A nurse in an urgent care center is caring for a young adult client who requires suturing of a laceration. The client tells the nurse, "My family should have been here by now. I can't go through this without them." Which of the following responses should the nurse make?

Rationale

A. Access the online drug formulary for an unfamiliar medication: Consulting a reliable drug reference ensures the nurse understands the medication’s indications, dosage, contraindications, side effects, and interactions. This step is essential when administering a medication for the first time to promote safe and informed practice.

B. Use one patient identifier prior to medication administration: Safe medication administration requires two patient identifiers (e.g., name and date of birth) to verify the correct client. Using only one identifier increases the risk of medication errors and does not meet standard safety protocols.

C. Read the medication label twice prior to administration: Best practice is to read the medication label three times, when removing it from storage, before preparing it, and before administering it to ensure accuracy. Reading only twice may allow for errors in drug selection or dosage.

D. Ask the client if they have ever taken a similar medication: While obtaining medication history from the client is useful, it does not replace verification of proper dosage, route, or interactions. Client recollection may be incomplete or inaccurate, so relying on a reference is safer for first-time administration.

Rationale

A. Perform hand hygiene with at least 4 to 5 mL of hand sanitizer when leaving the client's room: Alcohol-based hand sanitizer is ineffective against C. difficile spores, which require mechanical friction with soap and water for removal. Handwashing is the required method when caring for clients with confirmed C. difficile.

B. Provide a mask for the client when they are outside their room: The client has influenza, which requires droplet precautions to prevent respiratory particle spread during coughing or talking. Wearing a mask when outside the room reduces the risk of transmitting the virus to others in the hallway or waiting areas.

C. Place the client in a room with positive air flow: Positive airflow rooms push air out into the hallway and are not appropriate for infections spread by respiratory droplets or for infections requiring contact precautions. The client with influenza and C. difficile should be placed in a standard private room using droplet plus contact precautions.

D. Don a gown when entering the client's room: C. difficile is spread through contact with spores shed in stool, and gowns protect clothing from contamination. The presence of ongoing diarrhea increases the risk of spore dispersal in the environment. Wearing a gown helps prevent the spread of infection during direct and indirect contact.

E. When removing personal protective equipment, remove gloves first: Gloves have the highest level of contamination because they come into direct contact with infectious materials such as stool and respiratory secretions. Removing gloves first prevents the transfer of pathogens to clean PPE surfaces or the nurse’s skin during removal.