A nurse is disinfecting the room of a client who has a Clostridium difficultiesinfection. Which of the following solutions should the nurse use?

Chlorhexidine.

Isopropyl alcohol.

Chlorine bleach.

Triclosan.

Answer and Explanation

The Correct Answer is C

According to the CDC1, chlorine bleach is an effective disinfectant for killing C. difficile spores on environmental surfaces.

It should be used in a 1:10 dilution of household bleach and water, freshly mixed daily.

Chlorine bleach can also kill other pathogens that may be present in the room of a client with C. difficile infection.

Choice A is wrong because chlorhexidine is not effective against C. difficile spores.

Chlorhexidine is an antiseptic that can be used for hand hygiene and surgical asepsis, but it does not kill spores.

Choice B is wrong because isopropyl alcohol is also not effective against C. difficile spores.

Alcohol-based hand sanitizers are not sufficient for preventing the spread of C. difficile, and soap and water should be used instead.

Choice D is wrong because triclosan is a type of antibacterial agent that is commonly found in some consumer products, such as soap and toothpaste. However, triclosan has no activity against C. difficile spores.

Triclosan may also contribute to antibiotic resistance and has potential adverse effects on human health and the environment.

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Correct Answer is D

Explanation

The correct answer is D. Using two gloved fingers to open the client’s mouth for cleaning.

Choice A rationale:

Lowering the side rail on the side of the bed where the AP will stand is necessary for safe access to the client. However, the AP should ensure the opposite side rail is up to prevent the client from falling.

Choice B rationale:

Using an oral care sponge swab moistened with cool water is an appropriate method for cleaning the mouth of an unconscious client. It helps maintain oral hygiene and comfort.

Choice C rationale:

Wearing clean gloves is essential for infection control and is a standard practice when performing mouth care to protect both the client and the caregiver.

Choice D rationale:

Using two gloved fingers to open the client’s mouth is not recommended as it can cause injury to the caregiver if the client bites down reflexively. Instead, a padded tongue blade should be used to gently open the mouth.

A. Offer the clients many choices regarding care. B. Restrict the number of visitors for clients. C. Assign different nurses to provide care for clients each day. D. Turn on loud music in client care areas.

Correct Answer is B

Explanation

This action can help to reduce environmental stressors for clients in an acute care unit by limiting noise, crowding, and potential sources of infection.

Visitors should be allowed according to the client’s preference and condition, but excessive or inappropriate visitors should be discouraged.

Choice A is wrong because offering the clients many choices regarding care can increase their stress and anxiety, especially if they are confused, overwhelmed, or unable to make decisions.

The nurse should respect the client’s autonomy and preferences, but also provide guidance and education to help them make informed choices.

Choice C is wrong because assigning different nurses to provide care for clients each day can reduce the continuity and quality of care, as well as the trust and rapport between the client and the nurse.

The nurse should strive to provide consistent and individualized care for each client and establish a therapeutic relationship.

Choice D is wrong because turning on loud music in client care areas can increase environmental stressors for clients in an acute care unit by creating noise pollution, disrupting sleep, and interfering with communication.

The nurse should maintain a quiet and calm environment for the clients and use music only if it is soothing and requested by the client.

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A nurse is disinfecting the room of a client who has a Clostridium difficultiesinfection. Which of the following solutions should the nurse use?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse observes assistive personnel (AP) perform mouth care for a client who is unconscious. Which of the following actions by the AP requires intervention by the nurse?

Correct Answer is D

Explanation

A nurse is assisting in creating a plan to reduce environmental stressors for clients in an acute care unit. Which of the following actions should the nurse include in the plan?

Correct Answer is B

Explanation

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