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 B
Explanation
B. Assessing the client's activated partial thromboplastin time (aPTT) is important to monitor the effectiveness of treatment and manage bleeding risk. Hemophilia A is characterized by a deficiency in clotting factor VIII, which prolongs the aPTT.
A. Applying heated compresses is not recommended for hemarthrosis; instead, cold compresses should be used to reduce bleeding and swelling.
C. Low-dose aspirin is contraindicated for clients with hemophilia because it can further inhibit platelet function and increase bleeding risk.
D. Autologous blood transfusion is not typically required for hemophilia; factor replacement therapy is the standard treatment.
Correct Answer is A
Explanation
A. A client with extreme muscle weakness on the affected side should use a cane or other assistive devices to aid in mobility and ensure safety. This intervention helps the client maintain stability and prevent falls.
B. The client with muscle weakness should use the unaffected hand for daily activities to ensure safety and improve functional outcomes. Using the affected hand may increase the risk of injury.
C. A soft diet and thickened liquids are generally recommended for clients with dysphagia, which is not specifically indicated in the context of muscle weakness due to a stroke.
D. Encouraging the client to complete all ADLs independently may not be feasible or safe due to the muscle weakness. Support and assistance with ADLs are likely needed.
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