A nurse is planning care for a client who has Clostridium difficile gastroenteritis. Which of the following is an appropriate nursing action?
Place the client in a protective environment.
Clean surfaces with chlorhexidine.
Wash hands with alcohol-based hand rub.
Obtain a stool specimen with gloves.
The Correct Answer is A
Clostridium difficile is a spore-forming bacteria that can cause severe diarrhea and other gastrointestinal symptoms. It's highly contagious and can easily spread to other patients. Alcohol-based hand rubs are not effective against spores and should not be used for hand hygiene in this case. Chlorhexidine is also not sporicidal and should not be used for environmental cleaning. A protective environment is indicated for clients who are at risk of infection from others, not for clients who are infectious to others. Gloves are important for preventing the spread of infection, but they should be used in conjunction with other infection control measures, such as handwashing and protective isolation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
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Correct Answer is D
Explanation
Lymphedema is a contraindication to acupuncture because it increases the risk of infection and worsens the swelling. Acupuncture should not be performed on an oedematous limb at risk of lymphoedema.
The other options are not contraindications to acupuncture.
Correct Answer is D
Explanation
The nurse should instruct the client to trim toenails straight across to prevent ingrown toenails and infection. The nurse should also advise the client to inspect the feet daily for any signs of injury or ulceration, to avoid applying lotion between the toes as this can cause maceration and fungal growth, and to avoid soaking the feet as this can dry out the skin and increase the risk of injury.
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