A nurse is performing hand hygiene after caring for a client who has Clostridium difficile. Which of the following cleansing agents should the nurse use?

A) Establishing the priorities of client care:

Establishing priorities of client care typically occurs during the planning phase of the nursing process, not during implementation. During the planning phase, the nurse identifies the most urgent client needs based on assessments and formulates a plan of action to address those needs.

B) Reinforcing teaching about the client's diagnosis:

Reinforcing teaching about the client's diagnosis is an appropriate activity during the implementation phase of the nursing process. Implementation involves carrying out the planned interventions, which may include educating the client about their diagnosis, treatment plan, and self-care strategies. Reinforcing teaching ensures that the client understands their condition and how to manage it effectively.

C) Asking the client about the presence of pain:

Assessing the client for pain is typically part of the assessment phase of the nursing process, not the implementation phase. During assessment, the nurse gathers data about the client's pain experience, including location, intensity, quality, and factors that alleviate or exacerbate pain.

D) Comparing the client's current laboratory values to previous results:

Comparing laboratory values is a component of data interpretation and analysis, which occurs primarily during the evaluation phase of the nursing process. While the nurse may review laboratory values during implementation to monitor the client's response to interventions, comparing current values to previous results is more closely associated with evaluating the effectiveness of care provided.

A) Ensure the client wears nonskid slippers when walking around the house:

Wearing nonskid slippers can help improve traction and stability, reducing the risk of slips and falls, especially on smooth or slippery surfaces commonly found in homes. Ensuring the client wears nonskid slippers is a proactive measure to prevent falls.

B) Install a raised toilet seat in the client's bathroom:

A raised toilet seat can make it easier for older adults with mobility issues to sit down and stand up from the toilet safely. It reduces the distance the client needs to lower themselves, decreasing the risk of falls, especially for those with balance or strength limitations.

C) Encourage an annual review of the medications the client is taking:

Medication review is essential to identify any medications that may increase the risk of falls due to side effects such as dizziness, drowsiness, or orthostatic hypotension. An annual review ensures that any potential fall-inducing medications can be identified and addressed promptly.

D) Attach full-length side rails to the client's bed:

While side rails may prevent falls out of bed, they can also increase the risk of entrapment and injury. The use of side rails is controversial and should be based on individualized assessment and risk-benefit analysis. In many cases, alternative interventions to prevent falls should be considered before resorting to side rails.

E) Place throw rugs on uncarpeted floors in the client's home:

Throw rugs can be tripping hazards, especially for older adults with mobility issues. They can easily slip or bunch up, leading to falls. Removing throw rugs or securing them firmly to the floor is recommended to reduce the risk of falls in the home.