A nurse is providing teaching to a client who has long-term symptoms of GERD (gastroesophageal reflux disease). Which of the following statements should the nurse include in the educational materials?

Choice A Reason:

Removing the protective gown before removing gloves is incorrect. The correct procedure is to remove gloves first, followed by the gown, to prevent contamination from the gown to the hands.

Choice B Reason:

Using an electronic thermometer is not recommended for clients with Clostridium difficile. Disposable thermometers or dedicated equipment should be used to prevent cross-contamination.

Choice C Reason:

This is the correct answer. The protective gown should be removed before leaving the client’s room to prevent the spread of Clostridium difficile spores to other areas of the healthcare facility. Proper removal and disposal of PPE are crucial in infection control.

Choice D Reason:

Shaking bed linens is incorrect as it can aerosolize Clostridium difficile spores, increasing the risk of spreading the infection. Linens should be carefully handled and placed in a linen bag without shaking.

Choice A Reason: Superficial palpation

Superficial palpation is typically performed after auscultation to avoid altering bowel sounds. It involves gently pressing on the abdomen to detect tenderness, masses, or other abnormalities. This step helps in identifying areas that may require deeper examination.

Choice B Reason: Auscultation

Auscultation is performed after inspection and before palpation to listen to bowel sounds without interference. Using a stethoscope, the nurse listens for the presence, frequency, and character of bowel sounds. This step is crucial as palpation can stimulate bowel activity, potentially leading to inaccurate findings.

Choice C Reason: Inspection

Inspection is the first step in an abdominal assessment. The nurse visually examines the abdomen for any abnormalities such as distension, scars, or discoloration. This step provides initial information about the child’s abdominal health and helps guide the subsequent steps of the assessment.

Choice D Reason: Deep palpation

Deep palpation is performed last to assess the deeper structures of the abdomen. This step involves applying more pressure to feel for masses, organ size, and tenderness. It is important to perform this step last to avoid causing discomfort or altering the findings of the other assessment steps.