A nurse working on a surgical unit is developing a care plan for a client who has paraplegia. The client has an area of nonblanchable erythema over his ischium. Which of the following interventions should the nurse include in the care plan?

Rationale:
A. "This medication can increase your risk for osteoporosis.": Long-term warfarin use may affect bone density slightly, but this is not the primary teaching point for safety and daily management. It is less immediately relevant than bleeding risk.

B. "This medication can cause hearing loss.": Warfarin is not associated with ototoxicity or hearing loss; this statement does not reflect a known adverse effect of the medication.

C. "Avoid drinking cranberry juice while taking this medication.": Cranberry products can interact with warfarin and increase the risk of bleeding by potentiating its anticoagulant effect. Clients should be advised to avoid or limit cranberry intake to maintain safe INR levels.

D. "Increase your intake of foods high in vitamin K while taking this medication.": Consuming consistent amounts of vitamin K is important, but the client does not need to increase intake. Sudden increases can counteract warfarin’s effect; the emphasis is on maintaining a stable vitamin K intake.

Rationale:
A. Wear a gown when providing care: A gown should always be worn when caring for a client with C. difficile to prevent contamination of the nurse’s clothing with infectious spores. This is part of contact precautions, which are essential to stop transmission via direct or indirect contact.

B. Wash hands with an alcohol-based cleaner: Alcohol-based sanitizers are ineffective against C. difficile spores. Handwashing with soap and water is required after client contact because mechanical friction is needed to remove spores from the skin.

C. Change gloves after contact with infectious material: Gloves must be changed immediately after contact with contaminated surfaces or body fluids to prevent cross-contamination.

D. Wear an N95 respirator when providing care: An N95 respirator is unnecessary for clients with C. difficile because the infection is transmitted by contact, not airborne routes. Standard and contact precautions are sufficient for infection control.

E. Remove the thermometer from the client's room for use on another client: Equipment used for a client with C. difficile should remain dedicated to that client. Sharing devices like thermometers risks spreading spores to other clients, so disposable or patient-specific equipment must be used.