A nurse is caring for a client who has a stool culture that is positive for Clostridium difficile.
Which of the following infection control precautions should the nurse take?
Wear a face shield prior to entering the client's room.
Place a mask on the client prior to transport.
Use an alcohol-based hand rub following client care.
Remove the protective gown while in the client's room.
The Correct Answer is D
The correct answer is Choice D, remove the protective gown while in the client’s room.
Choice A rationale: Wearing a face shield is not specifically required for Clostridium difficile infection (CDI) precautions. CDI is primarily spread through the fecal-oral route, and while a face shield could provide protection against splashes during procedures that might generate them, it is not a standard precaution for entering the room of a patient with CDI.
Choice B rationale: Placing a mask on the client during transport is not a standard precaution for CDI. While it is important to prevent the spread of infection, CDI is not transmitted through the respiratory route, so a mask for the client would not be necessary in this context.
Choice C rationale: Using an alcohol-based hand rub is generally recommended for hand hygiene. However, for CDI, alcohol-based hand rubs are not effective against C. difficile spores. The Centers for Disease Control and Prevention (CDC) recommends washing hands with soap and water after caring for patients with CDI to physically remove the spores from the hands.
Choice D rationale: Removing the protective gown while still in the client’s room is the correct action to prevent the spread of contamination. Gowns should be removed before leaving the patient’s room to avoid dispersing contaminants to other areas of the healthcare facility.
Infection control for CDI involves several specific actions due to the resilience of C. difficile spores. These spores can survive on surfaces for a long time and are resistant to many common disinfectants, which is why environmental cleaning and disinfection with agents effective against C. difficile, such as bleach-based products, are crucial. Additionally, healthcare workers should use gloves and gowns when entering the rooms of patients with CDI and should ensure that these are disposed of correctly after use.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
"Uneven shoulder and pelvic heights." This is the correct answer. Uneven shoulder and pelvic heights, along with an asymmetrical appearance of the spine when viewed from the back, are clinical manifestations of scoliosis. Scoliosis is a sideways curvature of the spine that often develops during the growth spurt before puberty. Screening for scoliosis typically involves assessing the alignment of the spine and looking for these asymmetries.
Choice B rationale:
Exaggerated curvature of the sacrum is not a typical sign of scoliosis. Scoliosis primarily affects the upper back and can cause a side-to-side curvature of the spine, not the sacrum.
Choice C rationale:
Limited range-of-motion of the hips is not a specific indicator of scoliosis. Restricted hip movement might suggest other musculoskeletal issues but is not directly related to scoliosis.
Choice D rationale:
Mild pain in the hip region is not a characteristic symptom of scoliosis. While scoliosis can cause discomfort, it typically manifests as back pain, not specifically in the hip region. Pain symptoms can vary widely among individuals and might not be present in all cases of scoliosis.
Correct Answer is D
Explanation
Choice A rationale:
Managing conflict within the group is an important skill, but it is more appropriate for the working phase of group therapy. During the orientation phase, the focus is on establishing trust, setting group norms, and creating a safe environment. Conflict resolution skills become more relevant as the group progresses.
Choice B rationale:
Encouraging the use of problem-solving skills is essential in group therapy, but it is a skill that is developed during the working phase. During the orientation phase, the nurse focuses on building rapport, creating a comfortable atmosphere, and explaining the purpose and goals of the group.
Choice C rationale:
Maintaining the group's focus on identified issues is a crucial aspect of the orientation phase. The nurse should guide the discussion to ensure that participants understand the purpose of the group and stay on topic. This helps in establishing clear goals and expectations for the group sessions.
Choice D rationale:
Establishing a rapport with group members is a primary goal of the orientation phase. Building trust and a therapeutic relationship with the adolescents creates a supportive environment where they feel comfortable sharing their experiences and emotions. A strong rapport enhances the effectiveness of the support group.
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