A nurse is initiating bladder retraining for a client who has urge urinary incontinence. Which of the following instructions should the nurse give the client?

Rationale:

A. Change gloves after contact with infectious material: Gloves must be changed after contact with infectious material to prevent cross-contamination. C. difficile spores can survive on surfaces and be transferred if gloves are not properly changed between tasks or patients.

B. Wear an N95 respirator when providing care: An N95 respirator is not required for C. difficile, as it is transmitted via the fecal-oral route through spores, not by airborne particles. Standard and contact precautions not airborne are appropriate for this infection.

C. Wear a gown when providing care: Wearing a gown is essential when caring for a client with C. difficile, as the spores can contaminate clothing and surfaces. Contact precautions require both gloves and gowns for direct care.

D. Remove the thermometer from client's room for use on another client: Equipment used for a client with C. difficile should remain dedicated to that client to prevent environmental contamination. Sharing items between patients increases the risk of spreading spores.

E. Wash hands with an alcohol-based cleaner: Alcohol-based hand sanitizers are ineffective against C. difficile spores. Hands should be washed with soap and water, which is the only effective method for removing these resilient organisms.

Rationale:

A. Encourage the client to attend a group therapy session: This action does not immediately address the restraint status. The client’s calm and cooperative behavior should prompt reassessment of restraint necessity before introducing other interventions.

B. Continue to monitor the client every 15 min: Ongoing monitoring is important but it is not the priority once the client has de-escalated. If the behavior no longer warrants restraints, the nurse should act promptly to remove them to preserve the client’s rights and dignity.

C. Remove the restraints from the client: Restraints should be discontinued as soon as the client demonstrates self-control and no longer poses a risk to themselves or others. Keeping restraints on unnecessarily can lead to psychological harm, reduced mobility, and legal/ethical violations.

D. Offer the client PRN pain medication: Offering pain medication assumes the client is experiencing discomfort, but there is no indication of pain in the scenario. Medication is not the priority when behavioral signs point to de-escalation and restraint removal is warranted.