A nurse is assisting with the care of a client with the history below:
A nurse is caring for the client. Which of the following actions should the nurse take? Select (2) answers that apply.
Wear a protective gown while caring for the client.
Place the client in a private room.
Wear an N-95 respirator while caring for the client.
Place the client in a negative pressure room.
Place a mask on the client when they leave their room.
Correct Answer : A,B
A. Wearing a protective gown is necessary when caring for a client with C. difficile to prevent the spread of spores and protect the nurse from contact with contaminated surfaces.
B. Placing the client in a private room helps to isolate the infection and prevent transmission to other patients, which is essential in managing C. difficile infections.
C. An N-95 respirator is not required for C. difficile as the primary mode of transmission is via the fecal-oral route, not through airborne particles.
D. A negative pressure room is used for airborne infections like tuberculosis, not for C. difficile. C. difficile requires contact precautions rather than airborne precautions.
E. A mask is not necessary for the client with C. difficile when leaving the room; instead, hand hygiene and proper gowning are essential for preventing the spread of the infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Pupil size and reaction: Pupil size and reaction are typically assessed to monitor neurological function and are not directly related to tissue integrity.
B. Heart rate and blood pressure: Heart rate and blood pressure are vital signs that provide information about cardiovascular function but do not specifically assess tissue integrity.
C. Respiratory rate and oxygen saturation: Respiratory rate and oxygen saturation are indicators of respiratory function and oxygenation status and are not directly related to tissue integrity.
D. Skin turgor and moisture: Skin turgor, the skin's ability to return to its normal shape after being pinched, and moisture levels are important assessments for monitoring tissue hydration and integrity. Changes in skin turgor and moisture can indicate dehydration, which can impair tissue integrity and wound healing.
Correct Answer is D
Explanation
A. Endogenous Infection: Endogenous infections originate from the client's own microbiota and typically do not involve medical interventions such as urinary catheterization.
B. Systemic Infection: Systemic infections affect the entire body and may not necessarily be related to the urinary tract.
C. Exogenous Infection: Exogenous infections originate from sources outside the client's body.
While the urinary tract infection could be caused by bacteria from the environment, it is more specifically categorized as a healthcare-associated infection (HAI) due to the indwelling urinary catheter being a risk factor.
D. Health Care-Associated Infection: A healthcare-associated infection (HAI) occurs as a result of healthcare interventions and can include infections related to urinary catheterization, surgery, or other medical procedures.
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