A nurse is teaching a group of newly licensed nurses about caring for a client who has a Clostridium difficile infection. Which of the following Instructions should the nurse include in the teaching?
Wear a gown while providing personal hygiene.
Place the client in a room with negative airflow,
Apply a mask when providing care.
Wipe the stethoscope with alcohol after leaving the client's room.
The Correct Answer is A
Rationale:
A. Wear a gown while providing personal hygiene: Contact precautions are required for clients with Clostridium difficile to prevent transmission via contaminated surfaces or direct contact. Wearing a gown during personal care protects the nurse’s clothing and skin from spores.
B. Place the client in a room with negative airflow: Negative airflow rooms are required for airborne infections such as tuberculosis or measles. C. difficile is spread via the fecal–oral route and does not require airborne isolation measures.
C. Apply a mask when providing care: Masks are necessary for droplet or airborne pathogens, but C. difficile spores are transmitted through direct or indirect contact, not respiratory droplets, so masks are not routinely required unless there is another indication.
D. Wipe the stethoscope with alcohol after leaving the client's room: C. difficile spores are resistant to alcohol-based disinfectants. Cleaning equipment requires soap and water or a sporicidal disinfectant to effectively remove spores and prevent spread.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "A living will is a document that includes my wishes about health care decisions.": A living will is an advance directive that specifies a client’s preferences for medical treatment in situations where they are unable to communicate.
B. "My partner needs to be present as a witness when I sign a living will.": Witness requirements vary by state, and typically a neutral adult, not necessarily a partner, must witness the signing.
C. "My provider will make my health care decisions if I complete advance directives.": Advance directives are intended to communicate the client’s own wishes, not delegate decision-making solely to the provider. The provider’s role is to follow the client’s documented preferences.
D. "Advance directives outline who inherits my material possessions in the event of my death.": Inheritance is addressed in a will, not advance directives. Advance directives focus exclusively on medical and end-of-life care decisions.
Correct Answer is C
Explanation
Rationale:
A. A blister-like area: Blistering is not the expected reaction used to interpret a Mantoux test. The result is based on the presence and size of induration, not the formation of blisters.
B. A cool, blanched area: Coolness and blanching are not indicators of a positive test. These findings may reflect poor circulation or local skin reaction unrelated to tuberculosis screening.
C. An elevated, hardened area: Induration (elevated, firm area) at the injection site, measured in millimeters, is the basis for determining a positive result. The size threshold for positivity depends on the client’s risk factors for tuberculosis.
D. An area of ecchymosis: Bruising at the site is a local skin reaction that can occur after any injection and is unrelated to the diagnostic criteria for a positive Mantoux test.
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