A nurse is providing care to a client who is immunocompromised.
Which of the following should the nurse identify as a possible source of infection?

The correct answer is choice D: "My partner will use condoms with spermicides.”

Choice A rationale:

"My partner and I will use petroleum jelly with latex condoms.” This statement is incorrect because petroleum jelly can degrade latex condoms, making them more likely to break. It’s important to use water-based or silicone-based lubricants with latex condoms to maintain their integrity and effectiveness.

Choice B rationale:

"My partner and I will both use a condom during intercourse.” Using two condoms at once, also known as ‘double-bagging’, is not recommended as it can increase the friction between the condoms and lead to breakage. Therefore, this statement does not indicate an understanding of proper condom use.

Choice C rationale:

"I will be able to remove my contraceptive sponge immediately after intercourse.” The contraceptive sponge should be left in place for at least 6 hours after intercourse to ensure effectiveness, but not more than 30 hours in total. Immediate removal does not provide the necessary time for the spermicide in the sponge to deactivate the sperm.

Choice D rationale:

"My partner will use condoms with spermicides.” This statement is correct. Condoms with spermicides provide an additional layer of contraceptive protection by combining the barrier method with a chemical that deactivates sperm. This indicates an understanding of the teaching on effective contraceptive practices.

The correct answer is Choice C.

Choice A rationale: Quoting client comments when documenting provides accurate and direct information. It ensures the client's exact words are recorded, which is important for clear communication among healthcare providers and for legal documentation.

Choice B rationale: Documenting medication administration should occur immediately after giving the dose, not prior. This ensures accuracy and prevents potential errors or omissions, maintaining the integrity and safety of the client's medical record.

Choice C rationale: Documenting information telephoned in by a nurse who left the unit ensures continuity of care. It accurately records details that may be critical to the client's treatment and care plan, ensuring that all healthcare providers have up-to-date information.

Choice D rationale: Limiting documentation to subjective information is not sufficient. Comprehensive documentation should include both subjective (client's statements) and objective (measurable data) information to provide a complete and accurate picture of the client's condition and care.