A nurse is caring for a client.
Which of the following actions should the nurse take? Select all 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,E
The correct answers are a. Wear a protective gown while caring for the client, b. Place the client in a private room, and e. Place a mask on the client when they leave their room.
Choice A rationale: Clostridium difficile (C. diff) is primarily spread through contact with feces, surfaces, or objects contaminated with the bacteria. Healthcare workers can inadvertently spread the bacteria to other patients if proper contact precautions are not followed. Wearing a protective gown while caring for a client with C. diff helps to prevent the spread of bacteria and maintain proper infection control measures.
Choice B rationale: Isolation precautions are recommended for clients with C. diff to prevent the spread of the bacteria to other patients. Placing the client in a private room can help to achieve isolation and minimize the risk of cross-transmission.
Choice C rationale (Incorrect choice): While wearing personal protective equipment (PPE) is crucial when caring for clients with infectious diseases, an N-95 respirator is not necessary for C. diff. The bacteria is not airborne, and its transmission primarily occurs through contact with contaminated surfaces or objects. Standard surgical masks are sufficient for healthcare workers when caring for clients with C. diff, as they can protect against droplet transmission.
Choice D rationale (Incorrect choice): A negative pressure room is not required for clients with C. diff, as the bacteria is not airborne. Negative pressure rooms are typically used for patients with airborne diseases, such as tuberculosis, to prevent the spread of infectious particles through the air.
Choice E rationale: If a client with C. diff needs to leave their room for any reason, placing a mask on the client can help minimize the risk of droplet transmission. This precautionary measure can reduce the potential spread of bacteria to other areas within the healthcare facility.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
The nurse should not inform the client of the need to pre-pay for the consent of authorization. Precertification for surgery is related to obtaining approval from the client's insurance provider and not about pre-payment.
Choice B rationale:
Contacting the client's insurance carrier to obtain authorization is the correct action to take when obtaining precertification for surgery. Many insurance companies require pre-authorization for surgical procedures to ensure coverage and to confirm that the procedure is medically necessary. This step is essential to prevent financial burdens on the client and ensure they have coverage for the surgery.
Choice C rationale:
Notifying the provider to obtain approval for the surgery is not the nurse's responsibility in the context of precertification. The primary responsibility lies with obtaining approval from the client's insurance carrier.
Choice D rationale:
Witnessing the client sign the surgical consent form is an essential step in the surgical preparation process but is not the same as obtaining precertification. Precertification involves confirming insurance coverage and approval for the surgery, which is the responsibility of the insurance carrier, not the client's consent.
Correct Answer is C
Explanation
Choice A rationale:
Serosanguineous drainage noted on the abdominal dressing is a common finding in the early postoperative period. It is a mixture of clear and bloody drainage and is often seen after surgery. This does not typically require immediate reporting unless it becomes excessive or changes significantly. The nurse can continue to monitor and assess the situation.
Choice B rationale:
Postoperative laboratory results of Hgb 15% and Hct 40% are within the normal range for most adults, and there is no immediate need to report these results to the provider. These values suggest that the client's hemoglobin and hematocrit levels are within an acceptable range, indicating adequate oxygen-carrying capacity.
Choice C rationale:
The client's urine output has been 50 mL since surgery, which is significantly decreased and could indicate a potential issue with renal function or fluid balance. This should be reported to the provider, as it may be indicative of kidney impairment, dehydration, or other postoperative complications.
Choice D rationale:
The client's pain level decreasing after the administration of morphine is an expected response to pain management interventions. There is no need to report this information to the provider unless the pain relief is inadequate or the client experiences adverse effects. Pain management is an essential part of postoperative care, and successful pain reduction is a positive outcome.
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