The nurse prepares to assess a client's temperature.
Which should the nurse keep in mind that can falsely lower the body temperature? (Select all that apply.)

Choice A rationale:

Using a fire extinguisher should not be the nurse's first action in this situation. The nurse's priority is to ensure the safety of the clients and staff in the vicinity. Attempting to use a fire extinguisher might not be effective and can potentially cause harm, especially if the fire spreads quickly.

Choice B rationale:

Activating the fire alarm is the nurse's priority in this situation. By activating the fire alarm, the nurse can alert everyone in the facility about the fire, ensuring that people are aware and can evacuate safely. This action initiates the facility's fire response protocol, leading to a quicker and organized response to the emergency.

Choice C rationale:

Moving clients to safety is important, but it is not the nurse's immediate priority in this situation. Activating the fire alarm should be done first to ensure that everyone in the facility is aware of the danger, and then the nurse can assist in moving clients to safety if necessary.

The correct answer is Choice D. Speak with the AP before leaving the shift about the appropriate protocol.

Choice A rationale: Giving the AP the appropriate PPE is not the best action for the nurse to take. While this might prevent the AP from spreading the infection to other clients or themselves, it does not address the root cause of the problem, which is the AP’s lack of knowledge or compliance with the infection control policies. The nurse should educate the AP about the importance of wearing PPE and the consequences of not doing so. Giving the AP the appropriate PPE might also imply that the nurse condones the AP’s behavior, which could undermine the nurse’s authority and credibility.

Choice B rationale: Notifying the charge nurse about the AP’s lack of PPE is not the best action for the nurse to take. While this might alert the charge nurse to the issue and prompt corrective action, it does not demonstrate the nurse’s leadership and communication skills. The nurse should first attempt to resolve the issue directly with the AP, as this shows respect and professionalism. Notifying the charge nurse might also create a sense of distrust and resentment between the nurse and the AP, which could affect their working relationship and teamwork.

Choice C rationale: Volunteering to provide an in-service about infection control is not the best action for the nurse to take. While this might be a helpful and proactive way to educate the staff about the infection control policies and procedures, it does not address the immediate issue of the AP’s lack of PPE. The nurse should first speak with the AP and ensure that they understand and follow the contact precautions for the client. Volunteering to provide an in-service might also be seen as overstepping the nurse’s role and scope of practice, as this is usually the responsibility of the infection control nurse or the staff development coordinator.

Choice D rationale: Speaking with the AP before leaving the shift about the appropriate protocol is the best action for the nurse to take. This shows that the nurse is concerned about the AP’s safety and the client’s well-being, as well as the infection control standards. The nurse should explain to the AP why they need to wear PPE when entering the room of a client who is under contact precautions, and what are the risks of not doing so. The nurse should also provide the AP with feedback and reinforcement, and document the incident and the intervention. Speaking with the AP before leaving the shift also ensures that the issue is addressed in a timely and respectful manner, and that the nurse and the AP have a clear and consistent understanding of the expectations and the outcomes.