A charge nurse is evaluating the implementation of infection control measures by unit nurses when caring for clients who have Clostridium difficile. The charge nurse should intervene for which of the following actions by a unit nurse?
Uses alcohol-based hand sanitizer after removing gloves
Wears goggles when emptying the bedpan of liquid stool
Places the client in contact precautions
Cleans contaminated equipment with bleach-based solution
The Correct Answer is A
Choice A reason: This is an incorrect action by the unit nurse. Alcohol-based hand sanitizer is not effective against Clostridium difficile spores, which can cause severe diarrhea and colitis. The nurse should wash their hands with soap and water after removing gloves to prevent the spread of the infection.
Choice B reason: This is a correct action by the unit nurse. Wearing goggles when emptying the bedpan of liquid stool is a standard precaution that protects the nurse's eyes from exposure to body fluids. The nurse should also wear gloves and a gown when handling the bedpan.
Choice C reason: This is a correct action by the unit nurse. Placing the client in contact precautions is an appropriate measure for clients who have Clostridium difficile. Contact precautions prevent direct or indirect transmission of the infection through contact with the client or the client's environment. The nurse should use a single room or cohort the client with another client who has the same infection.
Choice D reason: This is a correct action by the unit nurse. Cleaning contaminated equipment with bleach-based solution is an effective way to kill Clostridium difficile spores, which can survive on surfaces for a long time. The nurse should follow the manufacturer's instructions for the dilution and contact time of the bleach solution.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Information regarding organ donation is not part of advance directives, but rather a separate document that the client can sign to indicate their willingness to donate their organs or tissues after death. The nurse should inform the client about the option and process of organ donation, but not include it in the advance directives.
Choice B reason: Instructions regarding treatments the client desires or does not desire is part of advance directives, as it allows the client to express their preferences and values regarding their health care in case they become unable to make decisions for themselves. The nurse should help the client understand the benefits and risks of different treatments and document their choices in the advance directives.
Choice C reason: Information regarding the disposition of the client's body upon death is not part of advance directives, but rather a personal or legal matter that the client can arrange with their family or attorney. The nurse should respect the client's wishes regarding their body after death, but not include it in the advance directives.
Choice D reason: A form with directions for contacting next of kin is not part of advance directives, but rather a routine document that the client can fill out when they are admitted to the facility. The nurse should obtain the client's contact information and emergency contacts, but not include it in the advance directives.
Correct Answer is D
Explanation
Choice A reason: Accompanying a client who just had a wound debridement to physical therapy is not a task that the nurse should assign to the LPN, as it requires the nurse to monitor the client's vital signs, wound status, and pain level. The nurse should accompany the client and delegate other tasks to the LPN or the assistive personnel.
Choice B reason: Providing postmortem care for a client who has just died is not a task that the nurse should assign to the LPN, as it requires the nurse to verify the death, notify the provider and the family, and document the care. The nurse should provide postmortem care and delegate other tasks to the LPN or the assistive personnel.
Choice C reason: Obtaining a urine specimen from an older adult client is not a task that the nurse should assign to the LPN, as it is a basic skill that the assistive personnel can perform. The nurse should assign this task to the assistive personnel and supervise their work.
Choice D reason: Reinforcing dietary teaching with a client who has heart disease is a task that the nurse should assign to the LPN, as it is within the LPN's scope of practice to reinforce the teaching that the nurse has initiated. The nurse should provide the initial teaching and evaluate the client's learning.
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