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Provide a room with negative-pressure airflow: While negative-pressure rooms may be used for clients with certain airborne infections to prevent the spread of pathogens, it is not typically necessary for clients with C. difficile infection. Standard precautions, including meticulous hand hygiene and appropriate environmental cleaning, are the primary measures for preventing transmission.

Wear an N95 respirator when caring for the client: N95 respirators are recommended for healthcare workers caring for clients with airborne infections such as tuberculosis or certain respiratory viruses. C. difficile is transmitted primarily through contact with contaminated surfaces or feces, so standard precautions, including gloves and gowns, are sufficient for preventing transmission.

Disinfect hands using an alcohol-based waterless antiseptic: While alcohol-based hand sanitizers are effective against many types of bacteria and viruses, they may not be sufficient for eliminating C. difficile spores. Handwashing with soap and water is preferred for removing C. difficile spores from hands.

Turn off electrical equipment in the client's room: While turning off electrical equipment can help prevent the spread of fire if the source is electrical, it may not be the most immediate action to take after removing the client from the room. The priority is to activate the alarm to alert others and initiate the fire response protocol.

Use a Class A fire extinguisher to contain the fire: Using a fire extinguisher is a potential action, but the type of fire extinguisher needed depends on the type of fire. Class A fire extinguishers are suitable for ordinary combustibles such as wood and paper. However, since the source of the fire is a trash can, the fire may involve combustible materials beyond Class A. Therefore, activating the alarm takes precedence over extinguishing the fire.

Close the door to the client's room: Closing the door can help contain the fire and prevent its spread to other areas. While this action is important, it is secondary to activating the alarm, which alerts others to the fire and initiates the response process.

A) "Why have you decided not to have the procedure?"
This response can come across as confrontational and might make the client feel defensive or pressured to justify their decision, which is not conducive to a therapeutic conversation.

B) "Don't worry. You will adjust to the colostomy quickly."
This statement dismisses the client's current feelings and concerns. Telling the client not to worry minimizes their emotional experience and may make them feel misunderstood or invalidated.

D) "Do you think that's the right decision for you and your family?"
This response introduces external pressure by involving the family and shifts the focus away from the client’s personal feelings and autonomy, which could increase their anxiety about making a decision.

Tying the restraint to the bed frame: This action is appropriate and ensures that the restraint is anchored securely to the bed frame, preventing the client from removing it independently. Tying the restraint to the bed frame is a standard practice to maintain the client's safety.

Applying the restraint over the client's gown: While it's generally preferable to apply restraints directly to the client's skin to minimize movement and ensure effectiveness, applying the restraint over the gown is acceptable in some situations. However, it's essential to ensure that the restraint is snug and properly secured to prevent the client from slipping out of it.

Using a quick-release knot to secure the restraint: Using a quick-release knot is essential when applying restraints to ensure that they can be quickly removed in case of an emergency or if the client experiences distress. This promotes client safety and allows for rapid intervention if needed.

Reinforce teaching about the client's prescribed medications: While medication education is important for overall health management, it is not the priority in this situation. The client's immediate need is assistance with ADLs to address functional deficits resulting from the cerebrovascular accident.

Provide the client with a list of community resources: Community resources may be beneficial for the client's long-term care and support, but addressing the immediate need for assistance with ADLs takes precedence. Referring the client to occupational therapy will address the functional limitations more directly and effectively.

Encourage the client to discuss nutritional needs with a dietitian: Nutritional needs are important for overall health and recovery, but addressing the client's physical limitations and ADLs is the priority at this time. Once the client's ability to perform ADLs improves, discussions about nutrition can follow as part of a comprehensive care plan.

"I will attempt to extinguish the fire before calling the fire department.": This statement indicates a misunderstanding of fire safety principles. It's crucial for individuals to prioritize their safety and evacuate the premises immediately in the event of a fire. Attempting to extinguish the fire before calling the fire department can waste valuable time and put the individual at risk.

"I should change the batteries in my smoke alarms every 2 years.": While changing smoke alarm batteries regularly is essential for ensuring they function properly, the recommended interval for battery replacement is typically every 6 months, not every 2 years. This statement reflects a misunderstanding of the recommended maintenance schedule for smoke alarms.

"I will use a Class A extinguisher for an electrical fire.": Using a Class A extinguisher for an electrical fire is not recommended because water-based extinguishers, typically classified as Class A, can conduct electricity and pose a risk of electrical shock to the individual using them. It is safer to use a Class C extinguisher, which is specifically designed for electrical fires and contains non-conductive extinguishing agents.

SQ: While SQ could stand for subcutaneous (as in SQ injection), it's generally recommended to use the full term "subcutaneous" in documentation to avoid confusion or misinterpretation. Using abbreviations like SQ can lead to errors or miscommunication in healthcare settings.

AU: This abbreviation typically stands for "each ear" when documenting information related to the ears, such as when administering eardrops or assessing for symptoms. However, similar to SQ, it's preferable to use the full term "each ear" in documentation to ensure clarity and avoid ambiguity.

HS: HS commonly stands for "hour of sleep" or "at bedtime" when documenting medication administration times. However, like other abbreviations, it's advisable to use the full term "at bedtime" to prevent misunderstandings or errors related to medication dosing schedules.

Determine which clients need priority medical treatment: This task requires clinical judgment and assessment skills beyond the scope of practice for assistive personnel. Nurses are responsible for assessing clients' needs during emergencies and determining priority for medical treatment based on the severity of their conditions.

Answer questions from area residents who have health concerns: While it's important to provide information and support to those affected by the tornado, answering questions about health concerns requires knowledge and expertise in healthcare that is typically within the nurse's scope of practice. Nurses should address inquiries and provide education to ensure the well-being of the community.

Complete distal capillary refill checks for a client who has an open leg wound: While assessing capillary refill is an important aspect of wound care, performing this task for a client with an open leg wound requires specialized knowledge and skills in wound assessment and management. It falls within the scope of nursing practice and should not be delegated to assistive personnel.

Asking a staff member from another unit to complete the evaluation: While involving someone from another unit may offer an external perspective, it may not necessarily ensure impartiality. The evaluator should have direct knowledge of the nurse's performance to provide a fair assessment.

Focusing primarily on areas that need improvement: This approach may lead to a biased evaluation, as it overlooks the nurse's strengths and positive contributions. A comprehensive evaluation should consider both areas of strength and areas needing improvement to provide a balanced assessment.

Discussing the evaluation with the nurse manager: Consulting with the nurse manager about the evaluation could introduce bias, especially if the manager has preconceived notions about the nurse being evaluated. Peer evaluations should aim to be independent of managerial influence to maintain impartiality.

Incorporate the process change into daily practice within the facility: While incorporating process changes is an essential step in quality improvement, it should not be the first action taken. Before implementing changes, it is crucial to gather data and identify areas for improvement to ensure that interventions are targeted and effective.

Determine if the implemented change has lowered the current infection rate: Assessing the effectiveness of interventions is an important aspect of quality improvement, but it should occur after identifying baseline data and implementing interventions. Without baseline data, it is challenging to determine the impact of changes accurately.

Select a potential intervention to lower the current infection rate: While selecting interventions is a necessary step in quality improvement, it should follow the identification of current infection rates and areas for improvement. Without data on current infection rates, it is difficult to select appropriate interventions.