Before rigor mortis occurs, what is the nurse responsible for?

Correct Answer: B

Rationale: Before rigor mortis occurs, it is essential to place a pillow under the body's head and shoulders to maintain proper positioning. This helps prevent postmortem changes and ensures a more dignified appearance. Providing a complete bath and dressing change, removing clothing, or wrapping the body in a shroud are tasks typically done after rigor mortis sets in or later in the postmortem care process. Allowing the body to relax normally does not address the need for proper positioning before rigor mortis occurs.

Correct Answer: D

Rationale: The correct answer is D (Providing oral hygiene) because standard precautions mandate glove use during procedures involving contact with mucous membranes, non-intact skin, or potential exposure to bodily fluids. Oral hygiene involves contact with saliva and oral mucosa, both of which are potential sources of pathogens like herpes simplex virus, cytomegalovirus, or blood from gingival bleeding. Gloves act as a barrier to prevent cross-contamination between the healthcare provider and the patient, reducing transmission risks. Additionally, oral care often requires handling used toothbrushes or floss, which may harbor microorganisms. Choice A (Providing a back massage) is incorrect because it typically involves intact skin contact without exposure to bodily fluids or mucous membranes. Standard precautions do not require gloves for non-invasive touch unless the patient has open wounds or lesions on their back. While hand hygiene is essential, gloves are unnecessary unless there's a specific risk of fluid exposure, which is unlikely during routine massage. Choice B (Feeding a client) is incorrect because it does not ordinarily involve contact with bodily fluids or mucous membranes. Unless the patient requires assistance with oral intake due to dysphagia (which might involve saliva or food residue), gloves are not required. In fact, glove use during feeding may compromise patient dignity and tactile sensitivity needed for safe assistance. Handwashing before and after the task suffices for infection control. Choice C (Providing hair care) is incorrect because routine hair washing or brushing does not involve exposure to bodily fluids or mucous membranes. Gloves might only be necessary if the patient has scalp lesions or drainage, which would fall under transmission-based precautions rather than standard precautions. For most hair care activities, hand hygiene is adequate to maintain infection control standards. The rationale for glove use under standard precautions hinges on risk assessment: procedures with predictable exposure to potentially infectious materials require gloves, while those without such exposure do not. This distinction ensures both patient and provider safety while avoiding unnecessary glove use, which can contribute to resource waste and latex sensitivity development. Oral hygiene uniquely meets the criteria for glove use due to its inherent contact with moist body surfaces and potential for fluid exposure.

Correct Answer: A

Rationale: The most accurate method for assessing temperature in an alert client is the oral method. It provides a more reliable reflection of the body's core temperature compared to axillary or radial methods. In cases of dehydration, it is important to get an accurate temperature reading to monitor the client's condition closely.

Correct Answer: D

Rationale: When a nurse finds a client's pulse rate to be above normal, it is documented as tachycardia. Tachycardia specifically refers to an elevated heart rate, while tachypnea is rapid breathing, hyperpyrexia is high fever, and arrhythmia is an irregular heartbeat. Therefore, the correct term to describe an above-normal pulse rate is tachycardia.

Correct Answer: C

Rationale: When assisting a client to get up in a chair, it is essential to use a wide base of support to maintain stability and prevent injuries. Spreading the feet apart provides a broader base, increasing balance and support for both the client and the caregiver. This position helps distribute the weight evenly and allows for better control when assisting the client in moving.