A nurse is planning care for a client who has manifestations of a Clostridium difficile (C. difficile) infection. Which action should the nurse plan to take?

Place a surgical mask on the client during transport.

Use gown and gloves when entering the room.

Use an alcohol-based agent to perform hand hygiene when caring for the client.

Obtain a blood specimen to test for C. difficile.

Answer and Explanation

The Correct Answer is B

Choice A reason: Placing a surgical mask on the client during transport is not the primary precaution for C. difficile infections. C. difficile is primarily transmitted through contact with contaminated surfaces and not through respiratory droplets. Therefore, while masks may be used for other infections, they are not the main precaution for C. difficile.

Choice B reason: Using gown and gloves when entering the room is essential for preventing the spread of C. difficile. This infection is highly contagious and can be transmitted through contact with contaminated surfaces or feces. Gown and gloves provide a barrier that helps prevent the transmission of the bacteria to healthcare workers and other patients.

Choice C reason: Using an alcohol-based agent to perform hand hygiene is not effective against C. difficile spores. Hand washing with soap and water is recommended because it is more effective at removing the spores from the hands. Alcohol-based hand sanitizers do not kill C. difficile spores and should not be relied upon for hand hygiene in this context.

Choice D reason: Obtaining a blood specimen to test for C. difficile is not the standard diagnostic method. C. difficile infections are typically diagnosed through stool tests that detect the presence of the bacteria or its toxins. Blood tests are not used for diagnosing C. difficile infections.

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Correct Answer is A

Explanation

Choice A Reason:

Use good body mechanics is correct. Good body mechanics involve using the body in an efficient and careful way to prevent injury. This includes bending at the knees instead of the waist, keeping the back straight, and using the legs to lift heavy objects. Proper body mechanics reduce the strain on the back and joints, preventing injuries.

Choice B Reason:

Maintain proper posture is also important but is part of using good body mechanics. Proper posture involves keeping the spine in a neutral position, avoiding slouching, and ensuring that the head is aligned with the spine. This helps distribute weight evenly and reduces the risk of injury.

Choice C Reason:

Use assistive devices is correct. Assistive devices such as transfer boards, mechanical lifts, and gait belts can help reduce the physical strain on nurses when moving or lifting patients. These devices are designed to make tasks safer and easier, thereby minimizing the risk of back and joint injuries.

Choice D Reason:

Stay physically fit is also important. Physical fitness helps maintain muscle strength, flexibility, and endurance, which are crucial for performing physically demanding tasks. Regular exercise can help prevent injuries by improving overall body mechanics and reducing fatigue.

A. Position the collection device below the level of the chest. B. Clamp the tube when providing care activities. C. Apply an occlusive dressing over the chest tube site. D. Empty the chest tube collection chamber every shift.

Correct Answer is A

Explanation

Choice A reason: Positioning the collection device below the level of the chest is crucial to ensure proper drainage of air or fluid from the pleural space. This positioning uses gravity to facilitate drainage and prevent backflow into the pleural cavity, which could lead to complications such as pneumothorax or pleural effusion. The collection device should always be kept below the chest level to maintain effective drainage.

Choice B reason: Clamping the chest tube is generally not recommended unless specifically ordered by a physician or during certain procedures. Clamping can lead to a buildup of air or fluid in the pleural space, increasing the risk of tension pneumothorax. It is essential to keep the chest tube unclamped to allow continuous drainage and prevent complications.

Choice C reason: Applying an occlusive dressing over the chest tube site is necessary to prevent air from entering the pleural space and to secure the tube. However, this is not the primary action related to the positioning of the collection device. The occlusive dressing helps maintain the integrity of the chest tube insertion site and prevents infection.

Choice D reason: Emptying the chest tube collection chamber every shift is not a standard practice. The collection chamber should be monitored and emptied as needed based on the volume of drainage and the specific protocols of the healthcare facility. Regular monitoring is essential, but unnecessary emptying can disrupt the closed system and increase the risk of infection.

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A nurse is planning care for a client who has manifestations of a Clostridium difficile (C. difficile) infection. Which action should the nurse plan to take?

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