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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Naxlex Comprehensive Predictor Exams
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 B
Explanation
A. Administer medication for high blood pressure: Administering medication generally requires a physician's order and is not considered an independent nursing action.
B. Reposition the client every 2 hours: This intervention is within the nurse’s scope of practice and does not require a physician’s order. It is an independent action that helps prevent complications like pressure ulcers.
C. Starting IV antibiotics: This action requires a physician's order and is a dependent nursing intervention.
D. Administering medication for pain: Administering medication requires a physician’s order and is not considered an independent nursing action.
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