A nurse is caring for a client who has a new diagnosis of Clostridium difficile and is placed on contact precautions. Which of the following actions should the nurse take?
Use a portable electronic thermometer to take the client's temperature.
Wipe the stethoscope with alcohol after use.
Remove the protective gown before leaving the client's room.
Remove the protective gown before removing gloves.
The Correct Answer is C
A. Using a portable electronic thermometer is incorrect as the device must be dedicated to the client to avoid cross-contamination.
B. Wiping the stethoscope with alcohol after use is insufficient because alcohol-based sanitizers are ineffective against C. difficile spores. The stethoscope should be cleaned with bleach-based disinfectant.
C. Removing the protective gown before leaving the client's room is correct as it prevents the spread of C. difficile spores outside the isolation area.
D. Removing the protective gown before removing gloves is incorrect. Gloves should be removed first to prevent contamination when removing the gown.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Difficulty swallowing in a client with facial burns can indicate airway compromise due to edema and should be reported immediately as it may require urgent intervention to secure the airway.
B. While pain is a significant concern and should be managed, it is not as immediately life-threatening as potential airway obstruction.
C. A respiratory rate of 24 breaths per minute is elevated but within the range of mild tachypnea, which could be due to pain or anxiety, and is not the most urgent finding.
D. Urinary output of 25 mL/hr is below normal and indicates possible hypovolemia or kidney injury, but airway concerns take precedence in this scenario.
Correct Answer is A
Explanation
A. The statement about keeping the temperature cold to avoid becoming overheated requires further teaching. While avoiding excessive heat is important for individuals with SLE, maintaining an overly cold environment can also trigger symptoms, as cold temperatures can lead to vasoconstriction and Raynaud's phenomenon, which is common in SLE patients.
B. Following the prescribed medication regimen and informing the healthcare provider of any side effects is an essential component of managing SLE. This indicates that the client understands the importance of medication adherence in controlling the disease.
C. Managing stress through relaxation techniques and therapy is appropriate, as stress is a known exacerbating factor for SLE. This statement reflects the client's understanding of the need to reduce stress to prevent flare-ups.
D. Wearing protective clothing when going outside is important because UV light exposure can trigger SLE exacerbations. This shows that the client is aware of the need to protect their skin from sunlight.
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