A charge nurse is evaluating the implementation of infection control measures by unit nurses when caring for clients who have Clostridium difficile. The charge nurse should intervene for which of the following actions by a unit nurse?
Uses alcohol-based hand sanitizer after removing gloves
Wears goggles when emptying the bedpan of liquid stool
Places the client in contact precautions
Cleans contaminated equipment with bleach-based solution
The Correct Answer is A
Choice A reason: This is an incorrect action by the unit nurse. Alcohol-based hand sanitizer is not effective against Clostridium difficile spores, which can cause severe diarrhea and colitis. The nurse should wash their hands with soap and water after removing gloves to prevent the spread of the infection.
Choice B reason: This is a correct action by the unit nurse. Wearing goggles when emptying the bedpan of liquid stool is a standard precaution that protects the nurse's eyes from exposure to body fluids. The nurse should also wear gloves and a gown when handling the bedpan.
Choice C reason: This is a correct action by the unit nurse. Placing the client in contact precautions is an appropriate measure for clients who have Clostridium difficile. Contact precautions prevent direct or indirect transmission of the infection through contact with the client or the client's environment. The nurse should use a single room or cohort the client with another client who has the same infection.
Choice D reason: This is a correct action by the unit nurse. Cleaning contaminated equipment with bleach-based solution is an effective way to kill Clostridium difficile spores, which can survive on surfaces for a long time. The nurse should follow the manufacturer's instructions for the dilution and contact time of the bleach solution.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: This is not the correct choice because this action is not the nurse's responsibility. Coordinating the team and the plan of care is the role of the case manager or the social worker, who can facilitate communication and collaboration among the different disciplines involved in the client's care.
Choice B reason: This is not the correct choice because this action is not the nurse's responsibility. Ordering durable medical equipment for the client's home is the role of the occupational therapist or the physical therapist, who can assess the client's functional needs and abilities and recommend the appropriate devices.
Choice C reason: This is not the correct choice because this action is not the nurse's responsibility. Helping the client obtain financial assistance is the role of the social worker or the financial counselor, who can identify the client's eligibility and options for funding and insurance coverage.
Choice D reason: This is the correct choice because this action is the nurse's responsibility. Performing a dietary assessment is part of the nursing process and the scope of practice of the nurse, who can evaluate the client's nutritional status and needs and provide education and counseling on diet modifications and interventions.
Correct Answer is B
Explanation
The correct answer is: B.
Choice A reason:
Suctioning a client's long-term tracheostomy is a complex procedure that involves sterile technique and assessment skills that are beyond the scope of assistive personnel's practice. It requires clinical judgment and the ability to respond to complications, which are responsibilities typically reserved for licensed nursing staff.
Choice B reason:
Using a pain rating scale to monitor a client's pain level is a task that can be delegated to assistive personnel. It involves asking the client to rate their pain on a scale, which does not require clinical judgment or advanced skills. The assistive personnel can then report the pain level to the nurse, who will make decisions regarding pain management.
Choice C reason:
Performing a dressing change on a client's peripherally inserted central catheter (PICC) is not within the scope of assistive personnel. This task requires aseptic technique and knowledge of PICC line management to prevent infection and other complications, which are typically the responsibility of the registered nurse or licensed practical nurse.
Choice D reason:
Instructing a client on self-administration of a tap water enema involves teaching and assessment to ensure the client understands and can perform the procedure safely. This is a task that requires licensed nursing knowledge and skills to educate the client and evaluate their competency.
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