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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. Allow the client's partner to translate: Family members should not serve as interpreters due to concerns about accuracy, confidentiality, and potential bias in sensitive health information.

B. Ask a nursing student who speaks the same language as the client to translate: Using untrained personnel, including students, is discouraged because they may lack professional interpreting skills and could miscommunicate critical health information.

C. Have the client's child translate: Children are not appropriate interpreters due to their limited language skills, emotional immaturity, and potential to misinterpret medical information.

D. Request a female interpreter through the facility: A professional medical interpreter ensures accurate, confidential communication, respects cultural and gender preferences, and is the safest approach for gathering admission data, particularly regarding sensitive postpartum issues.

A. Administer fluid bolus immediately when the client arrives to the facility. B. Administer one-third of the total fluid volume for resuscitation within the first 12 hr. C. Calculate fluid volume for resuscitation beginning with client arrival time at the facility. D. Use the total body surface area of the client's burns when calculating fluid volume for resuscitation.

Correct Answer is D

Explanation

A. Administer fluid bolus immediately when the client arrives to the facility: Rapid fluid boluses are reserved for clients in hypovolemic shock. For burn resuscitation, fluids are calculated and administered according to formulas rather than as a one-time bolus.

B. Administer one-third of the total fluid volume for resuscitation within the first 12 hr: Burn fluid resuscitation formulas, such as the Parkland formula, typically require half of the total calculated fluids to be given within the first 8 hours post-burn, not 12 hours.

C. Calculate fluid volume for resuscitation beginning with client arrival time at the facility: Fluid calculation is based on the time of the burn occurrence, not the arrival time, to ensure accurate resuscitation over the initial 24 hours.

D. Use the total body surface area of the client's burns when calculating fluid volume for resuscitation: The extent of burns, expressed as a percentage of total body surface area (TBSA), is a key factor in calculating fluid needs. Accurate TBSA assessment ensures appropriate fluid resuscitation to maintain perfusion and prevent complications.

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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?

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Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

A nurse in the emergency department is caring for a client who has major burns. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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