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 B
Explanation
Choice A reason: A client who has gestational diabetes and is receiving biweekly nonstress tests is incorrect. Gestational diabetes requires monitoring of maternal blood glucose levels and fetal well-being. Nonstress tests are a common method of assessing fetal well-being in pregnancies complicated by conditions such as gestational diabetes. Nurses caring for clients with gestational diabetes need to understand the management of blood glucose levels, dietary considerations, insulin administration if needed, and fetal monitoring techniques. This requires obstetrical-specific knowledge and expertise.
Choice B reason: A primigravida client who is 1 day postoperative following a Cesarean section and has a PCA pump is correct. This client is postoperative following a Cesarean section and is likely in need of pain management through a PCA pump. Postoperative care after a Cesarean section involves monitoring for signs of complications such as infection, bleeding, and wound healing, as well as managing pain effectively. While nurses with medical-surgical experience may be familiar with PCA pumps, the postoperative care of a cesarean section client involves obstetrical-specific considerations such as uterine monitoring, assessment of lochia (vaginal discharge after childbirth), and breastfeeding support.
Choice C reason: A client who is at 32 weeks of gestation and has premature rupture of membranes is not an appropriate assignment for the RN who has floated from a medical-surgical unit, as it involves a high-risk pregnancy that needs close monitoring and intervention to prevent preterm labor and infection. The charge nurse should assign this client to an RN who is competent in the obstetrical unit.
Choice D reason: A multigravida client who has preeclampsia and is receiving misoprostol for induction of labor is not an appropriate assignment for the RN who has floated from a medical-surgical unit, as it involves a complex and potentially life-threatening condition that requires frequent assessment and intervention to prevent eclampsia, hemorrhage, and fetal distress. The charge nurse should assign this client to an RN who is proficient in the obstetrical unit.
Correct Answer is A
Explanation
Choice A reason: This is the correct choice because a social worker can help the parent with financial assistance, insurance coverage, or other resources to obtain the nebulizer and the medication for the child. A social worker can also provide emotional support and education to the parent and the child about asthma management.
Choice B reason: This is not the correct choice because a pharmacist can only provide information about the medication, such as the dosage, side effects, and interactions. A pharmacist cannot help the parent with the cost of the nebulizer or the medication.
Choice C reason: This is not the correct choice because child protective services is not a referral that the nurse should recommend in this situation. The parent is not neglecting or abusing the child, but rather expressing a concern about the affordability of the nebulizer. Reporting the parent to child protective services could cause more harm than good to the parent-child relationship and the child's well-being.
Choice D reason: This is not the correct choice because a respiratory therapist can only provide technical assistance and education on how to use the nebulizer and the medication. A respiratory therapist cannot help the parent with the cost of the nebulizer or the medication.
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