A nurse is caring for a client.

Exhibits

A nurse is caring for the client. Which of the following actions should the nurse take? Select all that apply.

Wear a protective gown while caring for the client.

Place the client in a private room.

Wear an N-95 respirator while caring for the client.

Place the client in a negative pressure room.

Place a mask on the client when they leave their room.

Answer and Explanation

Correct Answer : A,B

A. Wear a protective gown while caring for the client: C. difficile is spread by contact with spores, so gowns must be worn to prevent contamination of clothing and transmission to other patients.

B. Place the client in a private room: A private room is necessary to prevent cross-contamination since C. difficile spores can survive on surfaces for long periods. Cohorting is an option only if private rooms are unavailable.

C. Wear an N-95 respirator while caring for the client: An N-95 respirator is not needed because C. difficile is not airborne. Standard surgical masks are not routinely required unless there is a risk of splashes.

D. Place the client in a negative pressure room: Negative pressure rooms are reserved for airborne pathogens like TB or measles. C. difficile requires contact precautions, not airborne isolation.

E. Place a mask on the client when they leave their room: Since C. difficile is transmitted via contact and does not spread through the air, a mask is not needed for the client when they leave their room for essential procedures.

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Correct Answer is B

Explanation

A. Washes their hands for 10 seconds: Hand hygiene requires scrubbing for at least 15 to 20 seconds to effectively remove microbes and debris. Ten seconds is insufficient to ensure proper cleansing and can increase the risk of pathogen transmission.

B. Holds their hands below the elbows while rinsing off soap: Holding the hands below the elbows allows water and soap to flow downward, preventing contaminated water from running back onto clean areas of the arms and hands.

C. Turns off the faucet with their hands: Turning off the faucet with bare hands can reintroduce microbes that were just washed off. The faucet should be turned off with a clean paper towel or elbow to maintain proper aseptic technique and prevent cross-contamination.

D. Uses hot water to wash their hands: Hot water can irritate or damage the skin, leading to dryness and cracks, which increase infection risk. Warm water is recommended because it is effective for lathering soap while protecting the integrity of the skin barrier.

A. Blood pressure B. Anxiety C. Oxygen saturation D. Breath sounds E. Irregular heart rate F. Chest tightness

Correct Answer is ["A","C","E","F"]

Explanation

A. Blood pressure: A significant drop from 118/76 mmHg to 88/56 mmHg indicates hypotension, which can compromise perfusion. This requires urgent follow-up because it may reflect cardiogenic shock or myocardial infarction complications.

B. Anxiety: Anxiety is a common response to chest pain and shortness of breath. While it should be acknowledged, it is not the priority compared to hemodynamic instability and hypoxemia.

C. Oxygen saturation: The drop from 98% to 88% on room air shows hypoxemia. This requires immediate follow-up, as low oxygen levels increase cardiac workload and worsen myocardial ischemia.

D. Breath sounds: Bilateral breath sounds remain clear and unchanged between assessments. This finding does not require follow-up since there is no evidence of pulmonary congestion or abnormal sounds.

E. Irregular heart rate: The shift from a regular rate of 78 bpm to an irregular, rapid rate of 128 bpm signals a new arrhythmia. This significantly impacts cardiac output and requires immediate follow-up.

F. Chest tightness: Chest pain radiating to the jaw and unrelieved by rest suggests unstable angina or myocardial infarction. This is a critical symptom requiring urgent evaluation and intervention.

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A nurse is caring for a client. Exhibits A nurse is caring for the client. Which of the following actions should the nurse take? Select all that apply.

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A nurse is caring for a client.

Exhibits

A nurse is caring for the client. Which of the following actions should the nurse take? Select all that apply.