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

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A reason: Data collection about specific client needs related to turning is not an assessment that the nurse should make before delegating care, but rather a task that the nurse should perform and communicate to the AP. The nurse should identify the client's risk factors, preferences, and goals for turning and share them with the AP.

Choice B reason: Changing the client's central IV line dressing is not a task that the nurse should delegate to the AP, as it requires sterile technique and infection control. The nurse should perform this task and document the findings and interventions.

Choice C reason: Checking the client's pain level prior to turning her is an assessment that the nurse should make before delegating care, as it affects the client's comfort and safety. The nurse should ensure that the client's pain is adequately managed and that the AP is aware of the client's pain status and medication regimen.

Choice D reason: The presence of the client's family is not an assessment that the nurse should make before delegating care, but rather a factor that the nurse should consider and respect when planning and implementing care. The nurse should involve the client's family in the care process as much as possible and provide them with education and support.

A. Diminished hand-to-mouth coordination B. Impaired voluntary cough C. Altered level of consciousness D. Unilateral ptosis

Correct Answer is B

Explanation

Choice A reason: Diminished hand-to-mouth coordination is not a finding that requires a referral to speech-language pathology, as it is related to the motor function of the upper extremities. The nurse should refer the client to physical therapy or occupational therapy for this issue.

Choice B reason: Impaired voluntary cough is a finding that requires a referral to speech-language pathology, as it indicates a possible dysfunction of the swallowing mechanism or the vocal cords. The nurse should refer the client to speech-language pathology for a swallowing evaluation and intervention.

Choice C reason: Altered level of consciousness is not a finding that requires a referral to speech-language pathology, as it is related to the neurological function of the brain. The nurse should monitor the client's Glasgow Coma Scale score and report any changes to the provider.

Choice D reason: Unilateral ptosis is not a finding that requires a referral to speech-language pathology, as it is related to the cranial nerve function of the eye. The nurse should assess the client's pupillary response and eye movements and report any abnormalities to the provider.

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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?

Nursing Test Bank

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