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","B","E"]
Explanation
Choice A rationale:
Depression commonly coexists with eating disorders. Patients with eating disorders often experience profound sadness, hopelessness, and a distorted body image, leading to depressive symptoms. Addressing both conditions simultaneously is crucial for effective treatment.
Choice B rationale:
Obsessive-compulsive disorder (OCD) frequently accompanies eating disorders. Obsessive thoughts about body weight, shape, and food intake are common in individuals with eating disorders. These obsessions can lead to compulsive behaviors, such as strict dietary rules or excessive exercise, reinforcing the connection between eating disorders and OCD.
Choice C rationale:
Schizophrenia is not typically considered a comorbidity of eating disorders. Schizophrenia involves distorted thinking, hallucinations, and impaired emotional responses, which are distinct from the symptoms of eating disorders. While it's essential to assess patients comprehensively, schizophrenia is not a common comorbidity of eating disorders.
Choice D rationale:
Breathing-related sleep disorder is not a direct comorbidity of eating disorders. However, individuals with severe eating disorders, especially anorexia nervosa, may experience complications like sleep apnea due to extreme weight loss. While this is a potential issue, it is not a direct comorbidity of eating disorders for all patients.
Choice E rationale:
Anxiety often coexists with eating disorders. Anxiety about body weight, shape, and food intake is a significant concern for individuals with eating disorders. This anxiety can further perpetuate disordered eating behaviors, creating a cycle that is challenging to break without addressing the underlying anxiety.
Correct Answer is D
Explanation
The correct answer is choice d. Determine any physical signs of injury.
Choice A rationale:
Asking the client for permission to take photographs is important for forensic evidence, but it should not be the first action. The nurse must first ensure the client’s immediate physical well-being.
Choice B rationale:
Providing community sexual assault support contacts is crucial for the client’s long-term support and recovery, but it is not the immediate priority in an emergency assessment.
Choice C rationale:
Documenting the client’s verbatim statements is essential for legal and medical records, but it should follow the initial physical assessment to address any urgent medical needs.
Choice D rationale:
Determining any physical signs of injury is the first priority. This ensures that any immediate medical needs are addressed, which is critical for the client’s safety and well-being.
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