A nurse assisting with the care of a client who is admitted to the medical-surgical unit.

The nurse is reviewing the client's laboratory findings and vital signs.

Select the 5 findings that require immediate follow-up.

A) "For a client who has Clostridium difficile, I will cleanse my hands with an alcohol-based rub.":
This statement is incorrect. When caring for a client with Clostridium difficile (C. diff), hand hygiene must be performed using soap and water, not an alcohol-based rub. Alcohol does not effectively kill C. diff spores. Handwashing with soap and water is essential to reduce the spread of this infection, as alcohol-based hand sanitizers are ineffective against C. diff spores.

B) "Droplet precautions require that I wear a gown and gloves when providing client care.":
This statement is incorrect. Droplet precautions require wearing a surgical mask to protect against large respiratory droplets that may be expelled during coughing or sneezing. Gowns and gloves are not routinely necessary unless there is a risk of contact with body fluids or secretions. Contact precautions, not droplet precautions, would require a gown and gloves.

C) "Following a blood spill, I should use a bleach solution with a ratio of 1 to 20.":
This statement is partially correct but not fully optimal. For blood spills, the correct bleach solution ratio for disinfection is typically 1 part bleach to 9 parts water (a 1:10 ratio) rather than 1:20. The bleach solution must be strong enough to effectively kill pathogens and viruses, so a 1:9 dilution is preferred.

D) "Soiled dressings should be placed in a biohazard trash receptacle.":
This statement is correct. Soiled dressings, particularly those that are contaminated with blood, bodily fluids, or pathogens, should always be disposed of in a biohazard trash receptacle. This ensures the safe and appropriate handling of potentially infectious materials and helps prevent the spread of infection.

A) Clenched teeth:
Clenched teeth are often a sign of discomfort or pain, especially in a client who is undergoing an epidural for pain management. This physical response typically occurs when the pain is not well controlled, as the body subconsciously tenses muscles in an attempt to cope with the pain. A clenched jaw is a clear indicator that the client is experiencing unrelieved pain, despite treatment.

B) Constipation:
Constipation is a potential side effect of medications such as opioids, which may be prescribed to manage pain. However, constipation itself is not necessarily an immediate indicator of unrelieved pain. While it can occur due to pain medications, it doesn't directly correlate with the effectiveness of pain relief from a spinal epidural.

C) Difficulty swallowing:
Difficulty swallowing, or dysphagia, is not a typical indicator of unrelieved pain. This symptom could be related to other issues such as neurological complications, side effects of medications, or other conditions. It is not a specific or common sign of ongoing pain, particularly in the context of an epidural for herniated disc treatment.

D) Urinary retention:
Urinary retention can occur due to the use of an epidural, especially if the epidural is affecting the lower spinal regions that control bladder function. However, it is more likely a side effect of the epidural itself rather than a sign that pain is unrelieved. While urinary retention should be monitored, it doesn't indicate whether the client’s pain is well-managed or not.