You're providing an in-service on transmission-based precautions to a group of nursing students. Which statement made by a student warrants re-education about the topic?

Patients with droplet diseases such as measles require an N95 mask.

I will always wash my hands with soap and water, not hand sanitizer, if I provide care to patients with C. diff, norovirus, and rotavirus infections.

I will make sure that any patient who is in droplet precaution wears a surgical mask when being transported.

I will always wear a gown and gloves when entering a room of a patient in contact precautions.

Answer and Explanation

The Correct Answer is A

A reason:

Patients with droplet diseases such as measles require re-education. Measles is an airborne disease, not droplet, and requires airborne precautions, including an N95 mask.

B reason:

Washing hands with soap and water, not hand sanitizer, for C. diff, norovirus, and rotavirus is correct. These infections require thorough hand washing to remove spores effectively.

C reason:

Ensuring patients in droplet precaution wear a surgical mask when being transported is correct. This helps to prevent the spread of infectious droplets.

D reason:

Wearing a gown and gloves when entering a room of a patient in contact precautions is correct. This prevents the spread of infections through direct and indirect contact.

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Correct Answer is C

Explanation

A reason:

Applying a heat lamp twice a day is incorrect. Heat lamps can increase the risk of burns and do not have a proven benefit in the treatment of pressure ulcers.

B reason:

Massaging reddened areas is incorrect. Massaging areas of redness can cause further tissue damage, especially in areas that are already compromised.

C reason:

Repositioning the client at least every 2 hours is correct. This helps to relieve pressure on the ulcer and promote circulation, which are crucial for the healing process.

D reason:

Cleaning the wound with hydrogen peroxide solution is incorrect. Hydrogen peroxide can damage healthy tissue and delay wound healing. Saline or other appropriate wound cleansers should be used instead.

A. Provide the client a sip of warm water, wait 5 minutes, and measure the temperature B. Document that the nurse was unable to measure the client's temperature C. Proceed to measure the oral temperature D. Wait 30 minutes and return to measure the oral temperature

Correct Answer is D

Explanation

A reason:

Providing a sip of warm water and waiting 5 minutes is not sufficient to ensure an accurate oral temperature reading. The temperature of the mouth needs to stabilize, which takes longer than 5 minutes.

B reason:

Documenting that the temperature could not be measured should be a last resort. The nurse should make an effort to obtain an accurate reading after an appropriate waiting period.

C reason:

Proceeding to measure the oral temperature immediately after consuming ice chips will likely yield an inaccurate reading, as the cold temperature can lower the reading artificially.

D reason:

Waiting 30 minutes before measuring the oral temperature is the correct action. This allows the oral cavity to return to its baseline temperature, ensuring a more accurate measurement.

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You're providing an in-service on transmission-based precautions to a group of nursing students. Which statement made by a student warrants re-education about the topic?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is developing a plan of care for a client who has a stage 3 pressure ulcer. Which of the following interventions should the nurse include in the plan?

Correct Answer is C

Explanation

A nurse is measuring a client's oral temperature. The client informs the nurse that he has just eaten some ice chips. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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