A nurse is caring for a client with the diagnosis of clostridium difficile. While providing care to the client, the nurse's glove tears. After removing the soiled gloves, what is the priority action by the nurse?
Wash hands with soap and water
Don a clean pair of nonsterile gloves
Wash hands with alcohol-based hand sanitizer
Wash hands with a bleach wipe from a nearby container
The Correct Answer is A
A. Wash hands with soap and water: Soap and water are the most effective method for removing Clostridium difficile spores from the hands. Alcohol-based hand sanitizers are ineffective against C. difficile spores, so washing with soap and water is the priority.
B. Don a clean pair of nonsterile gloves: While donning new gloves is important for continuing care, it does not address the need to properly disinfect hands after a contamination event, which should be done immediately.
C. Wash hands with alcohol-based hand sanitizer: Alcohol-based hand sanitizers are not effective against C. difficile spores, so they should not be used in this scenario. Soap and water are required to effectively remove the spores.
D. Wash hands with a bleach wipe from a nearby container: While bleach wipes are effective for disinfecting surfaces, they are not intended for hand hygiene. Soap and water should be used to clean hands in this situation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["10"]
Explanation
Rationale:
- Convert the patient's weight from pounds (lb) to kilograms (kg).
Weight in kg = 140 lb / 2.2 lb/kg
= 63.636 kg.
- Calculate the total desired dose in milligrams (mg).
Desired dose (mg) = Desired dose (mg/kg) × Weight (kg)
= 2 mg/kg × 63.636 kg
= 127.272 mg.
- Identify the available concentration of Golimumab.
Available concentration = 50 mg / 4 mL.
- Calculate the volume in milliliters (mL) to administer.
Volume (mL) = Desired dose (mg) / (Available concentration (mg) / Available volume (mL))
= 127.272 mg / (50 mg / 4 mL)
= 127.272 mg / 12.5 mg/mL
= 10.18176 mL.
- Round the answer to the nearest whole number.
= 10 mL.
Correct Answer is D
Explanation
A. BP of 120/80, pulse of 100, respiratory rate of 18: This assessment is within normal limits, although the pulse is slightly elevated. It is not immediately concerning for opioid toxicity or complications.
B. BP of 104/72, pulse rate of 80, respiratory rate of 24: This assessment shows a normal BP and pulse, though the respiratory rate is slightly elevated. A rate of 24 could be an expected finding in some patients, especially after surgery, but it does not indicate an immediate risk related to opioid use.
C. BP of 110/60, pulse of 70, respiratory rate of 14: This assessment shows normal vital signs for a post-operative patient. The respiratory rate of 14 is within normal range, and there is no indication of opioid-related respiratory depression or other complications.
D. BP of 90/50, pulse of 120, respiratory rate of 10: A low BP (90/50), elevated pulse (120), and a low respiratory rate (10) are signs of potential opioid overdose or severe sedation. Respiratory depression is a serious side effect of opioids, and the nurse should contact the provider immediately as the patient may be at risk of respiratory failure or shock.
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