A nurse manager is performing a quality improvement assessment to determine the source of a recurrence of Clostridium difficile on a unit. The nurse manager should identify that which of the following nursing actions is a possible source of infection?

Wearing gloves when performing perineal care

Failing to don a mask when entering a client's isolation room

Cleansing visibly fecal-soiled hands with alcohol-based hand rub

Putting on a protective gown before entering a client's room

Answer and Explanation

The Correct Answer is C

Cleansing visibly fecal-soiled hands with alcohol-based hand rub is a possible source of infection because alcohol-based hand rubs are not effective against Clostridium difficile spores. The nurse should wash his or her hands with soap and water for at least 15 seconds after contact with fecal material or surfaces contaminated with feces.

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Correct Answer is B

Explanation

The nurse should begin by testing the client while they are wearing glasses, as this reflects their usual visual acuity. The nurse should document the smallest line that the client can read on the chart, not the largest. The nurse should position the client 6m (20 feet) away from the chart, not 3.3m (10 feet). The nurse should instruct the client to begin the assessment with one eye covered and then switch to cover the other eye.

A. Use a separate, sterile swab for each stroke when cleaning the wound B. First clean the drain site and then clean the incision C. Cut a 4x4 piece of gauze to place around the drain site D. Don clean gloves before cleaning the wound.

Correct Answer is A

Explanation

The nurse should use a separate, sterile swab for each stroke when cleaning the wound to prevent cross-contamination and infection. The nurse should also clean from the least contaminated area (the incision) to the most contaminated area (the drain site). Cutting a 4x4 piece of gauze to place around the drain site may cause loose fibers to enter the wound and increase the risk of infection. The nurse should wear sterile gloves when cleaning the wound, not just clean gloves.

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A nurse manager is performing a quality improvement assessment to determine the source of a recurrence of Clostridium difficile on a unit. The nurse manager should identify that which of the following nursing actions is a possible source of infection?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing the visual acuity of a client who wears glasses using a Snellen chart. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is completing a dressing change on a client who has a surgical wound drain. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is caring for a client who is agitated and threatening to harm others. The nurse places the client in restraints, but does not notify the provider or obtain a prescription for the restraints. This situation represents which of the following torts?

A nurse is caring for a client who has restraints to each extremity. Which of the following assessments should the nurse perform first?

A nurse is caring for a client who has a chest tube following thoracic surgery. Which of the following tasks should the nurse delegate to assistive personnel?

A nurse is conducting the Weber's test on a client. Which of the following is an appropriate action for the nurse to take?

A nurse is providing preoperative teaching to a client over the phone in preparation for outpatient surgery. Which of the following information should the nurse include in the teaching?

A nurse is assessing an older adult client. Which of the following findings should the nurse expect?

A nurse is planning to provide discharge instructions to a client who does not speak the same language as the nurse. Which of the following actions should the nurse take?

A nurse is assessing a client who is receiving continuous IV fluids through a peripheral IV. Which of the following findings indicates to the nurse that the client is experiencing fluid overload?