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 D
Explanation
A. Anuria, or the absence of urine output, occurs in later stages of shock when there is significant renal hypoperfusion. It is not an early indicator of shock.
B. Hypotension is a classic sign of shock, but it generally occurs after compensatory mechanisms have failed. It is not the earliest indicator.
C. A decreased level of consciousness occurs later in the progression of shock due to decreased cerebral perfusion. It is not the earliest sign of shock.
D. Increased respiratory rate is often the earliest indicator of shock. As the body attempts to compensate for decreased oxygen delivery and tissue perfusion, the respiratory rate increases to enhance oxygenation and eliminate excess carbon dioxide. This compensatory mechanism is typically one of the first signs that shock is developing.
Correct Answer is C
Explanation
A. Pain-relieving medications may be appropriate for symptom management but do not address the need for diagnosis or treatment of gonorrhea exposure.
B. A basic metabolic panel (BMP) is not relevant to the diagnosis or management of gonorrhea. Testing for sexually transmitted infections (STIs) requires specific diagnostic tests.
C. Obtaining information about the client's recent sexual experiences is crucial for assessing risk factors, guiding testing, and determining appropriate treatment for gonorrhea.
D. A pelvic ultrasound is not typically the initial step in managing gonorrhea exposure. It might be used to assess complications but is not relevant for initial assessment or treatment.
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