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: This is not the correct choice because this assignment is not appropriate for a licensed practical nurse. A client who requires discharge instructions for type 1 diabetes mellitus needs education on self-care, medication administration, blood glucose monitoring, diet, and exercise. These are complex tasks that require the knowledge and skills of a registered nurse.
Choice B reason: This is the correct choice because this assignment is appropriate for a licensed practical nurse. A client who is 1 day postoperative and has a continuous bladder irrigation needs routine care, such as vital signs, wound assessment, fluid intake and output, and catheter care. These are basic tasks that can be performed by a licensed practical nurse under the supervision of a registered nurse.
Choice C reason: This is not the correct choice because this assignment is not appropriate for a licensed practical nurse. A client who requires a blood transfusion to be administered needs careful monitoring, such as checking for compatibility, verifying informed consent, observing for adverse reactions, and documenting the transfusion. These are advanced tasks that require the judgment and authority of a registered nurse.
Choice D reason: This is not the correct choice because this assignment is not appropriate for a licensed practical nurse. A client who is receiving IV chemotherapy needs specialized care, such as preparing and administering the medication, managing side effects, providing emotional support, and following safety precautions. These are specialized tasks that require the training and certification of a registered nurse.
Correct Answer is C
Explanation
Choice A reason: The client's code status is not part of the background information, but rather the recommendation or request section of the SBAR Communication tool. The code status indicates the level of resuscitation the client wishes to receive in case of a cardiac or respiratory arrest.
Choice B reason: The client's vital signs are not part of the background information, but rather the assessment section of the SBAR Communication tool. The vital signs reflect the client's current condition and response to treatment.
Choice C reason: The client's name is part of the background information, along with the client's age, diagnosis, reason for admission, and relevant medical history. The background information provides a brief overview of the client's situation and helps to identify the client.
Choice D reason: A prescribed consultation is not part of the background information, but rather the recommendation or request section of the SBAR Communication tool. A consultation is a referral to another health care professional for further evaluation or management of the client's condition.
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