nurse is caring for a client who has Clostridium difficile (C. difficile). Which of the following actions should the nurse take?
Clean hands with soap and water after caring for the client
Place the client in a room with negative pressure airflow
Wash hands for 10 seconds after caring for the client
Apply a mask on the client when they are outside their room
The Correct Answer is A
A. Clean hands with soap and water after caring for the client: C. difficile spores are resistant to alcohol-based hand sanitizers. Therefore, it is essential to use soap and water to effectively remove the spores from hands.
B. Place the client in a room with negative pressure airflow: C. difficile is not an airborne infection, so negative pressure airflow is not required. This measure is typically used for infections such as tuberculosis.
C. Wash hands for 10 seconds after caring for the client: Handwashing with soap and water should be done for at least 20 seconds to effectively remove C. difficile spores.
D. Apply a mask on the client when they are outside their room: A mask is not necessary for clients with C. difficile, as the infection is not transmitted through respiratory droplets but rather through fecal-oral transmission.
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Related Questions
Correct Answer is D
Explanation
A. Provide written educational material for the client: While important, this action is not the first step as it assumes the client is ready to receive and understand the information.
B. Ask the client to demonstrate checking their blood sugar: This is a practical step but should come after assessing the client’s readiness to learn and understanding their current knowledge.
C. Identify short-term goals for the client: Goal-setting is crucial but should follow an assessment of the client's readiness to learn to ensure that goals are realistic and tailored to their current level of understanding.
D. Determine the client's readiness to learn: This is the first step in the teaching process as it helps tailor the teaching plan to the client's current state of mind, comprehension level, and willingness to engage with the educational material.
Correct Answer is ["A","C","E"]
Explanation
A. Placing a high risk for falls armband on the patient: An armband alerts all healthcare providers to the patient's fall risk, helping to ensure appropriate precautions are taken.
B. Checking on the patient once a shift: This is not sufficient; patients on fall precautions should be checked more frequently, such as every hour or according to the facility's protocol, to ensure their safety.
C. Keep the bed in the lowest position: Keeping the bed at its lowest position reduces the risk of injury from falls and helps ensure the patient can easily get in and out of bed.
D. Placing all four side rails in the "up" position: Using all four side rails is not recommended as it can increase the risk of entrapment and may not be effective in preventing falls. Side rails should be used appropriately and in accordance with safety protocols.
E. Maintain call light within reach of the patient: Ensuring the call light is within reach helps the patient call for assistance if needed, which can help prevent falls.
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