A nurse is planning care for a client who has manifestations of a Clostridium difficile (C. difficile) infection. Which of the following actions should the nurse plan to take?

Use an alcohol-based agent to perform hand hygiene when caring for the client.

Obtain a blood specimen to test for C. difficile.

Place the client on contact precautions.

Place a surgical mask on the client during transport.

Answer and Explanation

The Correct Answer is C

A. Alcohol-based hand sanitizers are not effective against C. difficile spores; hand hygiene should be performed using soap and water to effectively remove the spores.

B. Testing for C. difficile typically involves stool samples, not blood specimens, making this option inappropriate for confirming the infection.

C. Placing the client on contact precautions is essential to prevent the spread of C. difficile, as it is highly contagious and can be transmitted via surfaces and direct contact.

D. A surgical mask is not necessary for clients with C. difficile unless they have respiratory symptoms; the primary concern is preventing contact transmission.

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Correct Answer is A

Explanation

A. Using attentive listening with the client demonstrates the principle of presence by showing that the nurse is fully engaged and invested in the client's experience, fostering a collaborative relationship.

B. While focusing on the client’s present circumstances is important, the personal stories shared by clients can provide context and enhance understanding, so limiting this aspect is not ideal.

C. Offering personal thoughts and beliefs can shift the focus away from the client and is generally not appropriate in professional communication.

D. While verbalizing understanding is a supportive action, it does not fully encapsulate the principle of presence, which emphasizes active engagement and listening.

A. Determine the location of the pain. B. Reposition the client. C. Administer the medication. D. Review the effects of the pain medication.

Correct Answer is A

Explanation

A. Determining the location of the pain is the first step, as it helps the nurse understand the nature and source of the pain, guiding appropriate intervention and medication administration.

B. Repositioning the client may provide comfort but should follow an assessment of the pain to ensure targeted interventions.

C. Administering the medication without understanding the specifics of the pain is inappropriate, as it may not adequately address the client’s needs.

D. Reviewing the effects of the pain medication is important but should occur after assessing the pain to ensure the correct medication is administered based on the client’s specific situation.

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A nurse is planning care for a client who has manifestations of a Clostridium difficile (C. difficile) infection. Which of the following actions should the nurse plan to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is using the communication principle of presence when establishing a collaborative relationship with a client. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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