Exhibits

A nurse is reviewing the electronic medical record of a client who is at 29 weeks of gestation. Which of the following findings should the nurse report to the provider? (Click on the exhibit tabs for additional information about the client. There are three tabs that contain separate categories of data.)

Rationale:
A. The client takes multiple steps while holding the walker: Taking several steps while holding the walker increases the risk of imbalance and falls. The correct technique is to move the walker forward one step length, ensure all four legs are stable on the ground, and then take a single step toward it before moving the other leg.

B. The client lifts the walker as it is moved forward: The walker should be lifted slightly and placed firmly on the ground to ensure stability with each step. Sliding the walker instead of lifting it can cause uneven movement or tipping, especially on rough surfaces, making lifting the correct method.

C. The client advances the walker and takes a step towards it: This is the proper technique for safe use. The client should advance the walker first, then step forward with the weaker leg, followed by the stronger leg, maintaining balance and even weight distribution.

D. The client grasps the walker by the hand grips on the upper bars: Proper hand placement on the upper hand grips ensures stability and correct posture during ambulation. Holding the walker anywhere else can cause poor control, imbalance, or wrist strain.

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.