67. The practical nurse (PN) assigns an unlicensed assistive personnel (UAP) to bathe a client who is on contact precautions due to Clostridium difficile. To maintain contact precautions, the PN should instruct the UAP to perform the following actions in which sequence? Arrange from first action on top to last on the bottom.
Put on disposable gown.
Remove gloves and gown in room.
Repeat standard hand washing.
Perform standard hand washing.
Don a pair of procedure gloves.
The Correct Answer is D,A,E,B,C
A. Put on disposable gown: Wearing a gown before providing care creates a barrier between the caregiver’s clothing and potential contamination from the client or environment.
B. Remove gloves and gown in room: PPE must be removed in the client’s room to prevent spreading C. difficile spores to other areas. Gloves are removed first, followed by the gown, to minimize contamination.
C. Repeat standard hand washing: Hand hygiene is performed after all PPE is removed to eliminate any pathogens that may have contacted the hands during care, ensuring safety and compliance with infection control.
D. Perform standard hand washing: Washing hands before putting on PPE removes transient microorganisms and reduces the risk of introducing pathogens to the client during care.
E. Don a pair of procedure gloves: Gloves are applied after the gown to protect the hands during direct contact with the client or contaminated surfaces, completing the PPE setup before providing care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Infection: Infection is a common complication of sickle cell disease due to functional asplenia, but it is not the hallmark symptom experienced during an acute sickle cell crisis.
B. Joint pain: Pain, especially in joints, bones, and extremities, is the most frequent and prominent symptom during a sickle cell crisis. It results from vaso-occlusion causing ischemia and tissue injury, making pain management a primary focus of care.
C. Fatigue: Fatigue is common in chronic anemia associated with sickle cell disease but is usually a baseline symptom rather than an acute manifestation of a crisis.
D. Decreased hemoglobin: Hemoglobin levels may decrease during a crisis due to hemolysis, but the child may not directly perceive this; the most noticeable symptom reported is pain.
Correct Answer is C
Explanation
A. Which medication works best?: While understanding medication effectiveness is important for ongoing management, it does not provide immediate insight into the content or risk associated with the hallucinations. Assessment of current hallucinations takes priority.
B. When are the voices most disturbing?: Identifying patterns of symptom severity can help plan interventions, but it does not reveal the content or potential danger of the hallucinations, which is critical for safety assessment.
C. What are the voices uttering?: Determining what the voices are saying is essential to assess the risk of harm to self or others. The content can indicate commands, threats, or distressing messages, guiding immediate safety interventions and care planning.
D. How does the client cope with the voices?: Understanding coping strategies is valuable for long-term care and therapeutic support, but it is secondary to assessing the immediate content and potential danger of the hallucinations.
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