A nurse is assisting with the plan of care for a client. Which of the following activities should the nurse include in the implementation phase of the nursing process?

Establishing the priorities of client care

Reinforcing teaching about the client's diagnosis

Asking the client about the presence of pain

Comparing the client's current laboratory values to previous results

Answer and Explanation

The Correct Answer is B

A) Establishing the priorities of client care:

Establishing priorities of client care typically occurs during the planning phase of the nursing process, not during implementation. During the planning phase, the nurse identifies the most urgent client needs based on assessments and formulates a plan of action to address those needs.

B) Reinforcing teaching about the client's diagnosis:

Reinforcing teaching about the client's diagnosis is an appropriate activity during the implementation phase of the nursing process. Implementation involves carrying out the planned interventions, which may include educating the client about their diagnosis, treatment plan, and self-care strategies. Reinforcing teaching ensures that the client understands their condition and how to manage it effectively.

C) Asking the client about the presence of pain:

Assessing the client for pain is typically part of the assessment phase of the nursing process, not the implementation phase. During assessment, the nurse gathers data about the client's pain experience, including location, intensity, quality, and factors that alleviate or exacerbate pain.

D) Comparing the client's current laboratory values to previous results:

Comparing laboratory values is a component of data interpretation and analysis, which occurs primarily during the evaluation phase of the nursing process. While the nurse may review laboratory values during implementation to monitor the client's response to interventions, comparing current values to previous results is more closely associated with evaluating the effectiveness of care provided.

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Correct Answer is D

Explanation

A) Triclosan:

Triclosan is an antimicrobial agent commonly found in soaps, hand sanitizers, and other personal care products. While it has broad-spectrum antimicrobial properties, it is not specifically recommended for hand hygiene in the context of C. difficile infection. Alcohol-based antiseptic rubs are preferred due to their rapid and effective action against C. difficile spores.

B) Chlorhexidine gluconate:

Chlorhexidine gluconate is an antimicrobial agent commonly used as a surgical scrub and skin cleanser. While it is effective against a wide range of microorganisms, including bacteria and fungi, its efficacy against C. difficile spores is limited compared to alcohol-based antiseptic rubs. Therefore, it is not the preferred choice for hand hygiene in the context of C. difficile infection.

C) Alcohol-based antiseptic rub:

Hand hygiene is crucial in preventing the transmission of Clostridium difficile, a bacterium that can cause severe gastrointestinal infection. Alcohol-based antiseptic rubs are not highly effective against C. difficile spores. Thorough handwashing with soap and water has demonstrated superior antimicrobial activity compared to alcohol-based rubs and are preferred for hand hygiene in such situations.

D) Non-antimicrobial soap:

Clostridium difficile (C. difficile) is a bacterium that can cause severe gastrointestinal infection, and proper hand hygiene is essential in preventing its transmission. While alcohol-based antiseptic rubs are effective against many pathogens, including C. difficile, non-antimicrobial soap and water are preferred for hand hygiene after caring for a client with C. difficile. Non-antimicrobial soap helps to mechanically remove C. difficile spores from the hands, reducing the risk of transmission. Although alcohol-based rubs are convenient and effective in many situations, they may not be as effective as soap and water for removing spores and should be used in conjunction with thorough handwashing when caring for clients with C. difficile.

A. Send the client for the test with the unsigned form. B. Wake the client and ask them to sign the form. C. Obtain consent from a family member. D. Inform the charge nurse.

Correct Answer is D

Explanation

A) Send the client for the test with the unsigned form:

This option is not appropriate because performing an invasive procedure without obtaining informed consent from the client violates ethical and legal principles. Proceeding without proper consent could lead to legal and ethical repercussions, and it is not considered a safe or acceptable practice.

B) Wake the client and ask them to sign the form:

Waking the client who has received a sedative to obtain their signature on the consent form is not advisable. The client may still be under the influence of the sedative, which could impair their ability to understand the information provided and make an informed decision. Additionally, obtaining consent in this manner may not be legally valid and could compromise the client's autonomy and rights.

C) Obtain consent from a family member:

While obtaining consent from a family member might seem like a reasonable option, it is not appropriate in this scenario without clear documentation of the client's inability to provide consent. Consent for medical procedures should ideally be obtained directly from the competent adult client unless they are incapacitated or unable to make decisions. In this case, the client is asleep due to the sedative, but there is no indication that they are incapable of providing consent. Therefore, relying on a family member's consent without attempting to obtain it from the client first may not be ethically or legally justified.

D) Inform the charge nurse:

This is the most appropriate action to take initially. Informing the charge nurse allows for consultation and guidance on how to proceed in this situation. The charge nurse may advise on the appropriate steps to follow, such as contacting the provider or waiting for the client to regain consciousness to obtain informed consent. It ensures that the situation is addressed promptly and in accordance with institutional policies and ethical standards.

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A nurse is assisting with the plan of care for a client. Which of the following activities should the nurse include in the implementation phase of the nursing process?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is performing hand hygiene after caring for a client who has Clostridium difficile. Which of the following cleansing agents should the nurse use?

Correct Answer is D

Explanation

A nurse is caring for a client who has a prescription for an invasive procedure that requires consent. When the nurse arrives at the bedside to obtain the client's signature they find that the client is asleep after receiving a sedative. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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