings.

💎 Supports legal compliance and quality patient care.

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Answer 6

Correct Answers:

Clean hands with soap and water after caring for the client.

Rationale :

💎 C. difficile spores are resistant to alcohol-based hand sanitizer, requiring soap and water.

💎 Negative pressure rooms are not indicated, as C. difficile is contact-transmitted.

💎 Handwashing duration should be at least 20 seconds, not just 10 seconds.

💎 Masks are not required unless droplet precautions indicated.

💎 Proper hand hygiene prevents nosocomial spread.

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Answer 7

Correct Answers:

Hand hygiene is the most important step to prevent spreading of infection.

Rationale :

💎 Effective hand hygiene prevents transmission of pathogens in healthcare settings.

💎 Compliance among staff is often suboptimal, making education critical.

💎 Alcohol-based gel is acceptable unless hands are visibly soiled.

💎 Patients should also be educated on hand hygiene for infection prevention.

💎 Regular hand hygiene reduces healthcare-associated infections (HAIs).

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Answer 8

Correct Answers:

Contact

Rationale :

💎 MRSA spreads via direct or indirect contact with contaminated surfaces or skin.

💎 Contact precautions include gown and gloves.

💎 Airborne and droplet precautions are not necessary for MRSA colonization.

💎 Protects other patients and staff from transmission.

💎 Early implementation reduces HAIs and improves patient safety.

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Answer 9

Correct Answers:

Gloves

Rationale :

💎 Gloves protect hands from contamination when handling linens.

💎 N-95 respirators, goggles, and face shields are not required unless exposure risk exists.

💎 Proper removal prevents self-contamination.

💎 Hand hygiene before and after glove use is essential for infection control.

💎 Reduces risk of pathogen spread within healthcare setting.

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Answer 10

Correct Answers:

Enamel

Rationale :

💎 Enamel is the hard, outer layer of teeth that protects against decay.

💎 Provides a barrier to plaque and acid erosion.

💎 Composed primarily of calcium and phosphate minerals.

💎 Healthy enamel supports long-term dental health.

💎 Regular dental hygiene prevents enamel breakdown and cavities.

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QLexNursing

1 :
A nurse is caring for a client who has a rectal temperature of 35° C (95° F). Which of the following actions should the nurse take?

2 :
A nurse is teaching a class about health disparities that impact access to health care. The nurse should include that which of the following factors can impact access to health care?

3 :
A nurse is teaching about intentional torts with a group of newly licensed nurses. The nurse should include which of the following examples?

4 :
A nurse is teaching a class about cultural bias in health care. The nurse should include that which of the following can occur as a result of cultural bias?

5 :
A nurse is teaching a class about documenting blood pressure. The nurse should include to document which of the following information?

6 :
A nurse is caring for a client who has Clostridium difficile (C. difficile). Which of the following actions should the nurse take?

7 :
A charge nurse is teaching a group of staff members about hand hygiene. Which of the following information should the nurse include in the teaching?

8 :
A nurse is preparing to admit a client who has a new diagnosis of methicillin-resistant Staphylococcus aureus (MRSA). The nurse should plan to place the client in which of the following types of transmission-based precautions?

9 :
A nurse is changing the bed linen for a client who is on contact precautions. Which of the following personal protective equipment should the nurse wear?

10 :
A nurse is teaching a class about oral hygiene. The nurse should include that which of the following substances coats the teeth to protect them from plaque?

QLexNursing

1 : A nurse is caring for a client who has a rectal temperature of 35° C (95° F). Which of the following actions should the nurse take?

2 : A nurse is teaching a class about health disparities that impact access to health care. The nurse should include that which of the following factors can impact access to health care?

3 : A nurse is teaching about intentional torts with a group of newly licensed nurses. The nurse should include which of the following examples?

4 : A nurse is teaching a class about cultural bias in health care. The nurse should include that which of the following can occur as a result of cultural bias?

5 : A nurse is teaching a class about documenting blood pressure. The nurse should include to document which of the following information?

6 : A nurse is caring for a client who has Clostridium difficile (C. difficile). Which of the following actions should the nurse take?

7 : A charge nurse is teaching a group of staff members about hand hygiene. Which of the following information should the nurse include in the teaching?

8 : A nurse is preparing to admit a client who has a new diagnosis of methicillin-resistant Staphylococcus aureus (MRSA). The nurse should plan to place the client in which of the following types of transmission-based precautions?

9 : A nurse is changing the bed linen for a client who is on contact precautions. Which of the following personal protective equipment should the nurse wear?

10 : A nurse is teaching a class about oral hygiene. The nurse should include that which of the following substances coats the teeth to protect them from plaque?

1 :
A nurse is caring for a client who has a rectal temperature of 35° C (95° F). Which of the following actions should the nurse take?

2 :
A nurse is teaching a class about health disparities that impact access to health care. The nurse should include that which of the following factors can impact access to health care?

3 :
A nurse is teaching about intentional torts with a group of newly licensed nurses. The nurse should include which of the following examples?

4 :
A nurse is teaching a class about cultural bias in health care. The nurse should include that which of the following can occur as a result of cultural bias?

5 :
A nurse is teaching a class about documenting blood pressure. The nurse should include to document which of the following information?

6 :
A nurse is caring for a client who has Clostridium difficile (C. difficile). Which of the following actions should the nurse take?

7 :
A charge nurse is teaching a group of staff members about hand hygiene. Which of the following information should the nurse include in the teaching?

8 :
A nurse is preparing to admit a client who has a new diagnosis of methicillin-resistant Staphylococcus aureus (MRSA). The nurse should plan to place the client in which of the following types of transmission-based precautions?

9 :
A nurse is changing the bed linen for a client who is on contact precautions. Which of the following personal protective equipment should the nurse wear?

10 :
A nurse is teaching a class about oral hygiene. The nurse should include that which of the following substances coats the teeth to protect them from plaque?