A nurse is assisting with the care of a client.

Exhibits

Complete the following sentence by using the list of options.

After notifying the provider, the nurse should first

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and then

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A. "Droplet precautions require that I wear a gown and gloves when providing client care." Droplet precautions require wearing a surgical mask when within three feet of the client, but gowns and gloves are only needed if direct contact with secretions is expected. Incorrect PPE use can lead to inadequate protection or unnecessary resource use. Understanding specific precaution types ensures proper infection control.
B. "Following a blood spill, I should use a bleach solution with a ratio of 1 to 20." Blood spills should be cleaned using a 1:10 bleach solution, not 1:20, to ensure effective decontamination. A stronger bleach concentration eliminates bloodborne pathogens like HIV and hepatitis B. The solution should be applied to the spill and left to sit before wiping. Using an incorrect dilution reduces disinfection effectiveness.
C. "Soiled dressings should be placed in a biohazard trash receptacle." Soiled dressings contain bodily fluids and potential pathogens, so they must be disposed of in a biohazard waste container. Regular trash does not provide adequate containment and increases the risk of contamination. Proper disposal protects healthcare workers and the environment from infection. Adhering to these protocols ensures compliance with infection control standards.
D. "For a client who has Clostridium difficile, I will cleanse my hands with an alcohol-based rub." Alcohol-based hand sanitizers are ineffective against Clostridium difficile spores, requiring handwashing with soap and water. The mechanical action of scrubbing is necessary to remove spores from the hands. Proper hand hygiene reduces transmission risks in healthcare settings. Infection control protocols emphasize soap and water for C. difficile prevention.

D. Place the client in high Fowler’s position. Positioning the client upright maximizes lung expansion and improves oxygenation. This is the first step to alleviate respiratory distress before additional interventions.

A. Administer oxygen to the client. Once the client is positioned appropriately, providing supplemental oxygen helps increase oxygen saturation and relieve hypoxia. The nurse should titrate oxygen as needed according to facility protocols or provider orders.

B. Notify the charge nurse. After immediate interventions are in place, the nurse should inform the charge nurse to ensure further assessment and necessary medical interventions. The charge nurse may escalate care or contact the provider for additional management.

C. Document client findings and interventions taken. Once the client’s condition has been addressed and reported, documentation is necessary to record assessment findings, interventions provided, and the client's response. Accurate documentation ensures continuity of care and legal protection.