A nurse is caring for a client who has a new diagnosis of Clostridium difficile and is placed on contact precautions. Which of the following actions should the nurse take?
Use a portable electronic thermometer to take the client's temperature.
Wipe the stethoscope with alcohol after use.
Remove the protective gown before leaving the client's room.
Remove the protective gown before removing gloves.
The Correct Answer is C
A. Using a portable electronic thermometer is incorrect as the device must be dedicated to the client to avoid cross-contamination.
B. Wiping the stethoscope with alcohol after use is insufficient because alcohol-based sanitizers are ineffective against C. difficile spores. The stethoscope should be cleaned with bleach-based disinfectant.
C. Removing the protective gown before leaving the client's room is correct as it prevents the spread of C. difficile spores outside the isolation area.
D. Removing the protective gown before removing gloves is incorrect. Gloves should be removed first to prevent contamination when removing the gown.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Keeping a body map of skin lesions is a key strategy for monitoring changes in the skin over time. This helps individuals track any new or changing lesions, which is crucial for early detection of skin cancer.
B. Reducing tanning bed use is important because tanning beds are a significant risk factor for skin cancer. However, the instruction should emphasize complete avoidance rather than just reduction, as tanning beds dramatically increase the risk of melanoma.
C. Examining your body every 2 months is not frequent enough for effective skin cancer monitoring. Monthly self-examinations are generally recommended to catch potential changes early.
D. Avoiding the sun after 3 p.m. is incorrect; the most dangerous sun exposure typically occurs between 10 a.m. and 4 p.m. The instruction should advise avoiding the sun during peak hours or wearing protective clothing and sunscreen.
Correct Answer is B
Explanation
A. Assessing for upper extremity injuries is important, but it is not the highest priority in an unconscious client who is at risk for airway obstruction.
B. Suctioning saliva from the client's mouth is the highest priority because an unconscious client is at risk for airway obstruction due to the accumulation of saliva or other secretions. Maintaining a clear airway is essential to prevent aspiration and ensure adequate oxygenation.
C. Monitoring electrolyte levels is important in the overall management of a client with cerebral hemorrhage, but it is not the immediate priority compared to securing the airway.
D. Recording intake and output is necessary for fluid balance monitoring but is secondary to the immediate need to maintain a patent airway in an unconscious client.
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